Physician Relationships with Industry

John Oliver's Last Week Tonight HBO show on February 8, 2015 highlighted what is common sense to the average patient: money and gifts from the medical industry bias doctors and can interfere with cost-effective, high-quality care. If you have not seen this 17-minute clip, take a look at it via www.youtube.com/watch?v=YQZ2UeOTO3I.

A patient who perceived such a bias wrote about it in Health Affairs:

Last year, four years after showing initial symptoms of multiple sclerosis (MS), I walked out the door of one neurologist's office and, after several months of searching, switched to a different doctor. It was the final act in a series of events that had gradually eroded my trust in the first neurologist's judgment, which I believe was colored by his financial relationships with drug companies who manufacture and market medicines for MS patients.¹

Yet many physicians do not agree that this bias exists, despite substantial evidence.²

Pharma gifts, even just pizza and pens, are marketing and sales tools that promote shareholder interests. Such industry gifts should generally be declined. Dr Sunita Sah, assistant professor at the Johnson Graduate School of Management, Cornell University, researches “institutional corruption, bias, transparency, improving decisions, influence, advice-giving and advice-taking; in particular how professionals who give advice alter their behavior as a result of conflicts of interest and disclosure policies.”³ In a 2012 article published in the Journal of Law, Medicine, and Ethics, she examined why physicians often do not get it:

Although professionals may state that small gifts will not impact their decision-making, research in influence and reciprocity robustly demonstrates the contrary. People are unable to remain objective, even when motivated to be impartial (which suggests an unintentional element), and people succumb to bias while concurrently denying that they have done so. This latter finding not only demonstrates an unconscious element to succumbing to bias but also suggests that educating physicians about bias is unlikely to be successful.⁴

The Sunshine Act has forced transparency in how much money physicians receive from Pharma. At the ProPublica website (www.propublica.org), anyone can type in the name of a physician and see the money she or he has been given. Try it on your own physicians and yourself.

The American College of Physicians Ethics Manual⁵ and the American Medical Association Code of Medical Ethics⁶ establish standards for professional conduct regarding gifts, research subsidies, and continuing medical education (CME). Hospitals, medical schools, and universities often have their own policies for relating to industry. These can all be helpful in framing what is appropriate behavior.

In taking stock of our own personal ethics of physician relationships with industry, some key checklist items to review include the following:

• • Ensure that research subsidies never exceed the fair market value of the work performed.

• • Avoid involvement in seeding trials that are an excuse for marketing rather than serious science.

• • Avoid paid speaking engagements for Pharma as a “thought leader” that are simply marketing tools for industry; instead, speak in CME programs with no industry control over content.

• • Ensure that any role on an advisory board or as a consultant to industry is to share your knowledge and expertise to develop better products and thereby help patients (a social good) and not to market their products or be influenced in prescribing patterns.

• • Use institutional safeguards for potential conflicts of interest, such as conflict of interest committees, institutional review boards, and your institution's legal counsel or compliance officer.

• • Take seriously the Association of American Medical Colleges recommendation that “drug and medical device companies should be banned from offering free food, gifts, travel and ghost-writing services to doctors, staff members and students…”⁷

As Breault, Shenson, and Dugdale² concluded in a lengthier review on this topic,

Ethically sound actions in physician relationships with industry should be guided by professional standards, medical society guidelines, and local institutional policies. Even minor gifts can affect decision-making. Transparency is an important remedy but does not solve every entanglement problem. Providing cost-effective, high-quality care to patients is critical to maintaining their trust and to furthering the goals of medicine.

• © Academic Division of Ochsner Clinic Foundation