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Seeking Middle Ground

Seeking Middle GroundAs a medical educator and practicing primary care general internist at our academic medical center, I have probably attended literally hundreds of pharmaceutical company-sponsored lunches and grand rounds over the course of the last 14 years. No doubt, I have received scores of pens and pads branded with the names of dozens of different proprietary pharmaceutical products. I have probably collected hundreds of similar items while walking the exhibit halls at major national medical meetings over a dozen years.

As a result of my behavior, many current observers would say that I have an inherent conflict of interest vis-a-vis the pharmaceutical industry and my work as a clinician. Evidence does support the fact that the pharmaceutical industry has contributed more than 60% of the total national support for continuing medical education (CME) on an annual basis. Does this make all of CME suspect? I would like to explore this perception of a conflict of interest and seek middle ground amidst the cacophony of shrill voices demonstrating their tightly held beliefs across the spectrum of viewpoints in this arena.
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Our current environment is poisoned by a slew of recent adverse publicity with regard to these perceived conflict-of-interest issues. The Boston Globe ran a front-page story this past summer detailing the recent investigations by the U.S. Attorney’s Office in Boston. These federal investigators are sending subpoenas to top academic medical centers, and elsewhere in the country, for records about their relationships with drug makers as part of a widespread crackdown on pharmaceutical company marketing practices. Federal prosecutors, according to the Globe, are looking into whether drug companies have been

using these grants, in some cases, to try to influence doctors at leading hospitals to prescribe their medications to patients. If true, such behavior would be illegal under federal anti-kickback laws and may play a role in skyrocketing prescription drug costs.

This Boston Globe story was then amplified in the medical press with a detailed piece in Modern Healthcare. Nationally prominent physician leaders such as Jordan Cohen, MD, the president of the Association of American Medical Colleges (AAMC), and others were asked to give their views. Predictably, and appropriately, the AAMC supports its long-standing view that there needs to be a very careful arm’s-length relationship, if any relationship, between academic medical centers and the pharmaceutical industry. At nearly the same time, the popular news program Dateline NBC featured a summer headline-getting program entitled “Drug Giant Accused of False Claims.” In this July 2003 story, a scientist from Warner Lambert confessed, “It was my responsibility to leverage the trust that physicians had with pharmaceutical companies to corrupt the relationship between the physician and the patient.” He specifically admitted to participating in activities promoting off-label use of certain neurological medications.
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Contemporaneously, Dana and colleagues, writing in the Journal of the American Medical Association, cite extensive social science research supporting their contention that individuals, even professionals, are often unable to avoid bias even when it is in their best interest to do so. They contend that physicians will deny and succumb to bias, even when explicitly instructed about it, which suggests to them that self-serving bias is unconscious. Furthermore, they believe that even small gifts, those in keeping with current guidelines published by the Accreditation Council on Continuing Medical Education (ACCME), can subtly bias how arguments are evaluated, and they can be surprisingly influential. They call for an outright ban on all gifts to physicians regardless of size or scope. Even some of our most influential leaders have repeatedly called for a complete separation between the marketing and educational functions of large pharmaceutical com-panies. Is there a middle ground in this controversy?

In the final analysis, I believe that some of the recent media attention to these perceived conflicts of interest regarding our relationship with the pharmaceutical industry comes as a toxic by-product of other corporate malfeasance along the lines of Enron, WorldCom, and others. These concerns transcend the U.S., as there is considerable international interest in comparable issues well described in a recent article in the British Medical Journal.

Personally, I do not believe that we should cancel all pharmaceutical-sponsored activities within medical schools or even prohibit the distribution of pens and pads! I am committed to finding that middle ground where we can work together to better understand how new agents diffuse into practice. I support educational research to find better outcome measures of our work together. Simply cataloging a change in physician attitudes or tracking script-writing behavior is insufficient for the 21st century. While we may be loath to admit it, the pharmaceutical industry has decades of experience in influencing and changing physician behavior. Perhaps there is something we can harness here that will serve our own needs with regard to the standardization of care, quality measurement and improvement, and error reduction. Provocative? Surely. Pragmatic? I hope so.

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