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Medical Ethics

Fees, gifts, and steak dinners from drug companies to doctors; conflicts of interest, but doctors still don't get it!

by David Sirkin

21 September 2008; updated 14 March 2009

In the May 2008 issue of American Psychiatry News, one of the free newspapers and magazines, paid for by the drug companies, that crowd my mailbox, and also those of every other psychiatrist, a Johns Hopkins psychiatrist, Glenn Treisman, decries the mainstream media and lay press for their unfair complaints against physicians receiving payments and gifts from pharmaceutical companies (Conflicts of interest). His comments seem outrageous and illustrate how appallingly out of touch we physicians are as a group with what the rest of society recognizes as inappropriate conflicts of interest.

Other professions seem to have a much clearer understanding of conflicts of interest. I recall that when Salt Lake City was preparing for the Winter Olympics, a journalist covering the preparations accepted from the organizers a ride down the bobsled course. The journalist was subsequently censured by his own employer and also chastised publicly in the national media. The members of his profession seemed to have no trouble recognizing that accepting the ride had the potential to compromise his objectivity.

Treisman states that we should not consider our whole judicial system to be crippled just because a judge here and there accepts a bribe. He implies that it is very wrong for a judge to accept a bribe, yet the rest of his piece seems to imply that there is nothing wrong with physicians accepting gifts and dinners from drug companies. He recites a ridiculously pointless litany of everyday “conflicts” experienced by the noble, selfless physician trying to do the best for his patients. Is he pretending not to understand what the term, “conflict of interest,” means in law and professional ethics? He seems not to recognize that there is something qualitatively different between on the one hand a psychiatrist having to balance the need to stay on schedule and the desire to spend more time with a patient and, on the other hand, a psychiatrist accepting a steak dinner from a maker of a psychiatric medication. But the average lay person understands immediately that one is an unavoidable situation not of the physician's choosing, while the other is an unnecessary acceptance of a gift that has the potential, or at least appears to have the potential, of compromising the physician's objectivity.

Dr. Treisman is not fooling anyone, except perhaps himself and the psychiatrist readers of the “free” newspaper who want to be fooled so they can feel ok about being wined and dined by the drug companies once or twice or several times a month. Indeed some of the things he writes in his piece suggest more than a little bit of self-deception. Startlingly, he gives as an example of physicians' generous and selfless behavior the efforts they make to add good medicines to the formularies of their institutions, or their patients' health plans. He does not mention that probably in the vast majority of cases such an effort is on behalf of some new expensive medicine that the physician is eager to start prescribing after being brainwashed over dinner into believing that it is better than the older medications, or that the physician may be making such efforts partly, consciously or unconsciously, to do something nice in return for being treated to some nice evenings out by a nice drug company representative. (Doctors know that the drug companies have access to their prescribing histories, and that the companies can thereby monitor the effectiveness of their field representatives. An outrageous story I heard was that a couple of doctors, after having a disagreement with a drug rep about the details of a planned dinner, decided to avoid prescribing that company's drug for several months. Talk about entitlement!)

Treisman, self-deceptively or ingenuously, offers as the typical conflict possibly confronted by psychiatrists when accepting gifts from drug companies: being pushed to prescribe one or another of a group of similar medicines, such as Prozac or Zoloft, which are both serotonin antidepressants. This example is now past history, as these medicines are now available as generics and so there are no dinners for them any more. Why does he not talk about what is going on now in the case of psychiatric medications, which is the promotion of the various second generation antipsychotics for just about every form of mental illness?

Then, a real jaw-dropper that should stretch the credulity of any reader to the breaking point: after acknowledging that physicians do tend to prescribe more of the drugs from the companies of the drug reps with whom they have the most contact, Treisman offers as an hypothesis to explain this that physicians are choosing to spend time with the reps from the manufacturers of the drugs they have independently chosen as their favorites. This hypothesis is counter to the experience of every psychiatrist I know. The ones who go to the drug dinners invariably say they do not discriminate, in order to be open-minded, when accepting the meals. However, even if Treisman's far-fetched hypothesis is correct, it is irrelevant and in no way justifies the acceptance of meals or any other gifts from drug companies. There are two major points about physicians accepting drug company gifts that Treisman neglects completely:

  1. Conflicts of interest must be avoided whether they actually result in biased/uneven prescribing or only create the appearance that such a bias might result. This principle is basic to ethical practice in any profession.

  2. There is an indisputable result of pharmaceutical company marketing. It is not the higher rate of use of one of the new drugs over another, but the increased use of all the newer drugs, and less of the older ones (I was first made aware of this effect by a volunteer speaker connected with the organization, No Free Lunch)—having possible medical consequences for patients (newer medications in general are less safe because they have a greater chance of turning out to have as yet unknown side effects—Lasser et al. 2002) and definite higher costs for the payers.

Instead of complaining about the unfair media attacks on us, Tresisman should be telling us to stop doing what the majority of lay people can recognize as unethical. Where are our professional organizations? The AMA, the APA (American Psychiatric Association) and others should make it part of the ethical standards for physicians: it is wrong to accept gifts, including meals, from companies whose products you may use or prescribe in treating patients. It is wrong. Period.

Treisman, as residency director at Hopkins, should be teaching professional ethics to the next generation, not encouraging a view of ourselves as a kind of noble fraternity of benevolent, selfless priests who are above such worldly issues as conflict of interest with which the members of the more lowly professions have to concern themselves.

Glenn Treisman clearly is working on behalf of the drug companies. He embodies the academic-industrial complex that is pervasive in US medical schools; it has a corrupting effect that threatens the integrity and honesty as well as the independence and intellectual freedom of their faculty members. In his opinion piece in the August 2008 issue of American Psychiatry News, Treisman rails against “evidence-based treatment algorithms” that are being provided to psychiatrists and other physicians as practice guidelines. He makes no mention of who is providing the algorithms to the doctors or why, except to say that they are “supposedly intended to remove errors made by practicing doctors.” I am certain that employers and payers of physicians are at least partly, if not primarily, motivated by a desire to contain costs in distributing these guidelines. The guidelines serve as a counterbalance to the messages that Treisman and other lackeys in the drug companies' employ would have us hear, which guide us primarily to try the newest and most expensive medicines first, last, and in combinations for every conceivable condition. Evidence-based guidelines are not more likely to stifle critical thinking, as Treisman complains, than are the attempts by the drug companies to brainwash us through through their reps and speakers and writers, such as Treisman, but they may help us reduce the incredibly expensive and possibly harmful overuse of the newest medications. Assuming that Treisman is paid for his work as Medical Editor of American Psychiatry News, he should have to choose between that work and his work as a professor and practicing psychiatrist. This is demanded by the ethical guidelines I list below (see item 4).

[Note that certain principles of medical ethics are in fact encouraged by the drug companies and their surrogates in academia. First and foremost among these is the principle that cost should not be taken into consideration when choosing a treatment for a patient. While this principle seems to be consistent with the fundamental principle that a physician's primary loyalty is to his patient, when taken to an extreme, its implementation may result in a large financial cost for the payer (or payers, possibly including the patient herself) for little or no health benefit. A physician today is likely to prescribe a new, expensive medication because (perhaps after being brainwashed by drug company propaganda) she may perceive it to have a slight chance of being slightly better than an older medication that costs a hundredth as much. This is an example of applying this principle ad absurdum, but it would be encouraged by many professors, who teach that cost-blindness should be adhered to strictly, even to the point of absurdity, while more inconvenient ethical principles can be discarded almost completely.]

What is needed: The following are a few actions that government and professional organizations should take to improve objectivity in clinical studies that assess treatments and to reduce conflicts of interests in physicians who study and prescribe medications. These preferably should be codified as federal laws or regulations. At the very least they should be included among the official ethical principles of the main medical professional organizations:

  1. It should be illegal for physicians to accept any gifts or meals from drug companies.

  2. More government-funded studies on the relative merits of different medications. Recent studies have revealed that thiazide diuretics are more likely to prolong life than newer medicines for hypertension, that lithium is more likely to prevent suicide than newer medicines for bipolar disorder, and that perphenazine compares favorably, considering efficacy and side effect profile, with newer medicines for schizophrenia. Governments should fund studies more frequently and earlier than they do now. We have had to rely for too long on information from manufacturer-funded, manufacturer-coordinated, trials after a new drug comes on the market. It would be much better if clinical trials were controlled completely by government agencies after collecting fees from the manufacturer.

  3. Free samples should be illegal. They are the Trojan horses of the drug companies' arsenals; they appear to be gifts, but are actually hooks for expensive prescriptions that ultimately financially defeat the patient and other payers. A study performed on resident physicians showed that those with access to free sample medications were more likely to make irrational prescribing decisions.

  4. While accepting gifts, including meals, from a drug company represents a conflict of interest, working for a drug company and holding drug company stocks represent stronger conflicts. Doctors working for drug companies (including part-timers who accept speaking fees from the companies to speak at dinners or continuing medical education venues), or for companies whose principle funding is from drug companies (such as McMahon Publishing, which publishes American Psychiatry News and several other medical magazines) should not be treating patients or teaching physicians in training at the same time.

  5. Practicing physicians should not be allowed to hold stock in pharmaceutical companies or other companies that make equipment or supplies used by physicians.

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The Medical Profession's Culture of Corruption, Part 1 --This short piece on Jay Cohen's MedicationSense website summarizes the 2006 JAMA article (Health industry practices that create conflicts of interest: a policy proposal for academic medical centers) by Brennan et al. It explains nicely how drug company tactics work, and the extent of their influence on physicians, in particular on those in academia (like Treisman!) who wield the most influence.

Medical Ethics

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