Doctors and medical industry

No business relationships with apothecaries – Law for the Regulation of the Practice of Medicine, Frederick II, King of Naples, 1241 Physicians have interacted with representatives of the medical industry for centuries. Today, ‘drug reps’ who visit physician offices are a common source of drug information. Visits may be accompanied by the giving of small gifts such as notepads, each page of which prominently bears a new drug's name and the company logo. Should paediatricians accept such gifts? Gift giving is an integral part of society. It demonstrates gratitude and appreciation, and plays a role in sustaining relationships. Acceptance is accompanied by gratitude; refusal induces disdain. Gifts have social significance (eg, we bring wine when invited to someone's home) and are forever linked to the giver – can you not name the source of every piece of jewelry you wear? Medical industry jargon refers to gifts bearing product or company logos as ‘reminder items’. Giving gifts is big business – millions of dollars are spent on gifts to physicians each year in North America. Gifts range from seemingly trivial notepads, to dinners with or without educational components, trips to lovely locations for conferences, and research and program support at academic health science centres. If one includes all the funds that are spent on drug promotion, figures for North America grow into billions. Why does the medical industry do this? Do they really believe we cannot afford notepads? Or is it that every published study in peer-reviewed literature shows that gift giving influences prescribing practices. Every time we write on a page of that notepad, the image of the drug and the company's name activates synapses which may translate into a behavioural change. Newer drugs are usually more expensive and may not have incremental benefits proportional to the increased cost. Although many physicians argue that they are independent and their prescribing practices are resistant to influence, the literature suggests otherwise. One might go so far as to suggest that the giving of gifts with a motive to influence behaviour that is related to the creation of profit falls not so short from what we would otherwise refer to as a bribe. All gifts have ‘strings attached’. Some are obvious and others are more subtle. Patients entrust us with their care under the presumption that we will act in their best interest. It is part of our code. To do so, we must independently apply ourselves to the task at hand unfettered by influences that may knowingly or unknowingly cause us to take actions with motives other than the patient's betterment. To do otherwise would be a violation of the ethics of care. If the patient were to know of these influences, would they still be willing to entrust us with the same confidence? Does the size of the gift matter? The sociology and anthropology literature suggests that all gifts influence the recipient and, indeed, it is human nature to have a ‘self-serving bias’ which leads to behaviours that enhance opportunity to receive gifts and sustain relationships after a gift is received. The media reflect a declining public trust in medicine. One can only imagine the further impact should it become clear that our actions are overtly or even covertly affected by the receipt of gifts from the industry. The medical industry is an integral part of the delivery of medical care. They provide us with diagnostic tools, treatments and intervention tools. Without them, it is unlikely we would have drugs, instruments and machines from which our patients derive enormous benefit. As businesses, they have the right and need to generate profit, which helps to sustain advancement of medical care and rewards them for this contribution. Every business in our culture of capitalism is allowed to market and profit. Gift giving is a standard part of doing business. Why should the medical industry be held to any different standard? With budgets constricting on all levels ranging from governmental research support to private foundations and health care delivery, perhaps contributions from the medical industry should be welcomed. Although studies show an influence on prescribing behaviour, no study shows that this has contributed to a downward turn in quality of care or increased morbidity and mortality. Some new products do benefit the patient. The amount of influence on physician behaviour has also not been measured. Does the notepad have a significant negative effect on a patient's care? Does the size of the gift matter? Finally, it may be argued that physicians are selected and trained as models of virtue. Perhaps some individual physicians are more resistant to the influence of gifts than others. In addition, the nature of the profession separates it from the business world. Even if prescribing practices are slightly shifted, overall delivery of care is designed on principles of beneficence. Also, it is a hard profession requiring long hours, difficult decisions and emotional upheaval, all of which are received in a climate that many would complain is plagued by underfunding, inadequate remuneration and infrequent rewards. Perhaps a gift here and there is well deserved. Interactions with medical industry are frequent, inevitable and ethically challenging. Depending on the jurisdiction, community and hospital, physicians may be subject to law and policy which set standards for these interactions. Even within such guidelines, there will remain challenging situations in which the physician must choose whether to engage in relationships with medical industry. Physicians must recognize that they are not exempt from influences of human nature. We often see ourselves as uninfluenced by forces which we believe differentially affect others. Gifts affect us all, and if choosing to accept them, we must understand their nature and meaning. Understanding the roles gift giving plays in the business of the medical industry and the influence on us is the first step to becoming aware of implications of the decisions to accept. We must also ask ourselves if the gift is ‘necessary’. Many would argue that, although free samples of drugs influence prescribing practices, the benefit of this ‘gift’ outweighs potential harm generated by the interaction with the drug companies. Can we say the same about a notepad? Is the notepad necessary? Would we not have paper to write on if generous drug companies did not give them to us? Why take such a gift if its benefit is so small even if its harm is also minimal? Perhaps there is no reason at all. The dilemma will certainly be more challenging when the gift is larger, yet the moral issues not less pertinent. Doctors must carefully consider, monitor and manage their relationships with the medical industry in an effort to minimize the negative impact such relationships might have on patient care. We are privileged to be entrusted by our patients and are at a position where we have the knowledge and skills to provide help which our patients seek. We must act with a purpose that is directed toward the patient's best interest more than our own, respecting their entrustment with an independence that allows action with minimal influence.

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