Monday, April 20, 2009

Will bans on drug industry sponsorship have unintended consequences for patients?

Today and for the rest of the week, I will be blogging from the Philadelphia Convention Center, where ACP will be holding its annual scientific meeting. Convention center workers are now doing all of the prep work for a successful medical convention, including setting up the exhibit hall.

I think it is timely then to think about the relationships between pharmaceutical companies, individual physicians, and physician membership organizations like ACP. There are some who argue that the links between industry and physicians should be severed - no funding for CME, no exhibit halls, no gifts, no free drug samples, no drug company symposia, nada. Others argue for a balanced approach, one that recognizes that industry support for CME and other professional activities can support a public good (such as making it possible for physicians to have access to top-notch CME at relatively low cost to them) but with controls over the inherent conflicts of interest that may be created.

The current issue of Health Affairs offers two interesting perspectives. Jonathan Han, MD, a family physician, writes about the unintended harm to indigent patients that resulted when his academic medical center prohibited distribution of free drug samples. His institution ended up backing off from an outright ban, cobbling together what Dr. Han calls a "morally suspect compromise" to ensure that patients get the medications they need. "It's ... untenable for doctors and other health care providers to be put in a position where you're damned if you do - and patients die if you don't," he laments.

Melinda Morton, a medical student, eloquently writes about her struggle in keeping her resolve not to accept free lunches and drug samples at her academic medical center, given what she calls the "pervasive" presence of freebies from drug companies.

For its part, the American College of Physicians continually re-examines its policies relating to physician-industry relations, and makes sure that every activity at its scientific meeting is fully in accord with such policies. ACP's current policy "strongly discourages" acceptance by individual physicians of industry gifts and calls on physicians "to gauge regularly whether any gift relationship is ethically appropriate and evaluate any potential for influence on clinical judgment. In making such evaluations, it is recommended that physicians consider such questions as 1) What would the public or my patients think of this arrangement? 2) What is the purpose of the industry offer? 3) What would my colleagues think about this arrangement? 4) What would I think if my own physician accepted this offer? In all instances, it is the individual responsibility of each physician to assess any potential relationship with industry to assure that it enhances patient care and medical knowledge and does not compromise clinical judgment."

Another ACP policy paper discusses the organizational relationships between physician organizations and industry. This paper says that acceptance of industry support from CME and other medical society activities is acceptable within strict guidelines to ensure the objectivity and transparency of any activities funded.

It is one thing to take the broad brush stance that acceptance of support from industry should be verboten, but bans can have unintended adverse consequences for patients, as Dr. Han found when his indigent patients could no longer get the free drug samples they depended upon. A premier scientific meeting like ACP's clearly services a public good (helping doctors keep up-to-date in their clinical knowledge and skills), and drug industry support, within strict guidelines, helps keep the meeting affordable. If industry support for CME was to be prohibited, I wonder where the money would come from to allow internists to continue to have access to CME at a price they can afford.

Today's questions: Should physicians be prohibited from distributing free drug samples to patients? What about drug industry support for CME programs like ACP's scientific meeting?


Jay Larson MD said...

Giving free drug samples to those patients who can not afford them is reasonable, especially since many pharma companies have patient assistance programs. Giving drug samples to patients with insurance when a generic is available will only result in more hastle as there will be a request by the insurance company to change to a generic. As far as CME goes, it is an important avenue to learn about current treatments and could be supported by pharma companies...provided that the speakers are not pushing the pharma drug only.

Steve Lucas said...

My wife is a government employee, administrator, and often works with vendors at conferences. Her employer has a zero level of vendor supplied items, pens, pads etc. What she is allowed to receive is food supplied as part of the conference, often a vendor will underwrite breakfast. Items supplied to the conference with vendor logos, bags given out at registration.

She often shares the speaking duties with vendors and is able to receive CLE for these activities. Vendors are aware they cannot "sell" during these presentation.

These rules have created some silly results. No coffee from the vendors coffee pot in the exhibit hall. Dinner bills have to be split, and she needs a receipt to prove a vendor did not buy a meal.

All in all the older vendors accept the restrictions as a necessary evil, many of them come from government backgrounds. The real problem is the young vendors who have grown up in an atmosphere where the goal is to make the sale. Some companies are known for looking for ways to push items on someone in hopes of an advantage. These companies are pushed to the edges of the exhibit hall and given little if any opportunity to interact with the larger group.

One interesting outgrowth of these restrictions is that many government offices are doing their own conferences. Smaller in scope they exclude vendors and are paid for by the government agencies involved. This eliminates conflict issues. Allows a focus on a small set of issues and closer scrutiny of speakers.

Steve Lucas