Medicine changes considerably during the working life of a doctor or pharmacist. Lifelong learning and unlearning is therefore a professional necessity and must be an integral part of normal work, not something to add on in spare moments.
Doctors, pharmacists and the public receive a flood of promotional information and suggestions that cannot be accepted at face value. Pharmaceutical promotion is advocacy that aims to create sales by presenting a product to its best advantage while playing down disadvantages. Something similar happens when over-enthusiastic colleagues talk about their preferred treatment.
When a new treatment or a new way of managing a problem appears, we need to ask:
- is the treatment that is offered worth considering and trying to understand?
- should I adopt it or recommend it to patients?
Often the answer to the first question is no, because the suggested treatment seems unnecessary or trivial or makes no sense. If however it looks as if it could be useful, the likely benefits and disadvantages need critical assessment. However, evidence to answer specific clinical questions is often lacking. In addition, if evidence is available individual doctors often do not have the time or the skills and experience to make reliable assessments that minimise biases. In practice it is more feasible and much more efficient for appropriate independent experts to do this - some with the relevant clinical expertise, others experienced in the evaluation of experimental data, such as clinical trials. They can then present their analyses and conclusions to all prescribers and pharmacists, who can read them in detail if they wish, discuss them, and decide whether they - as individual practitioners or as a group - want to use the new treatment in some situations. The assessment of medical treatments is best published in an independent drug bulletin.
The work of preparing impartial scientifically and clinically sound assessments resembles that of the Therapeutic Goods Administration (TGA) in licensing new products, and of the Pharmaceutical Benefits Advisory Committee (PBAC) in deciding whether the Pharmaceutical Benefits Scheme (PBS) should pay for them. However, these regulatory processes are part of government and are less helpful for clinical problems. The TGA can consider only whether a product is effective and reasonably safe: its primary job should be to protect the public and to limit what drug companies may claim about their products. The PBS needs expert advice to ensure that taxpayers get value for money and do not pay over the odds for minor or uncertain improvements.
Regrettably neither the TGA nor the PBAC is allowed to publish the evidence and the arguments on which they base their decisions. This secrecy makes it easy for aggrieved companies, doctors or patients to criticise them for being arbitrary or inconsistent.
To be able to think properly about the role of different treatments for a particular problem doctors need to understand and be able to discuss the evidence and the arguments. No one has found a better place for doing this than in an independent drug bulletin. Of course in principle any general medical journal could do it, but in practice there are two difficulties:
- general journals have to cover a very wide range of topics, so they have not got sufficient space to review and assess therapies
- almost all established medical journals are heavily dependent on advertising revenue from pharmaceutical companies, and if they are too critical they risk losing advertisers.
The member bulletins of the International Society of Drug Bulletins, including Australian Prescriber, contain no drug adverts: they must be free to express carefully considered unvarnished opinions. Independent drug bulletins are open to discussion, debate and argument. As medicine is not an exact science, drug bulletins are willing to reconsider and if necessary update their conclusions in the light of new evidence, and to consider other points of view.
Formularies and collections of therapeutic guidelines, while important and valuable resources, do not reduce the need for an independent drug bulletin. They are compendia for reference, giving compact and reliable information that is intended to remain current for a fairly long time - usually at least one year. Formularies have no space for detailed discussion, but most guidelines summarise the underlying concepts and arguments. The formularies and guidelines appear too infrequently to be topical, and neither encourages discussion among their users. The danger of guidelines is that too many people, among them clinicians as well as administrators of health services, regard them as mandatory - which they are not. They save work and time, but they must be applied flexibly to individual cases. In some cases it is better to depart from a guideline than to follow it. It would be valuable to build a collection of examples of such justified departures from guidelines, and this could be another role for independent drug bulletins.
Informing health professionals and the public about drugs and drug treatments is an important way to encourage the quality use of medicines. While drug bulletins such as Australian Prescriber clearly have a role, their message is reinforced if it also comes from other sources. It is important to ensure that information from different sources such as the Therapeutic Guidelines and the Australian Medicines Handbook is compatible. This user-friendly information should also be reinforced by other activities such as those of the National Prescribing Service. Integrated independent information, perhaps via the internet, will be well received by both health professionals and their patients.