August 2002 • Volume 8 • Number 8 |
Talk about your inflammatory issues! Did you hear about the June 19 fire sparked in a Salem, Va., medical clinic? The culprit: a bag of tortilla chips left too close to the warmer for the refried beans -- all part of a staff lunch courtesy of a drug company. The lunch was to serve as the backdrop for a sales pitch by a sales rep from the company, Pharmacia Corp.
Technically, the rep wasn't at fault. For you Clue® fans, it was the caterer with a can of Sterno® in the upstairs meeting room.
The point is, the consequences of interactions between pharmaceutical representatives and physicians or physicians-in-training are often unpredictable.
Few physicians, for example, would predict that a marketing spiel delivered over lunch with a drug rep might alter their prescribing behavior. Or that accepting a speaker's fee from a drug company could be associated with a subsequent request to add that company's drug to the hospital formulary -- despite the fact that equally effective and less costly drugs already appeared there. Yet solid research evidence shows these types of things occur. (See study citations.)
To its credit, organized medicine has over the past decade defined what constitutes ethical behavior by physicians and pharmaceutical interests, starting with the AMA's 1990 "Guidelines on Gifts to Physicians From Industry," and including the AAFP's "Principles for Cooperation" that 16 pharmaceutical firms signed onto last fall (see below).
Now, industry has addressed the gifts issue with the April release of the Pharmaceutical Research and Manufacturers of America's "Code of Interactions with Healthcare Professionals," a document that reads much like the AMA guidelines.
Visit http://www.phrma.org/press/newsreleases/2002-04-19.390.phtml for more information on the PhRMA code, including a link to the code itself.
AAFP President Warren Jones, M.D., of Ridgeland, Miss., applauded PhRMA's action, saying it's heartening to see the group of some 80 pharmaceutical and biotechnology companies promoting industry responsibility.
"As a physician," Jones said, "my primary responsibility is to patients. I monitor my interactions with pharmaceutical companies with this in mind." The PhRMA code, he added, demonstrates industry's intent to partner with physicians to see that interactions between the two groups are ethically appropriate and provide true patient benefits.
Some, however, are underwhelmed by the PhRMA document.
Christopher Ryan, M.D., of the Wilson Family Practice Residency, Johnson City, N.Y., is among the skeptics. Noting few differences between the code's precepts and the status quo, he questions the motivation behind PhRMA's action.
"I think the most dangerous part of the code is the preamble," Ryan said. "An excerpt: 'This Code is to reinforce our intention that our interactions with healthcare professionals are to benefit patients and to enhance the practice of medicine.'"
Such claims are misleading, Ryan said. "I would have had much more respect for the document and its authors if it read, 'The purpose of interactions between our salespeople and physicians is to increase sales of our products.' Honesty goes a long way."
ALLEGATIONS OF ABUSE
Admittedly, there are grounds for concern. One striking example can be seen in newly unsealed court documents alleging that a pharmaceutical company committed a number of unethical acts in the mid- to late 1990s. Among those allegations against Warner-Lambert:
Pfizer acquired Warner-Lambert in 2000 -- after the alleged abuses were said to have taken place. Pfizer has denied many of the allegations contained in the suit, brought by a former Warner-Lambert employee. The case is now being investigated by the Boston U.S. attorney's office.
TODAY'S ETHICAL CLIMATE
Such over-the-top allegations illustrate the potential seriousness of the gifts issue. No doubt most transgressions -- on each side of the physician/industry equation -- are far more innocent. Yet recent study results and increased media scrutiny have helped prompt, among other things, an ongoing investigation by the HHS Office of Inspector General into the extent of the gifts problem.
Physicians -- and politicians -- are seeking answers at various levels, although some "fixes" seem to beg the question of whether the cure is worse than the disease.
At one Seattle multispecialty practice, Polyclinic, drug reps are now charged a minimum of $30 to set foot in the door. Last month, Vermont Gov. Howard Dean, M.D., signed into law a pharmaceutical bill that included a provision requiring full reporting of industry gifts to physicians totaling more than $25.
Similar legislative measures are in play in other states. For Massachusetts gubernatorial hopeful Steve Grossman, the issue is one of several underpinning his campaign platform. His rival in the Democratic race, Robert Reich, a former U.S. labor secretary, proposes an outright ban on gifts.
Norman Kahn, M.D., AAFP vice president for science and education, while congratulating PhRMA on its new code, cited some differences between it and the AMA guidelines that could affect certain aspects of national CME meeting planning. Those differences, he said, would be discussed during upcoming meetings of the Accreditation Council for Continuing Medical Education, AMA and the Academy's Commission on Continuing Medical Education.
For the individual physician, Kahn noted, it's always wise to subject each interaction with industry to the "sunshine test."
"SUNSHINE TEST"
"You have to look at your own motives," said Kahn. If you're seduced by the thought of whatever perk is being offered by a company in exchange for a few minutes of your time, "Don't talk yourself into believing that you 'just won't listen to the pharmaceutical information being presented,'" he warned. "Look at it from your patients' perspective."
"I think it's no coincidence that www.nofreelunch.org (a Web site devoted to this issue) uses a CAGE questionnaire," said Daniel Sontheimer, M.D., of the Spartanburg (S.C.) Family Practice Residency, referring to a standard addictions screening tool. "Like the alcoholic who uses denial, I think I -- we -- have done the same. Asked why I shun reps, I won't tell you they're evil. My response is, 'They're that good.'"
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Copyright © 2002 by
American Academy of Family Physicians.