Legal: My pharm rep only gave me a pen!

August 1, 2008

Dr. Gift has practiced dermatology for 15 years and has enjoyed a long-term relationship with many of his pharmaceutical representatives. For years, he has enjoyed lavish dinners and sporting events; his staff has enjoyed wonderful lunches and dinners. At all such events, both he and his staff learned something.

Key Points

Dr. Gift has practiced dermatology for 15 years and has enjoyed a long-term relationship with many of his pharmaceutical representatives. For years, he has enjoyed lavish dinners and sporting events; his staff has enjoyed wonderful lunches and dinners. At all such events, both he and his staff learned something.

In fact, Dr. Gift has considered his relationship with such industry people as part of both his medical education and that of his staff.

Recently, the wonderful gifts have ended. Dr. Gift is perplexed; the pharmaceutical representatives claim that the issue is not one of money. They cannot do better. Why is this so?

The issue of whether drug companies should be allowed to continue to participate in medical education, at any level, is an important one.

All agree that medical education is important. However, as has been increasingly recognized, when the profit motive seeps into otherwise-objective continuing medical education (CME), ethical problems may arise for the drug company and physician alike.

In fact, CME may take place not only in university classrooms, but also in hospital classrooms, or even at off-site locales, such as country clubs or a variety of other social venues. These seminars are usually accompanied by the customary refreshments.

For example, lunchtime seminars usually are accompanied by lunch. Morning, afternoon and evening seminars may come along with coffee, doughnuts or cookies. Such sessions clearly cost money and, in reality, education providers do rely heavily on the drug industry for support. In 2003, for example, pharmaceutical company sponsorship accounted for 90 percent of the $1 billion spent annually on CME.

The degree of pharmaceutical company influence on physicians has become such an issue that the topic has been a subject of controversy, and ever-increasing scrutiny, for a decade.

What has become clear is that the luxurious cruises and champagne-and-caviar dinners are a thing of the past.

Guidelines for giving

The PhRMA Code, as well the AMA's ethical guidelines for physicians, have attempted to provide guidelines for "giving to" and "influence of" physicians.

Generally, drug companies may not spend more than $100 per attendee for gifts, and attendees may be provided with modest meals. Gifts must be nominal and not be given in a manner that suggests they be remuneration for sponsor-favorable prescribing behavior.

Additionally, these gifts must somehow relate to the practice of medicine. Provided examples include office supplies and coffee mugs. Under PhRMA guidelines, a handheld magnifier to examine nevi would be perfectly acceptable; golf bags that bear the name of the drug company sponsor would fail the "relates to the practice of medicine" test.

It should also be noted that many pharmaceutical companies voluntarily put in place their own additional guidelines.

Doctors' viewpoint

Many physicians often have responded to this "nominal giving" concept by suggesting that their prescribing behavior is not influenced by meals and gifts, even extravagant ones.

In addition, many physicians argue that given the state of affairs of the modern medical practice, physician time is valuable. Any time spent with pharmaceutical representatives is time spent away from patients.

In the era of managed care and conglomerates of hospital groups, the argument reasons, physicians must turn around more patients in a day to keep their practices profitable.

Of note, the more nominal the gifts a physician receives, the more likely he/she is to hold the view that such gifts do not influence prescribing patterns.

Behavioral tendencies

However, behavioral ethicists have suggested that the behavioral tendency to reciprocate a kind gesture - even one with an ulterior motive - can have a strong impact on the receiver's reaction. There ensues something of a sense of social duty or obligation on the part of the receiver that colors - either consciously or subconsciously- further dealings with the provider of the gesture or gift.

Social science studies have also shown that good food and the camaraderie of a shared meal can further enhance receiver tendencies toward being influenced.

A variety of groups, including the American Medical Student Association, have opposed all drug company gift-giving, contending that it conflicts with the duty of physicians to make prescribing decisions based on science rather than promotion.

Dr. Gift may not be happy with all of his new ballpoint pens, but such gifts are consistent with today's guidelines. If he wants to go to a major sporting event, he should - but it will be at his own expense.

Dr. Goldbergis the director of SkinLaser & Surgery Specialists of New York and New Jersey; director of Mohs surgery and laser research, Mount Sinai School of Medicine; and adjunct professor of law, Fordham Law School.

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