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By Jeyline Chou
Staff Writer

Sometimes, little sticky pads, pens, and magnets are not as innocuous as they seem. When given as gifts from pharmaceutical companies to physicians, they form the centerpiece for an ethical debate about conflict of interest and medical judgment.

“The majority of physicians in community practice, or even residents and medical students, have contacts with the pharmaceutical industry,” said Dr. Bernard Lo, UCSF professor of medicine and director of the UCSF Program in Medical Ethics. Lo recently served on an Institute of Medicine committee, which provided guidelines in a detailed report discouraging the practice of lavish gift-giving in industry-physician relationships.

It is a relatively common practice for drug companies to foot the bill for lunches at medical conferences or hand out nifty freebies to med students and physicians at continuing medical education events. Then there are the trickier, more involved relationships where a doctor is paid to be a consultant or a speech giver with the job of touting the drug company’s products.

“Even small gifts, the pens and post-its, may have an influence on physician prescribing behavior,” Lo said. Increasing attention has been given to the industry-physician relationship in recent years, with several states considering legislation that would require publicizing such relationships.

The report was very careful, however, to distinguish risky industry relationships with those that have clear benefits to the advancement of scientific research. Academia-industry collaborations have frequently been fruitful in the processes of drug discovery and translational research to make the newest therapies available to patients.

The recommendations were based on the cost-benefit to patient care. If there is no evidence that the industry relationship improved patient care or scientific research, it is not justifiable. In other words, although a brightly-colored, logo-bearing paper weight may not appear to do much harm, it doesn’t do any obvious good either for the physician’s primary responsibilities.

In Lo’s words, this was the committee’s million dollar question: “Is there a benefit to the advancement of science or the improvement of clinical practice that’s large enough to justify whatever risk there might be to undue influence?”

And a risk there is, indeed.

A review published in 2000 in the Journal of the American Medical Association found that 29 studies had come to the same conclusions about these relationships. Gifts from drug companies could impact a physician’s knowledge, making him less likely to identify false claims about a medication. They tend to increase a doctor’s positive attitude toward the drug, the company, and the sales representative, resulting frequently in rapid prescription of the new drug. The studies also found that gifts could influence a doctor to increase prescriptions of a newer, more expensive drug even if there were no proven advantages to a generic version.

“You really need to think about not just what goes on in terms of research grants and contracts but also clinical care and also medical education,” Lo explained. “Institutions need to look across the board at all the things they do.”

The report from the IoM encourages full disclosure of financial relationships by physicians to medical schools and hospitals.

“Until medical institutions like UCSF know the relationships that are going on, they’re not in the position to decide what to do about those relationships,” Lo said. “Unless you really know what the activity is and the amount of money, it’s hard to judge.”

The report also called for a stop to the practice of “ghostwriting,” where a drug company or a communications company representing them writes a scientific article and then contacts a member of the university faculty, offering them authorship.

“That’s not appropriate,” Lo said. “Doctors should think independently and do their own work. We teach our students not to take credit for things they didn’t do.”

Currently, some academic physicians – often eminent ones, Lo added – also act as speakers on behalf of a drug company, delivering a pre-approved speech with ready-made slides. And then they receive a hefty honorarium.

“They give you the slides, they give you the texts of the speech, they send you to training to help you improve your delivery, and they also make sure you stay on message,” Lo said.

“We think it’s especially a problem if university professors and faculty are engaged in that because it doesn’t make sense to try and tell students and residents that people need to be critical, think independently, exercise critical judgment and then turn around in another venue and give a speech by someone else,” he continued.

Several other members of the UCSF community also served on the committee, including Dr. Lisa Bero, a professor of clinical pharmacy, and Dr. Deborah Grady, a professor of medicine.
Medical student groups, Lo said, have also played a large role in placing the spotlight on this issue and raising difficult questions about deeply engrained traditions.

“There was lots of UC input on this important report,” Lo said. “It’s good that UC is in the middle of this discussion. A number of UC faculty have done research on conflicts of interest that the committee looked at and used as raw empirical data.”

The report has been published and publicized in such venues as the New York Times and the Wall Street Journal Health Blog. The challenge now, will be to see if and when the recommendations are enforced.