What’s in a name?
“That which we call a rose, by any other name would smell as sweet”.
We may all agree with Juliet that her lover Romeo would still be the object of her desires even if he had a different name. However, Juliet knew that names often mattered, and she realised that her family name of Capulet created images and expectations that were not helpful to her and Romeo.
As it is with Shakespeare, so it is in the world of communication with medical and healthcare professionals. Today, we have a confusing and misleading nomenclature that is in serious need of revision.
Over thirty years ago, when the outsourced industry that provides what is today called “Medical Communications” was created there was little or no opportunity for confusion. Everything they developed, both symposia and publications were simply called “Medical Communications”..
Opportunities for confusion
Today, there are significant opportunities for confusion. With increased regulatory scrutiny, the pharmaceutical clients have a greater need to be directorial and involved in the development of programmes and materials that bear their name. In addition, the advent of ongoing training and assessment for medical professionals and their subsequent need to obtain unbiased training and education has created a new type of programme, the independent education programme, developed to a new set of standards that avoids bias and influence from all possible sources.
What’s the problem?
“What’s the problem?” You might ask, “everyone knows what we are doing”. Perhaps not. Many people have observed the issues in the US Continuing Medical Education (CME) market over the last 7 or 8 years. While this is not the topic of this article it can be argued that one of the major issues in that market was that the pharmaceutical company sponsors were misled, or misled others, by calling their marketing activities by the wrong name. In this case they called their marketing activities ‘education’. This created confusion and ultimately lead to uncontested allegations of fraud from the US federal and state governments and to massive fines for the pharmaceutical companies of many hundreds of millions of dollars and, in some cases, well over a billion dollars. This brought the pharmaceutical companies in to disrepute and has damaged their reputation for many years to come.
“This brought the pharmaceutical companies in to disrepute and has damaged their reputation for many years to come”
If we put the interests of our clients high on our list of priorities, if we value the work of healthcare professionals and do not want to mislead them, even if inadvertently, we should consider the lessons from the USA very seriously. The nomenclature we use is misleading.
The primary purpose of much of the work done under the “Medical Education” banner is marketing, customer access and sales. I stress that there is nothing wrong with this in the slightest. However, calling it ‘education’ is misleading. Again, I stress that I realise there may be useful information, some might even argue that there is occasionally education, in some of these activities, but that is not their main purpose. In the interests of avoiding confusion and potentially misleading the audience it should be clearly stated that the programme is developed under the control of the client company and is for marketing and sales purposes. We must avoid phrases such as “an educational symposium” when we should honestly be saying “a symposium controlled by [drug company] for marketing purposes”.
Companies providing these services should proudly be described as “Marketing Services Companies”.
Similarly, programmes that are developed independently of influence from sponsors (and other vested interests) and have their primary purpose as unbiased education should indeed be called “Medical Education” and organisations that provide these programmes should proudly be described as “Medical Education Companies”. Whether these programmes receive CME or CPD credit is irrelevant, it is the primary purpose and how they are created that matters.
At this point, it may be helpful to define what is meant by education. The Concise Oxford English Dictionary is not too helpful, defining education as “information about or training in a particular subject”. For the purposes of our industry I propose a tighter definition of education, “information about or training in a particular subject where the information and/or training are developed without influence from any vested interest and the facts are presented in an open and unbiased manner”.
I would argue that there is no good reason to disagree with this contemporary nomenclature as all it does is make things clearer to the client, customer and regulator. It doesn’t stop any organisation doing anything at all. Indeed, I think we should go a small step further. We should agree at a global level that programmes are clearly labelled as being either independently developed or as being developed as a service to the marketing department of a client company. The table below suggests how this labelling might help. The labelling should be prominently displayed and explained to the customers.
What about publications?
I’m sure many people can understand how this approach will avoid misleading or confusing healthcare professionals and, hopefully, avoid the damaging and expensive problems encountered in the USA. However, what about the areas that are not so clear cut such as publications? We should take a simple approach and apply the test of whether the pharmaceutical company has influence and/or control. For example, if a publication is developed where the authors have control over the writing of the publication and control over where it is published/submitted and the pharmaceutical company does not have influence then, I suggest, this should be called an “independently developed medical education publication”. If, however, the pharmaceutical company has control or influence over the development of the publication then it should be described as a “publication developed under the influence or control of the client [company name]”.
“However, what about the areas that are not so clear cut such as publications?”
This article is too short to deal with the wave of issues that many publication professionals will throw up including the “protection” that the 2009 revised Good Publication Practice guidelines (GPP2) provide. I don’t doubt that GPP2 is a step forward in creating clarity around the authorship and provenance of a publication. Indeed, I believe that some or all of the objectives of GPP2 are fully congruent with my objectives, to avoid confusing and misleading the client and the audience. What better way to help this important process than to describe who has control/ influence over the content and, because of this, its primary purpose?
This may mean creating new and different types of contracts for authors, it may mean that those companies that provide both marketing services and publication services will need to separate these services as some of the more visionary organisations are already doing or at least contemplating.
Can a programme be both?
Some might argue that there are many types of programme that include elements of education as well as promotion. I’m sure this is true.
If a new drug is being launched and the manufacturer has commissioned an agent to develop a symposium at a forthcoming congress, and the drug company reviews the potential speakers and agrees the outline for the programme, the agency then executes on this brief with the drug company reviewing content from time to time. An interested audience would attend the symposium and leave with information they previously did not have on the patients that may benefit from the new drug and the likely dose for their patients. Is this education or marketing or both?
I will argue strongly that it cannot be education. Applying our simple test it is clear to see why. The content is understandably biased as the drug company had influence or control over the content. This doesn’t mean that the audience didn’t find the symposium useful. However, it does mean that we should be very clear with the audience and we should describe the symposium as “developed under the control or influence of the client [company name] and was developed as a marketing activity”.
In fact, I believe there will never be an occasion in which the criteria for both definitions are met, they are mutually exclusive. And this is helpful. Grey areas cause problems, as we have learned in the USA.
This article has not dealt with the obvious questions of who judges whether a programme has been developed in a way that can be described as independent, or whether the authors of a publication really had freedom to decide on how a publication should be written and submitted, or even whether the staff of an agency have behaved correctly. This is an important and potentially far reaching discussion that needs to develop, as does the discussion around dealing with (not just highlighting) conflict of interest in many of the areas discussed in this article. A number of groups, such as the Good CME Practice group are beginning to get to grips with these important issues in Europe.
“I am merely asking that we recognise that we should be more open and clear with our clients and customers”
It is important to stress that I am not providing a judgement on the relative utility of marketing services and medical education. On the contrary, both approaches are valid and valuable. I am merely asking that we recognise that we should be more open and clear with our clients and customers to avoid potentially confusing and misleading them and creating situations damaging to our respective industries and, ultimately, to healthcare professionals and their patients.
So, what’s in a name? As Juliet knew, sometimes a name can mislead. In the case of medical education and marketing services there is a lot at stake in the transparent naming of what we do. I urge us all to take a modern perspective and consider how we can help our clients and customers understand very clearly what they are being presented with. It makes sense for them, their patients, and our clients and for the long term professional standing of the industry we are in.
About the author:
Chris Stevenson has worked in the pharmaceutical, marketing services and medical education sectors in the UK, mainland Europe and the USA. He can be contacted at firstname.lastname@example.org.
Do medical marketing and education need standardised nomenclature?