In the February 2006 issue of the GME E-Letter, we wrote, "Writing in JAMA, some of medicine's most distinguished leaders recently called on academic medical centers to set the example for our profession by eliminating current conflicts of interest characterizing many relationships between physicians and the pharmaceutical and medical device industry.
The higher standards they advocate include refusing all industry gifts to physicians: from the ubiquitous pizzas, pens, pads and pills to the more insidious practices of industry-funded travel, speaking gigs and ghostwritten manuscripts for faculty.
"In another report, several academic leaders from Yale report on their institution's 'Guidelines for Interactions between Clinical Faculty and the Pharmaceutical Industry' in the February Academic Medicine. The AMA also has guidelines regarding gifts to physicians, and the Accreditation Council for Continuing Medical Education (ACCME) recently adopted more stringent guidelines.
"None of the current guidelines are as rigorous as those proposed in JAMA. Is it time for physicians to draw a brighter ethical line and totally refuse any gifts from industry?"
Below are the responses we received, with identifying information removed.
It is clear that the leaders in the academic medical centers do not feel that physicians can handle the provision of funds from any commercial source without bias creeping in.
On the other hand, physicians and administrators in these same centers feel that they should be the recipients of the funding, suggesting that they are quite able to handle money without any bias. The authors of the JAMA article went on to imply that the academic medical centers would be more qualified to handle, presumably without bias creeping in, monies for educational pursuits. This holier-than-thou assumption reveals an arrogance that is quite bothersome. This is particularly of concern when there was no mention of any medical specialty organizations or our AMA as being qualified to be the stewards of such funding. Bias seems to be only in the eye of the beholder, which should come as no surprise.
I feel that the ACCME guidelines are entirely adequate to control significant adverse influence leading to bias in the students (of any age) participating in CME. In addition, without some support of CME from industry, CME outside the academic medical centers, and to some degree within them, will dry up. I don’t think that the Internet system of medical education, or any other new venues, will be able to pick up the slack.
Our medical school class at Case Western Reserve School of Medicine (1971) was the first group to refuse the infamous "black bags" distributed by Eli Lilly. Most of us haven't forgotten the lessons.
I'm glad other programs are catching up. I have refused everything. I hope the lessons are learned.
I fear that we've gone from frighteningly freewheeling to prissily puritanical. There is already a backlash brewing, and a middle ground needs to be established.
This is indeed a thorny issue! I for one have received many minor gifts from drug reps during my 30-year career as a physician. They have mostly been in the form of lectures with dinner at local restaurants. Some have been full-day CME activities, again with a meal or two included. I once, about 20 years ago, was flown to the Bahamas for a 2-day lecture on captopril.
While some of these activities have increased my fund of medical knowledge and thereby hopefully improved the care I render to my patients, I sincerely feel that in no case have I altered my prescribing practices based on a drug rep's presentation. In fact, as my personal CME activities are far broader than just pharmaceutical industry-sponsored events, I always prescribe the least expensive and/or HMO allowed product when evidence-based literature demonstrates a lack of differing efficacy among similar products. I don't care who bought me a steak 2 months ago. I would bet that the vast majority of my colleagues comport themselves similarly.
The situation with residents is less clear as they are far less experienced and more impressionable. In our family medicine program we allow pharmaceutical company-sponsored luncheon presentations if they are given by a legitimate lecturer on a clinical topic and not a specific medication. The lecturer must disclose his interest in any product mentioned. These lectures are attended by at least one full-time faculty member who will comment to the group about his or her own experiences. We have found these events to have legitimate educational value and are not aware of any negative events. Our indigent patients also routinely benefit from the free samples provided.
I would be particularly interested in any evidence-based study demonstrating that a significant number of physicians have harmed patients through ill-advised alterations of their prescribing practices after educational meetings sponsored by the pharmaceutical industry. It should be obvious to all that acceptance of cash gifts or equivalents for prescribing a specific medication in unethical.
In summary, I don't know if we need to expend a great deal of energy policing a situation if there is no demonstrated harm but only a perception. I personally feel the profession is policed enough. At the same time, I could easily be persuaded to change my position if evidence shows patient harm.
I have very close and ethical relations with industry. I don't need the AMA, my institution, or ACCME telling me how to act. These proposals are so stupid as to make me wonder if all the people wanting to restrict everything have ever been in practice and out in the real world. Mind your own business and I shall do the same.
Quite frankly, we have become holier than thou. This is a form of censorship which is not only ineffective, but, in my opinion, intolerable in a free society. Most physicians are ethical. Attempts to develop rigid guidelines to catch those who are not are neither effective nor desirable.
The FDA has done this, perhaps inadvertently, with restrictions on educational programs that effectively require the speaker to act as a salesman for the company. I and many of my colleagues are no longer willing to give any educational talks that are sponsored by pharmaceutical firms--not because the pharmaceutical firm is inherently evil or tries to get us to say things that we don't believe, but because the "FDA-approved slides and material" amount to sales pitches. Not only is this censorship, but it promotes the use of physicians who are willing to act as a salespeople.
The AMA has more important issues that require attention. Such as 46 million uninsured.
Although I support the limitations and initiatives, I hope we do not lose sight of the role of legitimate CME activities for both faculty and residents. Many community hospital and some university programs are financed or facilitated by the support given to guest speakers in conferences or as visiting professors. Residents travel to present work at national conferences or attend meetings/congresses and special educational programs, which is often possible only with educational grants. Even our major meetings have industry support, without which they could not take place.
Advertising and promotion must be identified as such, but the support of legitimate educational endeavors needs to continue.
Content provided by: Graduate Medical Education