Physician's ethics: No more toys from drug companies

PhRMA -- the association of pharmaceutical companies -- has agreed to a voluntary moratorium on drug paraphernalia given to doctors:

Starting Jan. 1, the pharmaceutical industry has agreed to a voluntary moratorium on the kind of branded goodies -- Viagra pens, Zoloft soap dispensers, Lipitor mugs -- that were meant to foster good will and, some would say, encourage doctors to prescribe more of the drugs.

No longer will Merck furnish doctors with purplish adhesive bandages advertising Gardasil, a vaccine against the human papillomavirus. Banished, too, are black T-shirts from Allergan adorned with rhinestones that spell out B-O-T-O-X. So are pens advertising the Sepracor sleep drug Lunesta, in whose barrel floats the brand's mascot, a somnolent moth.

...

In 1999, Dr. Goodman started No Free Lunch, a nonprofit group that encourages doctors to reject drug company giveaways. "Practically anything you can put a name on is branded in a doctor's office, short of branding, like a Nascar driver, on the doctor's white coat," Dr. Goodman said.

The new voluntary industry guidelines try to counter the impression that gifts to doctors are intended to unduly influence medicine. The code, drawn up by Pharmaceutical Research and Manufacturers of America, an industry group in Washington, bars drug companies from giving doctors branded pens, staplers, flash drives, paperweights, calculators and the like. (Link in original.)

Good, but it doesn't go far enough.

There are things that are still allowed such as "free lunches for doctors and their staffs or to sponsor dinners for doctors at restaurants, as long as the meals are accompanied by educational presentations." These "educational presentations" are pretty common during medical school and residency where you have lunch on a drug company and they explain why their drug is better than the competition. In some cases, these lunches even count as continuing medical education (CME).

There is a lot of diversity of opinion about these lunches. Some people think that the don't hurt much, and most residents are poor and could use the food. Some think that they constitute the appearance of illicit conflict of interest even if not the fact.

Personally, I won't voluntarily attend them (sometimes they make you), and I don't think they are appropriate for CME. (If I was going to spend my lunch studying medicine, a trip to the library would be much more fruitful.) For the ones I have attended, the presentation never covers all of the story about a particular class of drugs. Even when the drug companies are not creating an clear conflicts of interest, these types of interactions are intended to subtly influence clinical decision making. I even heard a story where drug companies were recruiting former cheerleaders to do these presentations! That is just low and frankly kind of offensive: there are female doctors, you know.

But back to the random junk: do I think that pens and random junk influence clinical decision making?

Not really, although there is some evidence that it does. But I do think that drug companies use these give-a-ways as a means to get in the door and build trust, which is a gateway to other more pernicious means. This is an argument made by an excellent review of pharmaceutical company marketing strategies (Fugh-Berman and Ahari, 2007):

Gifts create both expectation and obligation. "The importance of developing loyalty through gifting cannot be overstated," writes Michael Oldani, an anthropologist and former drug rep [26]. Pharmaceutical gifting, however, involves carefully calibrated generosity. Many prescribers receive pens, notepads, and coffee mugs, all items kept close at hand, ensuring that a targeted drug's name stays uppermost in a physician's subconscious mind. High prescribers receive higher-end presents, for example, silk ties or golf bags. As Oldani states, "The essence of pharmaceutical giftingâ¥is 'bribes that aren't considered bribes'" [1].

Reps also recruit and audition "thought leaders" (physicians respected by their peers) to groom for the speaking circuit. Physicians invited and paid by a rep to speak to their peers may express their gratitude in increased prescriptions (see Table 1). Anything that improves the relationship between the rep and the client usually leads to improved market share.

(I recommend reading that whole review.) Influence strategies can be subtle. In many ways, this one is like Hare Krishnas trying to make you slightly more receptive by giving you a rose. (For other strategies of psychological persuasion, read this book.)

So I do agree with the ban, even though I much prefer a voluntary moratorium than a law against it -- which would just make everyone do more paperwork than we already do.

Are there any types of drug company interactions I don't have a problem with? There are a couple.

1) Drug companies should be able to mail info about their drugs, and they should answer questions when doctors call them.

2) The review above has a problem with this, but I don't have a problem with drug company "samples" that they give away to doctors. These samples are often given away by doctors when a patient begins a new drug, or given to poor patients so that they don't have to buy drugs.

3) I don't have a problem with a company giving doctors a price break if they are buying a drug from them in bulk. This is much for the same reason; the doctor could pass that cost savings on to patients. (This would be restricted to drugs that the doctors are buying themselves rather than drugs available by prescription. If the doctor is purchasing them, the drug company couldn't know how many prescriptions they are writing.)

The take home is that I think that an ethical physician should distance themselves as far as possible from drug companies. There are two many opportunities for conflicts of interest, however subtle, and these conflicts impair a physician making the best decision for their patients. Obviously, no one is going to be perfect about this, and we are all biased to some degree. A physician will be more likely to prescribe certain drugs that they have had good experiences with in the past. But as a guideline rather than a hard-and-fast rule, physicians should limit their interactions with drug companies, even when they include handy pens.

Extra credit ethical question: With respect to clinical decision-making, physician-scientists have a unique challenge. Say I want to run a drug trial using drug company money. I am going to have to recruit patients to do this. Presumably, I will only recruit patients that I genuinely believe will benefit from our drug, and presumably I will inform them of the risks and benefits of the new drug -- including unknown risks. I don't have an ethical problem with any of this, provided that the control group is still getting the standard of care.

After the study is done, it may work or it may not. We would publish it, and I would clearly disclose the financial conflict in that publication. Again, I have no ethical issues with this.

Here is the difficult ethical question, though: I have to go back to being a physician now. I may think that the new drug is just the bee's knees, but I have to make any further decisions with my patient's interest in mind. But I have had a very serious financial interaction with a drug company, and this interaction may influence future decisions I make about my patients.

Is it possible for me to be impartial having run this study? Has the participation as a preceptor in this study created an irresistible conflict of interest?