It has been two months since my last Drug Lunch.That statement may require some explaining. By "Drug" I mean Pharmaceutical Company, and by "Lunch" I mean any gift (edible or otherwise).
What is a Drug Lunch?
Pharmaceutical sales reps regularly visit doctors and they generally bring food. Over lunch they chat about the products of their company. They offer sample boxes of medications (to give to patients of course) and "trinkets" such as measuring tapes, boxes of tongue depressors and patient education booklets, all blazoned with the company's logo and feature products.
Pharmaceutical companies also run "educational" events such as dinner meetings with a local specialist as the speaker, and more elaborate weekend conferences with international guest speakers covering a range of medical topics. For example a company promoting a new antidepressant medication may organise for a local psychiatrist to give a talk on the treatment of depression to up-skill GPs.
This is pretty tame compared to the all expenses paid weekends away to golf resorts for doctors and their partners that used to be on offer. In Australia the marketing strategies of pharmaceutical companies have come under scrutiny and regulation since the 1960's and now any perks offered have to be directly related to educational content. Pharmaceutical companies also have to be able to justify how much they spend on meals - so the fine wining and dining has mostly been replaced by more modest meals.
In practice, for me, that meant free sandwiches or sushi for lunch on a pretty regular basis, with cake for dessert on a good day, and a bunch of stuff in my office with pharmaceutical company logos and products on it.
This is pretty tame compared to the all expenses paid weekends away to golf resorts for doctors and their partners that used to be on offer. In Australia the marketing strategies of pharmaceutical companies have come under scrutiny and regulation since the 1960's and now any perks offered have to be directly related to educational content. Pharmaceutical companies also have to be able to justify how much they spend on meals - so the fine wining and dining has mostly been replaced by more modest meals.
In practice, for me, that meant free sandwiches or sushi for lunch on a pretty regular basis, with cake for dessert on a good day, and a bunch of stuff in my office with pharmaceutical company logos and products on it.
For more info on the current regulations/guidelines click here: Medicines Australia - Code of Conduct
The Challenge:
I had a little about the potential conflict of interest but had been procrastinating on doing anything about it. The kick that I needed to finally do some thing about this came from a facebook discussion of all places! Someone posted a response on a friend's status update, their comment included the following:
"It is time to remove the title of doctor from people because the Medical profession is all about money. Research is not for cures, only repetitive medications for ongoing profit. Disband the AMA then we can fund health appropriately. "Silly me waded into the discussion - defending doctors and our prescribing patterns. Here is a snippet:
"I also won't dispute with you that big pharma is about profit, I would go further and say that big pharma is corrupt to it's core, but pardon me if I still chose to judiciously prescribe their products in the best interests of my patients."The person responded politely and then posed the following question:
"Do any Doctor's receive any benefits from prescribing particular brands/products including business trips etc.? "The simplistic answer is no. Doctors' do not receive incentives for prescribing particular products. But the question got me thinking. And reading. And the more I thought and the more I read the more it became obvious that my interactions with pharmaceutical companies were probably compromising my professional integrity and ability to practice unbiased medicine.
It is insidious, not innocuous:
Nearly all doctors I know interact with pharmaceutical companies sometimes. And most of the doctors that I have talked to feel that they do not allow pharmaceutical company information to affect their prescribing habits. This is what I used to think too. But the research disagrees. You can find links to articles dealing with this topic on the No Free Lunch site. Here is one example:
"These alterations in prescribing patterns occurred even though the majority of physicians who attended the symposia believed that such enticements would not alter their prescribing patterns." - Wateska L, Orlowski JP "The effects of pharmaceutical firm enticements on physician prescribing patterns. There's no such thing as a free lunch." Published in Chest, 1992 Jul;102 (1):270-3. Abstract available here.It must seem pretty arrogant (of just stupid) of me to have thought that I was not affected. But to be honest, most of the time I just did not think about the implications of these interactions. Which I am sure is just how the pharmaceutical companies want it.
The bottom line is that pharmaceutical companies wouldn't bother if it didn't work!
Once I started to actually think about the issue the ethical decision became crystal clear.
My pledge:
I will accept no gift, however large or small, edible or inedible, from a pharmaceutical company. I will accept no information, education or training from a pharmaceutical company, no matter how reliable or prestigious the invited speakers may seem.
The Response:
I wondered how my decision would be received at work. I suspected that my colleagues would think I was strange, or being over the top. (Hmm, maybe they already think that!) But actually my decision has been received very positively.
More Info:
If you would like more information on this issue you could check out the following organizations:
No Free Lunch encourages doctors to take the pledge reproduced below, and to let their patients know about it. The organization maintains a list of health professionals in the US who have signed on.
"I, __________________, am committed to practicing medicine in the best interest of my patients and on the basis of the best available evidence, rather than on the basis of advertising or promotion.
I therefore pledge to accept no money, gifts, or hospitality from the pharmaceutical industry; to seek unbiased sources of information and not rely on information disseminated by drug companies; and to avoid conflicts of interest in my practice, teaching, and/or research."
- copied from No Free Lunch.
I asked a friend if there was a similar organisation in Australia and he pointed me in the direction of Healthy Skepticism. (He is doing some research into this area and must have wondered why it took me so long to reach the decision to boycott drug lunches.)
Healthy Skepticism was started in 1983 in Adelaide Australia, but has members from around the world. From the web site:
"Healthy Skepticism is an independent, international, not for profit organisation for people with an interest in improving health. We aim to improve health by reducing harm from misleading drug promotion.
- from The Identity Statement of Healthy Skepticism
Healthy Skepticism is in the process of merging with No Free Lunch. Strength in numbers!
The DRS was formed in 1973 in Australia, specifically to support the introduction of Medicare, which was opposed by the Australian Medical Association at the time. The DRS has much broader interests than just the issue of pharmaceutical marketing but I think it is relevant to this discussion.
From the DRS website:
From the DRS website:
The DRS functions as a medico-political think tank, a lobby group and a public resource centre.
It is not affiliated to any political party, receives no corporate funding, and relies financially on subscriptions and donations.
The DRS will speak out against any political party, organisation or individual that threatens public health care.
- copied from the About Us section of the DRS website.
So, where am I at now?
- I have not attended a "Drug Lunch" in the last 2 months
- I have become a member of Healthy Skepticism.
- I plan to attend the August meeting of the Perth branch of the DRS.
- I have not finished removing all the Pharmaceutical paraphernalia from my consulting room but I am getting there.
- I am looking at educational events that are not sponsored by any pharmaceutical companies. This means I will have to pay to attend them but at least my conscience, and hopefully my clinical judgement, will be clearer.
