Should medical journals carry pharmaceutical advertising?

What are best practices?

Best practices are evidence based. When it comes to pharmaceuticals, this best practice is tethered to randomized controlled trials (RCTs) and systematic reviews or meta-analyses (summaries of several RCTs). We train medical students and residents to be aware of relevant RCTs and, more important, we encourage them to base practice decisions and patterns on systematic reviews and on unbiased clinical practice guidelines that are not funded by pharmaceutical companies.

Best practice today is anchored, rightly, in the use of high-quality guidelines. Good physicians use unbiased guidelines, and excellent physicians tailor these guidelines to the specific goals and realistic expectations of their individual patients. This is best practice transformed into best-quality medical care. Good practice is only very rarely guided by a single RCT, much less by a single drug. Pharmaceutical advertising always promotes the prescribing of a single drug, usually one still under patent protection.

Guidelines rarely recommend a specific pharmaceutical unless there is only one product available or the RCT and systematic review evidence is overwhelmingly in favour of a single product. Rather, they recommend classes of drugs for the reason that no one drug has been proven better than any other of the class, pharmaceutical advertising notwithstanding.

Does pharmaceutical advertising educate physician readers?

Clearly it does not. But worse, it conveys to the reader, subtly but effectively, that prescribing the advertised drug is best practice. And the advertisements’ very presence in the journal of a professional association suggests that they are “medical education” endorsed by the College; that reading the advertising is best practice.

Why do professional medical associations like CFPC accept pharmaceutical advertising?

Readers will surely accept my position and perhaps even comment that of course this is well known and that it is even trivial to dwell on it. Members will also realize that editing and distributing a medical journal costs money and that pharmaceutical advertising (which provides about 60% of the costs of producing CFP) is a necessary, if distasteful source of money—the lesser of evils. This is a dismal argument, at best.

There is no free lunch. Pharmaceutical companies in Canada (and indeed in the United States) derive their revenue from the sale of drugs. The retail price of drugs is determined in large part by the companies’ costs, including the costs of advertising. Pharmaceutical companies do not pay for their advertising out of the charitable pockets of executives or shareholders. They pay for advertising out of the pockets of patients whose prescription costs include the costs of promotion and advertising. And in the case of a country like Canada, most of these costs come out of general tax dollars for health care.

I find it difficult to identify much moral high ground for CFP or the CFPC when accepting pharmaceutical advertisements.

What’s a journal to do?

Specifically, what could a good journal like CFP do if it declined all pharmaceutical company advertising? Editing and electronic journal production are not free. Indeed, editorial costs per article published in a good US journal are $13 000 (US) per article.2 There are several ways to reduce costs, but abandoning the print journal would be a good place to start. On April 30, 2010, the Web reached its 17th birthday. Is it not time to move on?

Most research is funded and funders (including the Canadian Institutes of Health Research) are increasingly willing to provide support for publication charges. Indeed, Open Medicine, for example levies modest author charges to cover technical costs of editing (eg, copy editing) and uses robust, free open-source software to prepare the journal in the electronic format needed for PubMed.3

Perhaps College members also would be willing to contribute some of their dues to CFP’s costs of editing?

But this debate is not about sources of revenue: it is about the educational and practice value of pharmaceutical advertising and the conflict of interest inherent in all relationships between physicians and the pharmaceutical industry. Pharmaceutical advertising has no place in CFP. Period.