Although physician groups, the manufacturers, and the federal government have instituted self-regulation of marketing, research in the psychology and social science of gift receipt and giving indicates that current controls will not satisfactorily protect the interests of patients. More stringent regulation is necessary, including the elimination or modification of common practices related to small gifts, pharmaceutical samples, continuing medical education, funds for physician travel, speakers bureaus, ghostwriting, and consulting and research contracts. We propose a policy under which academic medical centers would take the lead in eliminating the conflicts of interest that still characterize the relationship between physicians and the health care industry.The JAMA authors described how many physicians seem to believe two key -- but ultimately faulty -- assumptions: first, that small gifts or basic interactions don’t have significant influence on physician behavior, and second, that disclosure of financial conflicts is sufficient to satisfy the need to protect patients' interests.
THE PSYCHOLOGICAL INFLUENCE OF “GIFTS” FROM DRUG COMPANIESInterestingly, the JAMA authors reported that the rate at which physicians prescribe a particular drug increases substantially after they see sales representatives, attend company-supported symposia, or accept samples of that drug. The writers cited evidence that doctors are no more immune than the general public to the psychology of gift-giving, in which one feels obligated to “give back.”
University of Pennsylvania researcher Dana Katz, writing in 2003 on the ethics of pharmaceutical industry gift-giving, found: "When a gift or gesture of any size is bestowed, it imposes on the recipient a sense of indebtedness. The obligation to directly reciprocate, whether or not the recipient is conscious of it, tends to influence behavior..Feelings of obligation are not related to the size of the initial gift or favor."
Dr. Ashley Wazana, in her January 2000 JAMA article titled “Physicians and the Pharmaceutical Industry: Is a Gift Ever Just a Gift?,” found that meetings with drug company representatives were frequently associated with requests by doctors to add those drugs to the hospital formulary, and changes in the doctors’ prescribing practices. Doctors who went to educational sessions sponsored by drug-companies preferentially highlighted the sponsor's drugs, compared to other continuing medical education (CME) programs. And attending free educational sessions, accepting funding for travel or lodging for educational symposia were all associated with increased prescription rates of the sponsor's medication, and what Wazana refers to as “nonrational prescribing.”
DISCLOSURE: PANACEA OR PLACEBO?One way that hospitals, universities and medical journals have tried to address the issue is by instituting policies requiring doctors to disclose these sorts of gifts, payments and financial ties with drug companies, including consulting, research funds, speaker’s bureau or speaking fees, honoraria, and travel reimbursements, among others. The rationale of disclosure policies seems to be the belief that in publicizing the relationship, patients, lecture attendees, or journal readers are alerted to a potential prejudice or bias, and problems are averted.
The issue of disclosure is controversial, however. The JAMA study authors felt that there is little evidence to support the assumption that disclosure to patients is enough to resolve problems created by physicians' conflicts of interest. The authors write:
First, physicians differ in what they consider to be a conflict, which makes the disclosure of conflicts incomplete. Because declarations of conflict are usually unverified, their accuracy is uncertain. Second, recipients of information who are not experts in a particular field often find it impossible to identify a biased opinion that they read or hear about that subject. Third, disclosure may be used to ‘sanitize’ a problematic situation, suggesting that no ill effects will follow from the disclosed relationship. Rather than eliminate the conflict, it is easier to disclose it and then proceed as though it did not exist.Dr. Jerome Groopman, author of the bestselling book How Doctors Think, agrees that disclosure may be an easy out, and in reality, work against its purpose. Groopman writes: “...patients or readers may believe that disclosure frees the physician or scientist from potential bias associated with personal gain when in fact disclosure does no such thing.”
In his 2004 article, “Doctors and drug companies” in the New England Journal of Medicine, Dr. David Blumenthal explains why disclosure often doesn't work:
Physicians also tend to be confident that they themselves are invulnerable to any bias inherent in the educational content offered or supported by drug companies. A study of residents found that 61 percent believed that they were not influenced by the marketing efforts of pharmaceutical companies (although only 16 percent were equally confident about their colleagues)... Despite the confidence of physicians in their ability to resist efforts by drug companies to affect their behavior —- especially in ways that may serve company purposes rather than their own or those of their patients —- a substantial body of theoretical and empirical literature (as well as physicians' own concern about their colleagues) suggests that many physicians may be mistaken...Blumenthal also finds that physicians are subject to a powerful, unconscious "self-serving bias." He writes: “They have trouble seeing themselves as biased when the bias serves their needs or advances their own perceived interests.”