ACCME's Dirty Little Commercial Funding "Secret"

Having nothing better to do on a Saturday morning, I posted results of my latest analysis of sources of Continuing Medical Education (CME) funding reported by ACCME (Accreditation Council for Continuing Medical Education) in its 2010 annual report (see "Pharma Support for Accredited CME Continues to Decline"). I was tardy in doing this yearly task -- the report was made public last July. Better late than never.

The real reason why I posted my ACCME analysis over the weekend, however, is because I had in my hands a study of physician attitudes about commercial support of continuing medical education that was going to be published on Monday and the data was relevant to the post I made after the study was published (see "Physicians Are Concerned About Pharma Support of CME, But Are Unwilling to Pay Their Own Way!").

In the meantime, Derek Warnick (@CuratioCME), CME Director at Curatio, an ACCME accredited medical education company (MECC), posted a response to my analysis of the ACCME data (see "Response to CME Post on Pharma Marketing Blog"). Derek takes issues with many points I made in my analysis, but the most interesting comment he made was this:

"I’m going to let you in on a little secret (although, if you work for an accredited CME organization, you probably already know this): those numbers used by the ACCME to report Total Commercial Support? Yeah, they’re not as cut-and-dried as you might think. Sure, you can look at them and say, “Hmmm... looks like MECCs are getting a LOT less commercial support.” But here’s the thing: the Total Commercial Support numbers you see only reflect the amount of commercial support given directly to the accredited provider sponsoring the activity [Derek's emphasis].

"So, if there is an activity that is co-sponsored by two accredited organizations, the organization responsible for certifying the activity is the organization that receives the commercial support. They then re-distribute the money to the other organization for their role in the activity. Typically, the organization that directly receives the commercial support reports the entire amount to the ACCME; the other organization doesn’t report anything. This has been my experience. The ACCME does allow the option of each organization individually reporting their split amount of the grant, but that gets pretty confusing if you have a lot of activities and lots of partners. The ACCME is fine with it either way; [Derek's emphasis] they just don’t want the money 'double-reported'."

This raises a couple of interesting question. First, however, let me say that this may not be as big a secret as Derek thinks.

In July, 2008, Pfizer announced that it would no longer directly fund CME courses provided by for-profit, third-party companies (MECCs) although it would keep paying for courses offered by medical schools, teaching hospitals and medical societies. Shortly after that, I hosted a survey (see "What's the Best Way for Pharma to Support CME?") that asked respondents if they thought all pharmaceutical companies should follow Pfizer’s lead. The following chart shows the results:

An anonymous respondent clued me in on the "little secret" Derek referred to in his post:

"Med schools, teaching hospitals, and medical societies frequently use MECCs to create their CME anyway, and unless CME is funded by pooled grants (ie, from multiple pharma companies), the bias will be no less than it is in the MECCs, or not much less."

Derek claims that because of this kind of "subcontracting," MECCs may not be getting as small a piece of the CME funding pie as I estimated from the ACCME numbers. Fair enough. But I note that only a small fraction of MECC respondents to my survey thought it was a good idea for other pharma companies to follow Pfizer's lead. That's understandable, because MECCs would have new academic bosses to deal with who may nickel and dime them. It's much better to get your slice of the pie direct from the baker than to beg a piece of someone else's slice!

I think Derek agrees with my analogy. He said:

"How often does this happen? Well, I can’t really speak for other companies, but my guess is it hapens (sic) a lot more frequently then it did 5 years ago. As already mentioned, the Pfizer’s and OMJ’s of the world no longer provide commercial support to MECCs. That eliminates a pretty big chunk of money that MECCs used to report to the ACCME. The alternative now is to find another accredited partner, such as a medical school or physician society, to co-sponsor the activity. That medical school or physician society is the accredited provider and they receive the commercial support. So in the past, where a MECC would have directly received a $100,000 grant from Pfizer (and reported it all to the ACCME), now a co-sponsor receives the $100,000 grant, reports it all to the ACCME, and then sends $50,000 to the MECC (or whatever the split is) for their role. That’s a $200,000 swing in how the commercial support is reported to the ACCME, when in reality the actual difference is only half that. Again, the ACCME is OK with this."

So, Derek and I agree that MECCs are losing more than just crumbs from the pie, but we differ on exactly how big the pieces really are. The more important issue, however, concerns bias. Is there any less bias in commercially-supported CME if industry funding in channeled through medical schools and medical societies to for-profit MECCs than if the funding went directly to MECCs?

Further reading:

• "Waning Pharma Support of CME: The Plight of For-Profit MECCs"

eDetailing Technology Spells Death of Traditional Pharma Salesman & Birth of "Sales Cyborg"

"You can't eat the orange and throw the peel away - a man is not a piece of fruit," says Willy Loman in Act 2 of Death of a Salesman. After reading this article in today's Wall Street Journal, many pharma sales reps may be feeling like tossed peeled fruit.

"Big pharmaceutical companies have found replacements for the army of sales representatives they've laid off in recent years: digital sales tools that seek to sell doctors on drugs without the intrusion of an office visit," says the WSJ.

"Tens of thousands of pharmaceutical sales reps have been eliminated in the U.S., creating a void that drug makers are now increasingly filling with websites, iPad apps and other digital tools to interact with doctors who prescribe their treatments."

Let's refer to "digital sales tools that seek to sell doctors on drugs without the intrusion of an office visit" as "eDetailing."

eDetailing in one form or another seems to be making a comeback since the recession hit the drug industry in 2007 and 2008 (see chart on right). I'm not really sure which is the "chicken" and which is the "egg"; ie, whether an uptick in adoption of eDetailing technology lead to the recent layoff of pharma reps or if reps were laid off because of the economy and subsequently replaced by machines.

Despite the title of this post, reports of the death of pharma "salesmen" may be somewhat exaggerated and not all sales reps can be replaced by machines. According to the WSJ:

"When German drug maker Boehringer Ingelheim GmbH launched the cardiovascular drug Pradaxa in the U.S., it put together a digital-marketing package to target doctors, including organizing webcasts for leading physicians to speak to other physicians about the drug. But the company found that sales calls to doctors' offices were still the most powerful tool for driving new prescriptions, says Wa'el Hashad, vice president of cardiovascular and metabolic marketing. 'No doubt digital marketing does have an impact...I don't believe, however, the shift happens overnight. I think it's a gradual shift,' he says."

In the Pharma Marketing News article "The Changing Role of Pharma Sales Reps," Nancy Lurker, CEO of PDI, Inc., says "reaching physicians requires a new level of sophistication. Live rep calls and dinner meetings and other live venues, however, are not going to go away. But the relative market share in terms of the amount of effort and money that is spent on live interactions is going to shrink and you’re going to see more money being spent in the digital communications space."

Some sales reps will morph into what I call "sales cyborgs" who engage in remote live human conversations with physicians aided by technology. See "Pharma TeleWeb e-Detailing" for more information about that.

Predicting the Impact of Technology on Sales
As of now, pilot programs such as TeleWeb e-Detailing have not been evaluated on how well they drive sales, but on other key indicators of success. Notwithstanding push back by some pharma marketing and sales managers, sales technology will continue to evolve and have greater impact in driving new prescriptions.

Back in 2006, Pharma Marketing News hosted a reader survey to predict future trends in the pharmaceutical marketing mix (see survey summary here).

The survey asked readers for their opinions regarding the impact and risk of several physician marketing channels. They were also asked how they saw the mix shifting in the next few years.

When evaluating impact, I asked respondents to think of reach, credibility, and content richness as important factors -- the greater these attributes, the greater will be the impact. Risk factors, on the other hand, include potential to cause customer dissatisfaction or push back, increased regulation, negative publicity, etc. If marketers should avoid the channel, then risk would be high.

The results of the survey can be plotted in graphical form:


Let's focus on traditional face-to-face promotion (rep) and eDetailing or epromotion.

While face-to-face promotion has a very high impact potential it is also risky and is becoming even more risky, according to survey respondents. [Risky because of increasing physician push back, denying reps access to physicians, and state laws attempting to limit access to physicians by sales reps.]

This is what the downward red arrow is showing. In fact, the tip of the arrow is where this channel may be at today!

eDetailing or ePromotion also has high impact. At the time this survey was run, eDetailing was thought to be as “risky” as face-to-face selling, but now it has the potential at least of being LESS risky and MORE impactful than traditional sales reps.

Additional Reading:

• Internet vs. Sales Reps: Which Do Docs Prefer?
• Rejiggering the Marketing Mix a la Merck

P.S. Forgive my use of the terms "salesman" and "salesmen." Obviously, I am trying to relate this to the play "Death of a Salesman." I am not implying that all pharma sales reps are men. Some reps are actually "cyborgs" with limited sexual attributes and some are machines that have no sex whatsoever!

Physicians Are Concerned About Pharma Support of CME, But Are Unwilling to Pay Their Own Way!

Talk about having your cake and eating it too! Commercial funding of continuing medical education (CME) and the potential for bias appear to concern many physicians, yet only a TINY MINORITY (7%) are willing to pay registration fees to eliminate or offset commercial funding sources, according to a report in the May 9 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.

Maybe physicians would like ObamaCME; ie, government subsidy of their education?

No, not quite. But they are willing to give up certain things to reduce costs such as eliminating a printed syllabus. They are not, however, keen to give up the free coffee and snacks!

The authors surveyed attendees at live CME courses delivered by the International AIDS Society–USA (IAS-USA), a nonprofit organization that pools the support it receives from industry so that no one company funds any particular program. In total, 770 attendees (a 57% response rate) completed the 22-item survey, which focused on beliefs about commercial funding and potential for bias, willingness to offset the cost of commercial support, knowledge about the costs of producing CME programs, and demographic information.

Although the study surveyed nurses, nurse practitioners, physician assistants, and persons with Ph.D.s or other academic degrees as well as physicians, I'll just focus on the responses from physicians (N = 378).

Potential for Bias
Although he authors never specifically define what they mean by "bias," I think we all know they are referring to influence over the content of CME courses in such a way as to benefit the commercial supporter.

There are several opportunities for bias to creep into CME, all of which involve money from drug and device companies:

• Faculty members' research may be supported by grants from companies
• Faculty members may be paid members of company speaker bureaus
• Faculty members may be paid directly to speak at CME programs
• The CME program itself is supported to some degree by a grant from a single or multiple companies

Of course, some CME programs are not funded in any way by the drug industry and is paid for entirely  from registration fees paid by physicians (the Institute of Medicine estimates that physicians, on average, spent slightly more than $1400 per year for CME in 2007).

The survey asked physicians how they would rate the bias of CME programs under each of these scenarios. The results are presented in the chart below:

This chart shows the percentage of physician respondents who believe the listed CME funding options have a moderate or large potential for bias.

According to the respondents to this survey, the least potential for bias in CME is when the faculty is completely independent; ie, receives NO funding of any sort from the drug/device industry. However, that is an unlikely scenario given the fact that perhaps 80% of the CME faculty pool receives some form of funding from pharma/medical device companies.

"Speakers will continue to have relationships with industry in various ways, especially for research funding," noted authors of a commentary that was published in the same journal as the report. "Bias will always need to be addressed through speaker disclosures and direct monitoring for bias at CME events."

Given that so many physicians feel that pharma support of CME introduces bias, you would think they would want to eliminate that support. Actually, only 17% of physicians surveyed agreed strongly or somewhat that commercial support of CME should be eliminated entirely (see chart below) and 56% agree that "Pharmaceutical/medical device company support is essential for accredited CME and should not be eliminated" (data not included in following chart).

Physicians were asked what they would be willing to do to "eliminate the need for pharmaceutical/medical device company support" of CME activities they attended. The choices are shown in the list in the above chart.

Only 50% of physicians would give up free food or snacks to eliminate the need for commercial support of CME. BTW, these costs are substantial. Hotels -- where most live CME programs are held -- charge as much as $8.47 for a cup of coffee! "A $9 cup of coffee may not seem to be the most economical use of CME dollars," noted the authors of the study.

It's the Internet Age, Stupid!
Reducing the cost of CME seems to be the best way to eliminate the need for commercial support.

"Barring a substantial reduction in the cost of delivering CME, however, a rapid reduction or elimination of funding might be unacceptably disruptive, and some have postulated that such a change will result in the disappearance of live CME as we know it..." said the authors.

What better way to reduce costs than by delivering CME via the Internet? The survey did NOT ask if physicians would participate ONLY in online CME programs if that meant eliminating the need for commercial support. In fact, more and more physicians are receiving CME credit online (see "Pharma Support for Accredited CME Continues to Decline").

Yes, delivering CME via the Internet would "result in the disappearance of live CME as we know it," but that's a good thing, not a bad thing, given the exobitant costs and biases in the CME as we now know it, IMHO.



Summary of Survey Results

Pharma Support for Accredited CME Continues to Decline

Pharmaceutical industry support - ie,  direct sponsorship PLUS advertising - of physician continuing medical education (CME) declined 13.3% in 2009 compared to 2008. This is based on income data (see here) provided by the Accreditation Council for Continuing Medical Education (ACCME). This marks the second consecutive year of decline as shown in the following chart:

The following chart illustrates the trend in both types of CME income (direct commercial support AND advertising income) that CME providers receive from pharmaceutical companies:

The pharma industry supports CME by funding different types of ACCME-accredited CME providers. These include for-profit Medical Education Communications Companies (MECCs), medical schools, and physician societies. The following chart shows how this funding has changed over the years:

Physician societies and medical schools continue to take pharma CME money away from MECCs as shown in this graph:

Online CME Trends
Meanwhile, the percentage of physicians who receive CME credit online continues to increase, albeit at a slower rate -- at least for the time being -- as shown in the following chart:

The above chart includes physicians who participating in "Enduring" online CME activities, which ACCME defines as: an Internet that is "available when the physician participant chooses to complete it. It is 'enduring,' meaning that there is not just one time on one day to participate in it. Rather, the participant determines when he/she participates. (Examples: online interactive educational module, recorded presentation, podcast)"

The chart does NOT include physicians who participate in "Live" Internet CME; ie, "an online course available at a certain time on a certain date and is only available in real-time, just as if it were a course held in an auditorium. Once the event has taken place, learners may no longer participate in that activity. (Example: webcast)"

In 2009, only about 38,000 physicians participated in live Internet CME courses compared to 4.5 million physicians participating in enduring online CME.

NOTE: These numbers refer to the number of registered attendees of CME events. Some physicians may attend more than one course and thereby be counted more than once.

Internet Searching and Learning
A third type of Online CME defined by ACCME is "Internet Searching and Learning," in which about 116,000 physicians participated in 2009. This is a CME activity "in which a learner accesses the content of the activity directly from the internet. This is differentiated from a 'course' and an 'enduring material' because the provider does not create the content but rather the learner chooses content based on what (s)he feels meets their needs or answers their questions."

Wow! Physicians can get CME credits just by searching for medical information on the Internet. No wonder Wikipedia has become an important source of information for physicians!

For-profit MECCs were responsible for 99.5% of physicians (115,324) who received "Internet Searching and Learning" CME credits.

I suppose MECCs draw up a list of multiple-choice questions that physicians must answer after searching the Internet. Perhaps they are directed to search certain sites such as WebMD or Wikipedia. It's likely that nobody reviews this information to determine if it is "unbiased." It's possible, therefore, for pharma companies to publish non-peer-reviewed content on these sites and thereby "game" the process and not be held responsible for sponsoring "biased" CME content.

P.S. The 2010 ACCME annual report will be available sometime this July at which time I will update these charts.

Pharma Tracks Docs at Medical Meetings Using RFID Technology

Although the pharmaceutical industry is dragging its feet implementing RFID (Radio Frequency Identification) technology to keep track of drug supplies, some companies are currently using the technology to track physicians' movements at scientific conferences.

"Dr. Wes" (Westby G. Fisher, MD, FACC) called this "Physician Tag and Release" (see "The Implications of Physician Tag and Release"). The photo on the left shows the back of Dr. Wes's badge at the recent American College of Cardiology Conference held 2-5 April 2011 in New Orleans, LA.

The technology is also being used at the Heart Rhythm Society conference going on right now. Propublica and USA Today co-published a story about how doctors are being bombarded with pitches for drugs and medical devices at this conference (see "Financial Ties Bind Medical Societies To Drug and Device Makers").

RFID tracking is a disturbing aspect of industry-sponsorship because it may give exhibitors access to the identity of any physician who enters (or merely passes by?) sponsor booths at medical meetings even if the docs do not talk to reps or give their permission to collect such information.

"Many physicians were unaware that exhibitors had paid to receive real-time data about who visited their booths, including names, job titles and how much time they spent," says Propublica.

The Heart Rhythm Society claims that exhibitors are not getting doctors’ personal information, but here's what the American College of Cardiology says about how its exhibitors benefit from RFID technology (see "Using Technology to Better Understand ACC Meeting Attendees"):

"The second way in which RFID technology is utilized is in the Exposition. Exhibitors were able to rent RFID readers from the vendor. They are able to use the data in much the same way as the ACC – to evaluate how effectively their work stations are structured and to improve their offerings to attendees. In addition, they are given access to limited information about the visitors to their booths. The information they are given is the same information that was available on meeting attendees badges in print (name/city/state/institution). No contact information is provided. ACC’s intention was not to create a revenue source by offering attendee data to exhibitors (in fact, only five out of more than 300 exhibiting companies decided to invest in RFID in their booths), but rather to provide exhibitors another resource by which to understand the traffic flow in their booths and to better align their displays with attendees’ needs."

Instead of "opting in" for tracking at scientific meetings, doctors must "opt out" from the use of tracking technology when registering for scientific meetings.

The practice "disturbs" Dr. Wes who says:

"It is no secret that these societies make a significant portion of their operating revenues from industry sponsors at these meetings. By instituting tracking, the value of their membership's privacy has taken a back seat to the income generated from tracking revenues."

and

"At the risk of sounding like a conspiracy theorist, it is not too hard to imagine one's credentials being called into question in court because a doctor did not demonstrate enough time in CME activities at the scientific sessions to quality for credit or because these data implicate a doctor in a purchasing agreement between a vendor and hospital system simply because a doctor visited a display booth."

Dr. Wes also imagines a scenario where RFID data collected at medical meetings can be combined with a doctor's prescribing information without their permission. That's a double whammy for physicians who wish to keep their prescribing habits private. The Supreme Court is deliberating that issue (see "Supreme Court to Decide Fate of State Laws that Prohibit Use of Rx Records by Pharma").

Social Media Clinical Research: Transformative or "A Taste of Armageddon"?

This tweet from my friend @Frank_Antwerpes, CEO at DocCheck (a German online physician community), appeared in my Twitter stream today:

Clinical Research goes social Web: http://bit.ly/kNCHop

If you follow the link, you will find this published study: "Accelerated clinical discovery using self-reported patient data collected online and a patient-matching algorithm". Here's the abstract:

Patients with serious diseases may experiment with drugs that have not received regulatory approval. Online patient communities structured around quantitative outcome data have the potential to provide an observational environment to monitor such drug usage and its consequences. Here we describe an analysis of data reported on the website PatientsLikeMe by patients with amyotrophic lateral sclerosis (ALS) who experimented with lithium carbonate treatment. To reduce potential bias owing to lack of randomization, we developed an algorithm to match 149 treated patients to multiple controls (447 total) based on the progression of their disease course. At 12 months after treatment, we found no effect of lithium on disease progression. Although observational studies using unblinded data are not a substitute for double-blind randomized control trials, this study reached the same conclusion as subsequent randomized trials, suggesting that data reported by patients over the internet may be useful for accelerating clinical discovery and evaluating the effectiveness of drugs already in use.

Pretty interesting, but also frightening.

This InformationWeek story presented the five advantages outlined by the authors of the study:

1. Speed. It took only nine months from initiation of the tool (March 2008) to the first public sharing of preliminary results (December 2008).
2. Patient access. There is a potential to rapidly recruit widely dispersed patients with rare conditions and to overcome selection bias favoring patients living near specialist centers.
3. Availability of control participants. Clinical outcome data were passively collected from thousands of patients who served as potential matched controls.
4. Cost. Online studies have lower marginal costs per patient as compared with thousands of dollars per patient in traditional trials.
5. Patient engagement. Patients who submitted data using the PatientsLikeMe website were connected with other patients, which may have a range of benefits.

InformationWeek did NOT list the inherent LIMITATIONS mentioned by the authors. The most important limitation cited by the authors: "Unlike randomized trials, which match the comparison groups on all possible confounding factors, subject only to chance variation, observational studies cannot control for unmeasured covariates."

In the PatientsLikeMe press release, PatientsLikeMe Co-Founder Jamie Heywood stated:

"The rising costs of healthcare and increasing complexity of managing disease require new approaches to comparative effectiveness research and real time management of disease. While there is much work to do, we have demonstrated a patient-centric approach that provides dramatic cost and time advantages."

In these days of budget cuts and R&D cutbacks, pharmaceutical companies may jump on the "Social Media Clinical Research" bandwagon. Some day -- probably not in my lifetime -- FDA may even accept results of such studies as part of the drug approval process. Drug companies, for example, may lobby the FDA to accept such studies as fulfilling post-marketing surveillance requirements imposed on them.

Thinking about the possibilities reminded me of a classic Star Trek episode titled "A Taste of Armageddon."

In that episode, the starship USS Enterprise, under the command of Captain James T. Kirk, sends a landing party to Vendikar, a city on the planet Eminiar VII. Kirk is informed that a fusion bomb just struck the city and killed half a million people. Curiously, everything in the city seems intact and there is no visible evidence or sensor readings of such an attack ever occurring. The landing party soon discovers that the entire war between the two planets is completely simulated by computers which launch wargame attacks and counterattacks, then calculate damage and select the dead. When a citizen is reported as "killed", they must submit themselves for termination by stepping inside a disintegration booth.

The advantages of computer-simulated war are similar to the advantages PatientsLikeMe noted for its Social Media Clinical Research. I imagine the most important advantage of such a computer-simulated war is COST savings! Speed also would be an advantage -- wars can be fought over a period of months rather than years. Access to and engagement of citizens seems to have been solved by the denizens of Eminiar VII. Controls are NOT necessary in warfare.

When researchers land on social communities such as PatientsLikeMe, they may also encounter anomalies such as reports of cures, side effects, trial results, etc. that conflict with "visible evidence or sensor readings," ie, scientific reality.

To which I say:

SOCIAL MEDIA, THE FINAL FRONTIER! ...of clinical research.

GSK, National Headache Foundation and "Migraine Diary." Is There an App for That?

Last week I came across this tweet posted by @GSKUS:

RT @NHF: Need help remembering your #migraines details? Find an online migraine diary from @GSKUS at http://bit.ly/hBS98Q

For my Twitter-challenged readers, I should point out that "RT" signifies that @GSKUS "retweeeted" a tweet originally made by @NHF, which is the Twitter account of the National Headache Foundation.

Whenever a pharma company retweets a message from a third party, it raises some flags. For example, suppose NHF was a patient advocacy organization that promoted off-label use of medications and suppose those medications were marketed by GSK? Further, what if GSK helps support NHF with funding? What if NHF received the majority of its funds from GSK? What if NHF was actually created by GSK and not independent at all?

I am asking these questions because I have previously cited the close relationship between GSK and a supposedly independent Restless Leg Syndrome patient advocacy organization (see Pharma Dollars (Pounds, Euros) are Grassroots Seeds).

These days there are quite a few tools I can use to answer my questions. But, first, let's look at the link in the tweet.

When you click on the http://bit.ly/hBS98Q link in the GSKUS tweet, you discover that the real link is http://www.lowerthepain.com/pdf/Migraine_Diary.pdf. The "Lower The Pain" website (www.lowerthepain.com) is a GSK site that prominently promotes a migraine survey. "Editorial and other support for the survey provided by National Headache Foundation with funding, development, and other support provided by GlaxoSmithKline," says GSK on the site. See this Fact Sheet on the NHF site for more about the survey.

But I also see an invitation to get "tips & tools you need that may enhance your conversation with your doctor today." Right NEXT to that is a picture of an iPhone, which GSK is careful to point out is a registered trademark of Apple Inc.

When I click on "Tools to Help" I am brought to the following screen:

This further HINTS that there is an app for that (ie, "MIGRAINE DIARY").

So, is there an iPhone version of the Migraine Diary?

Yes, there IS an iPhone "Migraine Diary," BUT it does NOT appear to be a GSK app or an NHF app. Here's the app by that name that I found on iTunes:

This is a nice little app, but it does NOT resemble the GSK's PDF version of "Migraine Diary."

The iPhone app was developed by Net Workz LLC, a Software Engineering Firm located in the UK, which is the only connection I can see between it and GSK. In fact, the creator of the app is Aaron Douglas. His about page states that "Net Workz LLC is a small company I started that I use for anything I do geeky-related. I don’t have much content here but I plan on expanding this site soon. My full time job employs me as a software engineer. This place is for my personal projects that need to be legit, like iPhone Apps."

Maybe GSK and Douglas are negotiating a deal right now to allow "Migraine Diary" to "go legit."

The only comment Douglas has received about his app is this:

"I like this app. It's not the fanciest, but I wanted something easy to fill out when I'm in pain! The only problem I have is that sometimes when I add a journal entry, it only shows up when I turn it off then on again, but it is there. I wish it had more graphs to see more than one month, to see a patten. An option for an "all day" headache instead of having to put in a time would be good!"

OK, so what about the relationship between GSK and NHF? There's obviously the survey mentioned above. There's a guest post to GSK's blog by Merle L. Diamond, MD entitled "Teaming up to Close the Gap in Doctor-Patient Migraine Communication" (see here). "Dr. Merle L. Diamond was compensated by GlaxoSmithKline for her participation in this campaign," GSK disclosed. Dr. Diamond is a member of the NHF board of directors.

Dr. Diamond is daughter to Seymour Diamond M.D., Executive Chairman of NHF, who originally founded the National Migraine Foundation, which was renamed the National Headache Foundation in 1987.

Seymour Diamond is the also the founder of Diamond Headache Clinic and Merle Diamond is it's president.

I'm not going to track this much further, but it would be interesting to know how many other physicians involved with NHF and the Diamond Headache Clinic are on GSK's payroll. Now that GSK has been required to list all payments to physicians, it should be easy to find out.

OK, I will track this a bit further. I just downloaded NHF's 2009 IRS Form 990, which has some interesting tidbits an accountant may be able to dechiper.

I notice, for example, that NHF made a "gift" of $1,112,748 to the Seymour Diamond Fellowship Fund [of] the Diamond Headache Clinic Research and Education Foundation. Are the Diamonds using the NHF as their personal piggy bank?

Also, NHF paid $814,955 to Vedanta Associates Inc., an independent contractor, for "research on various projects and programs." Seems like a lot of money for "research." What I've been able to find out about Vedanta Associates is it "provides marketing research and medical communications solutions to the pharmaceutical and heathcare industry."