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A. Doctors,
like everyone else, are influenced
by promotion. Though there have been no randomized trials,
there have been plenty of observational studies, and all
of them have reached a similar conclusion (see Wazana):
Doctors' prescribing behavior as well as other behaviors (for
example, requests to the hospital formulary) are influenced
by promotions and interactions with reps. Doctors who practice
on the basis of promotion, meet with reps, and use information
provided by them are more likely to prescribe more expensive,
inappropriate medication. Though the possibility of publication
bias exists, no study has shown that practicing on the basis
of promotion leads to more cost-effective prescribing. And
while no study has looked at the influence of gifts, or small
gifts, per se, it is reasonable to extrapolate the
vast social science literature on gifts (see below) to physicians.
Though many physicians may believe otherwise, there is no
reason to think that they are immune. Q. Surely you're not suggesting that something as inconsequential as a pen could possibly influence what I prescribe? A. That's exactly what we're suggesting. And the social
science literature suggests the same. Gifts create relationships;
they create obligation, the need to reciprocate (See Katz,
et al). For this reason even small gifts can be disproportionately
influential. Though many individuals, as well as most professional
society guidelines make distinctions among gifts of small
and large value (permitting the former while proscribing
the latter), presuming that larger gifts influence more than
smaller gifts, this distinction is probably baseless (see Dana & Lowenstein). Q. What about gifts that benefit patients? A textbook will help me to be a better doctor. A. A week of R&R
in the Caribbean would probably make you a better doctor,
but that doesn't mean the pharmaceutical industry should
pay for it. A gift is a gift, and gifts entail obligation.
There is no ethical distinction between different types
of gifts. If a drug company buys you a textbook, it merely
frees your money up to buy something else, like a trip
to The Caribbean, for example. Q. My friends in the business world are wined and dined all the time. Why should doctors be held to a different (higher) standard than business people? A. Because
the doctor-patient relationship, unlike many (but not all)
business relationships--but like that between a lawyer-client
or congressperson-citizen, is a fiduciary relationship.
A fiduciary is someone with specialized skills or knowledge;
holds the trust and confidence of others; is accountable
and obligated both ethically and legally; who is held to
a higher standard of conduct, and who therefore avoids
conflicts of interest. All of these characteristics pertain
to physicians. Though some may see medicine as “just a business,” clearly—at
the present time at least—patients, and society do
not see it this way: Patients rightly expect their physician
to act in their (the patient’s) best interest. Patients
do not enter the examining room caveat emptor. Patients
should be confident that the drug being is prescribed is
the best, the most cost-effective, not the best promoted. Q. But conflict of interests exist everywhere—what’s so different about this one? A. It's true,
conflicts of interest are ubiquitous, but that doesn't
mean they are all the same and are all acceptable. There
are conflicts resulting from academic, political, as well
as family interests (I may, for example, not heed all my
patient's complaints if I am in a rush to get to my son's
soccer game at 6PM). Some conflicts are unavoidable; but
that doesn't make all conflicts permissible. Conflicts
of interest should be avoided when possible, and the conflict
resulting from the acceptance of gifts from industry is
both voluntary and unnecessary. Q. Doesn't disclosure eliminate the "conflict of interest problem?" A. Disclosed information is only
useful if the disclosee knows what to do with the information
that is disclosed (see Dana
and Lowenstein). What do we do with the disclosure
that a speaker or author is a paid consultant for the manufacturer
of the drug she is speaking or writing about? Disregard the
results? Listen or read more critically? This is by no means
clear. Or consider the patient perspective: Even if a physician
were to disclose to a patient (not likely) that she had been
taken to dinner by the company who makes the PPI she is about
to prescribe, what would the patient do with this information?
If you think about it, disclosure only points to a potential
problem; it doesn't do anything to resolve the problem. Q. Advertising is just part of our society, like it or not, and aren’t gifts just a form of advertising? A. Gifts do share some characteristics
with other types of advertising and promotion: Like other
types of advertising, they cost money (patients’ money?)
and also like other forms of promotion, they influence behavior. But
there is an important distinguishing characteristic: Gifts,
unlike other forms of advertising, create obligation, a sense
of indebtedness, and a need to reciprocate (see above). This
has been called the “reciprocity rule” (see Katz,
et al): When someone does us a favor (e.g., gives us
a gift), we are expected to return the favor at some future
time. Notably (and most relevantly in regards to pens and
notepads), the sense of indebtedness is not related to the
size of the gift (in other words, small gifts may produce
an obligation to perform a large favor). Those who fail to
reciprocate are viewed negatively (“ingrates,” “moochers,” “freeloaders.”)
Further, there is not just an obligation to repay, but an
obligation to receive (that is to say, turning down gifts
is viewed somewhat negatively); this results in less choice
in regards to whom we are indebted. This gift giving-receiving
behavior is well studied by social scientists, and appears
to be present in all societies. (see Cialdini) Q. What if I’m already prescribing the rep’s medication on the best evidence, what’s wrong with accepting a few freebies? A. Because the company
has other medications. And now you have developed a relationship
with the rep and his/her company, and are open to all that
comes along with this (see above). And while the economic argument is
admittedly complex, it is hard to justify being wined and
dined by drug companies when our patients cannot afford the
medications we are prescribing them (perhaps on account of
these lunches!). These are not "freebies:" There
is, after all, no free lunch. Q. How are doctors supposed to keep updated about new medicines without reps? A. There is no longer any reason
(excuse?) for providers to rely on promotional sources--which
are likely to be biased--for information. While many
reps may be knowledgeable about their products, they get
paid for selling, not educating, and get rewarded when their
products are prescribed, not when they are prescribed appropriately.
There now exist (see Sources of Drug Information) many non-promotional
and less biased sources of information that the proverbial
busy provider can access via computer or PDA in a matter
of seconds. It is true, that these sources do not come with
free lunch, but physicians may just have to get used to the
idea of paying for their own lunch. Q. I meet with reps in order to get samples for my patients – what am I supposed to do without my samples? A. Not for nothing does the pharmaceutical industry spend over 1/2 its promotional dollar on “free” samples: Once a patient is given a sample, there is a good chance that this patient--and other patients--will be prescribed that medication at a later date, even though equally effective (or perhaps more effective, less expensive--and possibly less hazardous--) medications are available. (See Chew, et al) Vioxx (and before Vioxx, Rezulin, Trovan . . .) was heavily sampled and heavily prescribed. Patients would have been better off (and some of them still alive), if they had been prescribed older, safer drugs. While it is often stated that "samples are better than
nothing," this argument is a straw man: It is not “samples
vs. nothing:” Patient
Assistance Programs are available from the companies
themselves, and these have become easier to use and manage
via the internet. Also, with more and more drugs going off-patent,
less expensive generics are often available. If physicians
spent as much time advocating for universal heath care as
they did defending their free samples (and the food that
comes with them), we might not be forced to use whatever
sample is lying around the office as a solution to our patients’ lack
of health insurance. Q. I have lunch provided by different companies each day. Doesn't the bias cancel out?" A. No. Q. I work long hours, studied for many years, and have paid my dues. Aren't I entitled to all this stuff? A. Yes. And you are
also entitled to a Nobel Prize; but you aren't going to
get that either. You may be entitled to a high salary,
and this is why the physicians’ salaries,
in the U.S. at least, are considerably above the National
average. But you are not entitled to gifts from the pharmaceutical
industry any more than a congress-person is entitled to gifts
from lobbyists. And even less so if these gifts drive up
drug costs and lead to inappropriate prescribing. Q. I'm a medical student and can't prescribe anyway; so where's the conflict? A. As a medical student you have the longest prescribing life
ahead of you than anyone else, and industry is well aware
of this. If you develop a pattern of interacting with sales
reps, of accepting gifts, of creating relationships with
drug companies, these patterns of behavior will last a very
long time and may become very hard to break. Q. Aren’t you just communists? A. No. We support the capitalist system and
a free market (if only there were one!): May the best drug
win. But not the drug whose manufacturer provides the best
lunch. We are not talking about breakfast cereal here. We
are talking about medications, sometimes life saving medication,
the provision of which is under the control of the physician. We
suspect no one cares if their grandmother drinks Pepsi because
she likes the commercials. But there are few—if any—grandchildren
who wouldn’t care if she was taking the wrong medication
because her doctor had been taken out to dinner the night
before.
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