Drug company gifts: a response

Proposals that would have the Medical School implement an across-the-board ban of gifts from the pharmaceutical industry go overboard and discount the integrity of those in the medical profession.

by Patrick Sweeney, M.D.

I would like to respond to the article on drug company gifts published in the Nov. 8 issue of the George Street Journal.

It is important to differentiate between educational activities (i.e. continuing medical education, or CME) and marketing/promotional activities (i.e. advertising). While I do not defend past marketing abuses by some members of the pharmaceutical community, I am encouraged by the sincere efforts of the American Medical Association (AMA), the Accreditation Council for Continuing Medical Education (ACCME) and other organizations to address the relationships between CME providers and the pharmaceutical industry. I am equally encouraged by the willingness of accredited CME providers to comply with the guidelines and standards that govern these relationships. In addition, the AMA has a Code of Medical Ethics which addresses “Gifts to Physicians from Industry,” providing specific guidelines to avoid the acceptance of inappropriate gifts.

I do not share the cynicism of some of my colleagues. I still consider medicine to be the noblest of professions and those who enter it to be individuals of high ethical and moral character. They are the best and the brightest who studied long and hard to be at the top of their college classes so that they could get into medical school, where they studied harder to be competitive candidates for residency programs. They graduated with $100,000 in educational debts, then put their personal lives and earning potential on hold for three to five more years during residency. To imply that such professionals could be “bribed” with a $4 mug into prescribing a medication that will cost their patients three to four times that of an equally effective cheaper alternative is demeaning and insulting to the majority of physicians who place the interest of their patients first and who practice cost-conscious medicine. Frankly it is offensive to think that physicians can be so easily duped. I have more faith in the integrity and intelligence of my colleagues than to suggest that the way to prevent them from prescribing inappropriately is to remove the temptation of notepads and pizza. Pharmaceutical companies are businesses and they need to advertise. I believe physicians are smart enough to distinguish between advertising and scientifically sound research.

During my 31 years as a physician, I have never encountered a colleague who prescribed a more expensive medication for a patient purely because he/she received a pen or a sandwich at a hospital lunch. There are many valid reasons to prescribe newer, more costly drugs, including more favorable side-effect profiles or more convenient dosing schedules. In reality the choice of a specific preparation is more likely to be controlled by the patient’s insurance coverage than by the doctor’s prescription pad. Increasingly, despite a physician’s prescription for a name brand, the pharmacy will substitute a generic equivalent unless the prescription specifically limits the pharmacist’s option to do so.

More recently pharmaceutical budgets have shifted much of the emphasis from physician marketing to direct-to-consumer (DTC) advertising, which inundates the public with advertisements for name brand drugs like Celebrex, Allegra and Nexium. When patients demand these medications, busy physicians are faced with spending 15 unpleasant, sometimes confrontational, minutes trying to explain why that specific medication is unnecessary, or one minute prescribing it. DTC advertising works. Why bother with doctors when one can go directly to the patients?

The issue of drug samples always generates considerable debate. However, when used responsibly and judiciously, drug samples benefit many patients, particularly those with limited or nonexistent pharmacy coverage. Clinics that provide care to low-income patients are extremely sensitive to their patients’ inability to pay for expensive prescriptions. To suggest that health care providers who work in these facilities would use free samples to initiate therapy that would cost their patients dearly to complete is a disservice to these dedicated and caring professionals. These facilities tend to stock samples of commonly prescribed medications, not expensive designer drugs, and – with the obvious exception of long-term chronic therapy – they frequently dispense sufficient amounts to cover the entire course of treatment, saving their patients any out-of-pocket expense.

It is also worth acknowledging the tremendous benefits society reaps from the pharmaceutical industry, and the staggering costs associated with research and development of new drugs. The bulk of pharmaceutical research in the United States is funded privately by the pharmaceutical industry. Are taxpayers ready to assume this multibillion-dollar burden?

I am troubled by the lack of specificity in the campaign to have the Medical School implement an across-the-board ban of industry gifts. What is considered an industry gift – just the pads, pencils and pizza? What about research funded by the pharmaceutical industry? If the goal is to prevent undue influence, one could argue that accepting hundreds of thousands of dollars to conduct and monitor clinical trials is much more likely to produce a sense of obligation than consuming a doughnut. Should medical schools and academic faculty not participate in pharmaceutical-funded research? This very topic – the relationships among industry, academia and investigators – was the subject of an article in the November, 2002 issue of Academic Medicine in which Dr. David Korn states: “Conflicts of interest are ubiquitous and inevitable in academic life.…The challenge for academic medicine is not to eradicate them …but to recognize and manage them sensibly, effectively, and in a manner that can withstand public scrutiny.”

A decade ago abuses in the field of continuing medical education attracted the attention of politicians, the public and the media, and the profession responded. Accredited CME providers must now demonstrate compliance not only with educational planning, design and evaluation, but also with the Standards for Commercial Support (SCS), which govern the relationships between CME providers and commercial supporters. The SCS address the control of content, the management of funds, and the disclosure of faculty relationships. To state that “more often than not, attendees at CME programs or hospital grand rounds do not know the extent of industry funding for the session or for associated research” is simply untrue. As someone who has been involved with CME on a national level, I can honestly state that the issues surrounding disclosure of relationships has been a major focus of attention by both the accrediting organizations and the CME providers.

I believe the recent “Code on Interactions with Healthcare Professionals” from the Pharmaceutical Research and Manufacturers of America (PhRMA) will have a sobering effect on marketing practices. The guidelines prohibit gifts to doctors for personal use, payment for travel or expenses to educational events, tickets for entertainment or sporting events, and other inducements that are not directed to the care of patients. I believe the industry is trying to be more responsible, and I believe we should give the industry a chance to prove its commitment before we implement any sweeping ban on unspecified industry gifts. Medicine today is fraught with oversight and regulation. Instead of banning pharmaceutical representatives, we should respect physicians for the professionals they are and work collaboratively with the pharmaceutical industry to help implement the new PhRMA guidelines.

Patrick Sweeney, M.D., is associate dean of medicine for continuing medical education. For more than a decade he has been involved extensively in continuing medical education. Sweeney has served on the Accreditation Review Committee of the Accreditation Council for Continuing Medical Education (ACCME), the national organization responsible for monitoring accredited CME providers‚ compliance with educational guidelines and the AMA’s Standards for Commercial Support. He also has served on the Board of Directors of the Alliance for CME, an international association of CME professionals, and chairs the Rhode Island Medical Society’s CME Committee.