A group of influential doctors and academic
leaders are calling for a ban on all pharmaceutical gifts
to doctors at academic medical centers.
The plan also calls for stricter tabs on pharmaceutical
support to continuing medical education activity and to
research, as well as a stop to free samples. The reforms
are intended to resurrect and maintain the integrity of
medicine and medical professionals, the sponsors said.
"Gifts require reciprocity. Docs say they can't
be bought but each time you get a gift, ultimately it
does affect what you prescribe," said David J. Rothman,
president of the Institute of Medicine as a Profession
at Columbia University, New York, and co-chairman of the
committee that wrote the recommendations.
"We want to make certain that it's scientific knowledge
and patients' best interest, not reciprocity, conscious
or unconscious, that underlies doctors' prescribing,"
he added.
David Magnus, co-director of the Stanford University
Center for Biomedical Ethics, said, "It's a fantastic
idea. There's huge amounts of empirical evidence that
lower gift amounts have an influence dollar-for-dollar,
disproportionately even greater than large gifts. You
probably get a lot more bang for your buck with small
gifts. If it's unethical at high dollar amounts to buy
influence and it has the same impact at lower amounts,
it seems inescapable to conclude that you can't have it
at any dollar amount."
Supporters of the reform include Dr. Jerome Kassirer,
former editor-in-chief of the
New England Journal of Medicine; Dr. Jordan
Cohen, president of the Association of American Medical
Colleges; and Dr. David Blumenthal, director of the Institute
for Health Policy at Massachusetts General Hospital.
The recommendation appears in the Jan. 25 issue of the
Journal of the American Medical
Association.
Gift-giving and other support is a significant part of
the pharmaceutical industry and much of it is focused
on physicians. About 90 percent of the $21 billion marketing
budget of the pharmaceutical industry continues to be
directed at doctors, the study stated.
And, according to an earlier study, even third-year medical
students receive, on average, one gift or attend one activity
sponsored by a drug maker each week.
Now, however, such practices are coming under increased
scrutiny.
"We know more about drug-company marketing practices,"
Rothman said. "Drug companies are more and more powerful,
more and more energetic in terms of their marketing. Now
we have the data that these gifts matter, these company
practices matter."
The working group spent two years looking at industry
marketing practices and papers detailing the effects of
marketing on physician decision-making.
The new recommendations target academic medical centers
because they "should provide leadership for medicine
in the United States," the authors stated.
In addition to a total ban on gifts, including free meals,
the group recommends:
- A ban on providing drug samples to physicians. A system
of vouchers for low-income patients or some other system
of indirect distribution could take its place.
- A ban on manufacturers' providing support, direct
or indirect, to continuing medical education activities.
A centralized fund should be established for manufacturers
to contribute funds for physician travel or consulting,
so doctors would be insulated from influence by any
one donor.
- Doctors with financial relationships with drug companies
should not participate in hospital and medical group
formulary groups or committees overseeing purchases.
- Academic medical center faculty should not serve as
members of speakers bureaus for drug or device makers,
nor should they publish articles or editorials ghostwritten
by industry employees.
- Open-ended grants and gifts should be prohibited.
Terms of consulting and research contracts should be
posted on a publicly available Web site to promote more
transparency. Disclosure of financial relationships,
the authors stated, is not sufficient to eliminate conflicts
of interest.
Rothman hopes the article will motivate others to take
up the cause.
"Our hope is that when one of the two most prestigious
medical journals publishes this, we will arm the group
that's on our page," he said. "There are folks
out there already with us. We're hoping that they will
be able to use this publication as a way of getting the
movement moving along."
The timing may well be right.
"I think this will be the norm at major tertiary
care hospitals," Magnus said. "It will take
a lot longer to penetrate private clinics and private
practices but we're very much on our way."
In response to the article, Ken Johnson, senior vice
president of the Pharmaceutical Research and Manufacturers
of America, issued a statement that said: "PhRMA
and its members share JAMA's concern that patient
care be based solely on the needs of each patient and
a physician's medical knowledge and experience. For more
than three years, PhRMA has had a voluntary code to help
make sure that member company interactions with health
care providers focus on providing useful information about
a company's medicines. The code states that entertainment,
expensive meals and gifts that are for personal use by
the physician are not appropriate.
"Only practices that do not compromise independent
judgments of health providers, such as modest working
meals, gifts of minimal value that support the medical
practice and distribution of free samples, are permitted,"
he added.
