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Editorial

Physicians and the Pharmaceutical Industry

David S. Goldbloom, MD, FRCPC
Interim Editor-in-Chief, CPA Bulletin, Toronto, Ontario

As a self- righteous medical student in 1981, I wrote an editorial for the McGill Medical Journal on the role of drug companies in medical education (1). This obscure and justifiably overlooked essay suggested that, to protect physicians from conflict of interest while acknowledging industry’s stated commitment to education, there should be no gifts. Rather, educational material produced or sponsored by industry should be sold to physicians at cost. I argued that paying for material enhances physicians’ critical appraisal of it and avoids the costs’ being added to the retail price of drugs for patients—at least theoretically. In 2002, the American Medical Students Association took a far more absolutist stance, seeking a complete ban of industry involvement with education (2).

Recent years have seen a proliferation of guidelines on physician interaction with the pharmaceutical industry, promulgated both by medical organizations (3–5) and by industry itself (6,7). More similar than different, their simultaneous emergence reflects both growing professional uncertainty about what is the right thing to do and increasing public awareness of this potential conflict of interest.

The realities that underpin this complex relationship—that physicians often need to prescribe medications to achieve desired therapeutic goals for their patients; that industry often generates research-based medications to improve treatment; that industry views physicians as the rate-limiting step in the prescription of their medications; and that industry, primus inter pares, must profit to survive—establish the potential for both confluence and conflict of interest. At the same time, research- focused and productive university departments of psychiatry have enjoyed high-level collaborations with industry in both basic and clinical science—collaborations that have been investigator-initiated and governed by stringent research ethics requirements.

The industry presence at annual meetings of medical specialty societies has become more prominent, not so much in the exhibit halls as in the sponsorship of satellite symposia that often feature distinguished expert speakers. With regard to such symposia and the awarding of Maintenance of Certification credits, the Canadian Psychiatric Association has an elaborate review process, including not only prior anonymous critical review of all slides and related material but also auditing of the presentations themselves for evidence of bias. However, in exercising this level of vigilance, the CPA is in the minority of specialty societies.

As individuals, each of us needs to reflect on our own interactions with industry, asking whether they are consistent with the Canadian Medical Association guidelines that govern us, how they relate to our own understanding of the meaning of gifts in the context of a relationship, and what our patients and our students would think of these interactions.

Several recent articles may help us to navigate this relationship; one explores the nature of gifts from a social science perspective (8) and reminds us psychiatrists that the unconscious exists! Another chronicles the extent of the interaction from a journalistic perspective (9). A former resident in psychiatry at McGill provides a critical analysis of the gift relationship between physicians and industry (10).

The irony is that the gifts we can most easily afford to buy for ourselves—pens, notepads, lunches, etc.—are the only ones allowed by both medical and industry guidelines. An ethical palatability gradient has been suggested, based on the retail value of the gift. In “Throw Them Out?”—a recent editorial appearing in Psychiatric News— Paul Appelbaum, the immediate past president of the American Psychiatric Association, wrote about the distribution of such low-value gifts: “I don’t blame the companies for trying to foist this stuff on us; I blame us for taking it” (11).

The recent evidence from a national survey of Canadian psychiatry residency programs is that our teaching and awareness of this subject are variable and inadequate (12). We need to promote discussion and debate, both among ourselves and with industry, about how to manage the overlapping and conflicting interests of this complex relationship. Ostrich approaches are unlikely to generate clear-eyed solutions.

References

1. Goldbloom D. Drug companies and medical education: a modest proposal. McGill Medical Journal 1981;46:24.

2. American Medical Student Association. Policy on pharmaceutical promotions 2002. www.amsa.org/prof/policy.cfm.

3. Canadian Medical Association. Physicians and the pharmaceutical industry. CMA Policy (Update 2001). www.cma.ca/staticContent/HTML/N0/l2/where_we_stand/physicians_ and_the_pharmaceutical_industry.pdf.

4. Coyle SL, for the Ethics and Human Rights Committee, American College of Physicians American Society of Internal Medicine. Physician–industry relations. Part 1: individual physicians. Ann Intern Med 2002;136:396–402. www.annals.org/issues/v136n5/pdf/ 200203050-00014.pdf.

5. Coyle SL, for the Ethics and Human Rights Committee, American College of Physicians American Society of Internal Medicine. Physician-industry relations. Part 2: Organizational issues. Ann Intern Med 2002;136:403–6. www.annals. org/issues/v136n5/pdf/200203050-00015.pdf.

6. Canada’s research-based pharmaceutical companies (Rx and D). Code of marketing practices. 2003. www.Canadapharma.org/Industry_Publications/Code/Code_e.pdf.

7. The Pharmaceutical and Research Manufacturers of America. PhRMA code on interactions with health professionals, 2002. www.phrma.org/publications/policy//2002-04-19.391.pdf.

8. Dana J, Loewenstein G. A social science perspective on gifts to physicians from industry. JAMA 2003;290:252–5. jama.ama-assn.org/cgi/content/full/290/2/252.

9. Moynihan R. Who pays for the pizza? Redefining the relationships between doctors and drug companies. BMJ 2003;326:1189–96. bmj.com/cgi/reprint/326/7400/1189.pdf; bmj.com/cgi/reprint/326/7400/1193.pdf.

10. Wazana A. Physicians and the pharmaceutical industry. Is a gift ever just a gift? JAMA 2000;283: 373–80. jama.ama-assn.org/cgi/reprint/283/3/373.pdf.

11. Appelbaum P. Throw them out? Psychiatric News July 5, 2002:3. pn.psychiatryonline.org/cgi/content/full/37/13/3

12. Chakrabarti A, Fleisher WP, Staley D, Calhoun L. Interactions of staff and residents with pharmaceutical industry: a survey of psychiatric training program policies. Annals of the Royal College of Physicians and Surgeons of Canada 2002;35 (Suppl):541–6.