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- Anthony N. DeMaria, MD, MACC, Editor-in-Chief, Journal of the American College of Cardiology⁎ ()
- ↵⁎Address correspondence to:
Dr. Anthony N. DeMaria, Editor-in-Chief, Journal of the American College of Cardiology, 3655 Nobel Drive, Suite 400, San Diego, California 92122
I recently had the privilege of serving as the Samuel and Edith Marcus Visiting Professor Lecturer at the University of Arizona. During the 2-day visit Frank Marcus, the loving son of the honorees and my host, shared with me his feelings regarding the need for greater control over the interaction between the medical industry and physicians. In particular, we discussed the issue of gifts from industry to physicians such as lunches, pens, and other paraphernalia. That discussion, along with some literature that Frank provided, stimulated me to organize my own thoughts on the matter. Recognizing that the interaction has sometimes been inappropriate on the part of both industry and physicians, I am concerned that the pendulum may be in the process of over-swinging. I doubt that industry could gain control over the actions of most physicians with any gift, much less a pen or a piece of pizza.
Because most drugs and devices require a prescription, it is not surprising that medical companies have always directed the bulk of these educational and promotional activities to physicians. It has been reported that in 2004, drug companies spent $24 billion on promotion, of which $16 billion was in free samples and $7.3 billion for gifts and meals, nearly all of which went to physicians (1). In fact, only recently has direct-to-consumer advertising become prevalent, a concept to which many object (2). Over time it became apparent that some promotional activities were geared more to influence than inform. So in 2002, the pharmaceutical industry adopted guidelines for behavior between their representatives and physicians. However, a number of authorities believe that this code is inadequate.
Concern with the interaction between industry and physicians continued to mount. It reached a peak in 2006 when, in a publication in the Journal of the American Medical Association(JAMA), a group of 11 highly-respected medical authorities proposed a policy to eliminate conflicts of interest between the health care industry and physicians to be led by academic medical centers (3). They recommended the elimination or modification of practices, including small gifts, drug samples, continuing medical education, travel expenses, speakers’ bureaus and consulting, and research contracts. This coalition argued that industry activities often crossed the line between patient welfare and corporate profits, that even very small gifts influence behavior either consciously or subconsciously, and that full disclosure of potential conflicts is inadequate to address the issue. They specifically recommended that all gifts to physicians (zero dollar limit) should be prohibited. They recommended modifications of industry support of continuing medical education that they recognized would result in reduced contributions necessitating funds from other sources.
The JAMAarticle helped to galvanize a movement to prohibit gifts to physicians. The University of Pennsylvania and Stanford joined Yale in prohibiting faculty and staff from accepting any gifts whatsoever from industry. The University of California at Davis will implement this policy this summer. The culmination was the awarding this past month of a $6 million grant from the Pew Charitable Trust to a consortium of advocacy groups and the Institute of Medicine as a Profession to fund a national campaign, called the Prescription Project, to restrict interactions between doctors and drug/device companies. The goal of the Prescription Project is to extend the restrictions implemented by Yale, Penn, and Stanford to other academic institutions, physician organizations, and third-party payers.
No one can deny that some past excesses have existed in the interaction of health care industry with doctors. Some activities were clearly targeted more for marketing than education. I can remember instances earlier in my career when I was the guest of pharmaceutical companies at sporting events, theater, golf, and even the Kentucky Derby, sometimes without any educational component. So some tightening of behavior was in order. Even absent such activities, who could be against the concept that physician decisions be based upon scientific evidence and always made in the best interests of the patient? This is motherhood and apple pie. It is obvious that inappropriate behavior regarding continuing medical education, physician travel, and ghost writing must be stopped. I only question whether a pen, note pad, or sandwich for a lunch or cath conference renders it impossible to make evidence-based decisions in the patient’s interest.
I am aware of the arguments that even small gifts achieve influence. Psychosocial research has shown that presents of any size stimulate a strong desire to reciprocate (3). As has often been pointed out, drug/device companies would not continue to provide gifts if they did not think that the practice was effective. Moreover, I agree entirely that accepting gifts sets a bad example and can lead to an unfavorable perception of the medical community. Physicians, even house staff in this day and age, certainly are not among the neediest segments of society.
Nevertheless, I believe that other considerations must also be taken into account. Pen lights, bagels, and other gifts are of very little value, and unlikely to have major impact. In addition, such “freebies” are virtually ubiquitous in most medical settings. I have used pens supplied by virtually every pharmaceutical company that sells cardiac drugs, and I often find myself writing with instruments displaying the names of products that a cardiologist would never use. It seems hard to believe that any individual company could gain much influence by providing the same tokens as everyone else. I worry that a focus on this minor area may detract emphasis from the bigger problem areas in industry–physician interaction. Right or wrong, small gifts may provide a significant inducement for education. Years ago, I prohibited industry from providing food or drink for a teaching conference held from 5:00 to 7:00 at night. However, I relented when it became clear that attendance was much improved if food was available, even if greasy, cold, or tasteless. Clearly, these same perquisites could have been funded by other sources. In addition, although other measures could have attained the same goal, none would be tension-free or enable funds to be used for other aspects of the program. Rotating the industry representatives who provided food offset influence by any one company.
I worry that the initiative to rigidly restrict interactions between industry and physicians may ignore a number of realities. A major goal of the initiative is to achieve evidence-based medicine. However, industry representatives often are an important source of information, especially for busy practitioners. Authorities often view with alarm the fact that physician prescriptions increase after talking to industry representatives. However, given the abundant evidence of underutilization of therapies of proven efficacy, perhaps this behavior reflects appropriate action in the face of new evidence. Much of the important new evidence regarding clinical management comes from randomized controlled trials supported by industry; the 4S, GUSTO, and TIMI trials spring into mind. There is a certain irony in restricting the interaction of representatives of the entities responsible for the new evidence. We should recognize that industrial support of the medical enterprise is pervasive. Major scientific sessions are funded in part by industrial participation. In fact, the very venue in which the coalition of experts proposed the policy to eliminate conflicts of interest, that is a medical journal, contains substantial industrial advertising. The role of industry in many aspects of the medical enterprise is a reality; emphasizing some small issues of industry–physician interaction diminishes the arguments for reform of more significant problems.
It is not the purpose of this essay to argue for more gifts to physicians from industry, nor do I contend that drug/device companies provide such gifts for purely altruistic purposes. Rather, I am uncertain that such low-value objects are worthy of such a high-profile effort. Although it makes good press to prohibit all gifts to physicians from industry, I am not sure that it accomplishes very much. Personally, I find it hard to believe that these ubiquitous, inexpensive trinkets and morsels significantly affect medical decision making. They may even do some good if they succeed in inducing doctors to acquire good evidence upon which to base management. There is no question that there are serious issues regarding the interaction of industry and physicians in many areas of medicine, and these issues should be addressed. We should emphasize those conditions that could inappropriately influence physician behavior to achieve monetary goals. I just do not believe that any physician would sell their soul for a pen.
- American College of Cardiology Foundation