No more free lunches
This story has to do with money, medicine and influence — all topics that are relevant to medical ethics and yes, often, research ethics. The PhRMA (The Pharmaceutical Research and Manufacturers of America) Code on Interactions with Healthcare Professionals has been updated. The revisions will come into effect on January 19, 2009. As of December, approximately 40 drug companies have signed on to the voluntary Code, which indicates their intention to comply with it, revisions and all.
Here is the story in the New York Times: No Mug? Drug Makers Cut Out Goodies for Doctors
The revisions of the Code include a prohibition on the distribution of items such as pens, coffee mugs, t-shirts or mouse pads with logos or other promotional images on them. It also discontinues the practice of having drug reps take physicians and health care professionals out to meals in restaurants for educational presentations, a common practice up until now. It does allow for “modest” meals to be provided in-hospital accompanying an educational presentation. Interestingly, the Code gets very specific, even stating that the (very common!) “dine-and-dash” — in which a busy resident or nurse might pop in to grab a plate of food without staying for any of the presentation — is inappropriate and should not be permitted.
Two things to note. First, this is a voluntary Code. Signing onto it, however — as a number of large drug companies like Eli Lilly, Pfizer, Merck and Bayer have all done — does imply a commitment to comply with the principles and recommendations of the Code. It also means, for the kinds of large companies that I’ve listed here, that they face a serious decrease in revenue as a result of having their products prescribed less. While many physicians deny that they are influenced by the products names on their bandage scissors, pens, calculators and sticky notes (potentially everything one might pick up or use in a given day in the medical office), it must work. After all, drug companies have been spending up to 22 billion US dollars annually on distributing logo products and taking health care professionals out to lunch, on a paid vacation or for a round of golf. If they couldn’t demonstrate that this kind of an expenditure really worked to influence prescribing habits, chances are that they would have stopped this expense long ago.
Second, this is an American Code. While drugs prescribed in the US account for a significant portions of revenue for most companies, there are other markets that may even be better than the States in which companies may now turn to with more aggressive marketing tactics (Besides, they need somewhere to distribute all those leftover pens, now prohibited in the US). Markets in which there may be even more freedom for a prescriber — without worries about HMOs and to some degree, the ability of many patients to be able to afford the drugs that are prescribed — will now appear much more attractive to drug companies. Like Canada, for example. While many Canadian medical schools are teaching strategies on how to practice ethically, including efforts to avoid coercion in prescribing practices, it remains that once medical residents are out in practice, their ethical standards will be put to the test by aggressive drug reps.
Does this story have a research ethics angle? Well, seeing as most large multi-centre drug trials are funded by drug companies, ethics review boards are responsible for ensuring that researchers are not overly influenced by large influential funders that prefer to see particular kinds of results. While this doesn’t involve checking researchers’ offices for mouse pads and coffee mugs with logos on them, it requires looking at contracts and the kinds of safeguards in place to protect participants and researchers while ensuring integrity in the research processes and outcomes. Furthermore, the Code still allows for physician “consultants” who are paid by the drug companies to play a variety of roles, from advising to providing legitimacy in the dissemination of trial results. There is certainly potential for conflict of interest if these physician “consultants” engage in related research. As the main mandate of ethics review boards is to protect participants, this involves protecting the integrity of results and the reporting of results, which means examining the kinds of relationships that physician researchers have with drug companies that provide funding support.
Here are two other interesting and related sites to read more on how prescribing practices are affected by gifts and products. The first one is a blog written by a Texan medical resident, called Drug Rep Toys, with clever commentaries on the kinds of promotional products he has received from drug reps. No Free Lunch is an organization aimed at physician and medical students to educate them on how to maintain promotion-free practices, institutions and medical schools.