Reflections from HRS 2011: The ‘largesse’

Largesse: (Form thefreedictionary.com):

1. a. Liberality in bestowing gifts, especially in a lofty or condescending manner.

b. Money or gifts bestowed.

2. Generosity of spirit or attitude.

Two days into last week’s Heart Rhythm Society meeting, Propublica, an independent online investigative journalism-in-the-public-interest endeavor published a series of high profile articles as part of their Dollars for Docs series. Their marquee piece, published prominently in the USA Today, chronicled the strong financial ties (the ‘largesse’) that bind medical societies to industry. Reporters Charlie Ornstein and Tracy Weber highlighted the meeting’s ‘mansion’-sized exhibits, intense advertising, and the fact that most of the opinion leaders, officers of medical societies and guideline writers, the experts, have financial ties with medical device companies. More than half of HRS’ revenues came from industry.

Well.

I’ll offer four simple thoughts about all this conflict:

1. Nothing about industry influence at medical meetings is new news. I have been attending medical meetings for nearly twenty years, and industry has always been there. And here’s something you don’t read much about: it was far worse then. That’s all I will say about that. I won’t tell you how cool it was seeing the Charlie Daniels Band play at a medical meeting for free.

You can quibble with the extent of these current-day “cozy” relationships, or the glitz of exhibits at our gatherings, but you should also know that there is progress. The show is now out in the open. There is infinitely more disclosure. Smart people are now watching, tweeting, and reporting. Any doctor who’s been around more than a few years will agree that things have grown increasing more transparent. Which I believe is an improvement.

2. Heart rhythm medicine and sophisticated expensive tools are inseparable. I fix your heart with high-tech gadgets. These tools come from innovative, competitive corporations who profit when their products help people. On this point, I strongly agree with incoming HRS-president, Dr Bruce Wilkoff, who said, “this is the business we are in.”

There are too many medical device company successes to list, but just take JNJ’s saline-irrigated ablation catheter as one shining example: though any catheter can make burns in the heart, this newer, and more expensive one burns with a reduced risk of clots, which translates to a lower risk of stroke. What’s not to like? But getting this catheter to market required partnering with experts. Does their industry relationship negate everything they say about the catheter? Does it negate my experience? Some would even go so far as to say that these relationships nullify the entire AF ablation literature base.

I realize, of course, there are blunders. As long as humans make these tools, they will be imperfect, and occasionally harm will come to people. Medical treatments carry benefits and risks. This point backs up one of my blog’s main points to patients: it is better to prevent heart disease in the first place.

3. Heart doctors are a lot of things, but naive and stupid they are not. Even regular guys like me know that most of the experts have relationships with industry. We also know that ACC president Jack Lewin is wrong: advertising, money, and the glamor of the stage do have influence.

But, and this is a big but, we learners consider these relationships in our synthesis of the information. Sure, you can fool us once, telling us a catheter or device is great, but when it doesn’t work, we will stop using it. You can come to town and tout a drug with company-sponsored slides, but, if the drug doesn’t work, we will stop using it. And then…and this is the best part: if you persist in touting crap, we stop listening to anything you say. Do you think anyone listens to those that reported 100% success rates in catheter ablation of AF?

4. The alternative to the current situation is worse. How can a specialty that depends on tools made by medical industry completely divest themselves?  How can a medical company innovate without consulting with doctors who use these devices?

There will have to be studies. Randomized controlled clinical trials do not come cheap, nor does pre-and post-market surveillance. While I listened to the oodles of data presented at the meeting, I thought to myself how much it must have cost to collect and organize all that information. If industry doesn’t contribute to these costs, who will? The government? You? Me? The hospitals?  If science does not pay, then who will do it?

And, can HRS really expect to extract more from its members through fees? Can you expect a young doctor with 200k in med-school loans to shell out thousands to get educated at meetings? Or to be re-certified?

So, for now…

…I accept the current largesse with an open mind and a critical eye. I don’t deny the influence, but at the moment, the good seems to far outweigh the bad. In this opinion, I speak as a doctor trying to do the best possible work, as a patient who has benefited from high-tech orthopedic tools, and as a person who enjoyed seven extra years of friendship with a man whose life was saved by an evidenced-based ICD. A device made and marketed by a human-powered company that occasionally makes mistakes.

JMM

P.S. Despite the influence of industry, I learned a ton from the meeting, Stay tuned for some specifics on AF ablation, ICDs and even a little DNA-speak.