In an underreported story in this week’s New England Journal of Medicine, a representative from the American Medical Association writes to point out that it is unethical for doctors to accept gifts from drug companies. The AMA ethics opinion E-8.061 has been around since 1990. The New England Journal published an article in their April 26, 2007 issue that presented disturbing evidence that many doctors accept inappropriate gifts from industry. The AMA echoes that sentiment and says: “physicians should not accept such gifts, because the reciprocity they engender is known to affect prescribing decisions, which may harm patients and increase the cost of care”. Remimbursement for admission and travel to continuing medical education meetings and tickets to cultural and sporting events, are clearly prohibited under the AMA code. The AMA calls on drug companies and doctors to abide by their respective codes of conduct and to neither offer nor accept inappropriate gifts, for the benefit of patients and the public. The full text of the AMA letter that was published in the New England Journal is reprinted here
in full. In additon, also published and reprinted are letters from Doctor Grande of the University of Pennsylvania and one from Doctor Gorskie from San Diego that comment on the April 26, 2007 NEJM article citing the 35% figure of doctors violating their ethics codes by accepting gifts and calling for reforms in the entire system. These should be required reading for anyone concerned about the tremendous influence drug companies like Merck have upon the prescribing habits of doctors.
A National Survey of Physician-Industry Relationships
To the Editor: Campbell et al. (April 26 issue)1 present disturbing evidence that many physicians accept inappropriate gifts from industry. Physicians should not accept such gifts, because the reciprocity they engender is known to affect prescribing decisions, which may harm patients and increase the cost of care.
The authors should have known, however, that an American Medical Association (AMA) policy has addressed the ethics regarding industry gifts to physicians since 1990,2 more than a decade before the Pharmaceutical Research and Manufacturers of America (PhRMA) code was implemented in 2002. In fact, the PhRMA code was based largely on the AMA’s opinion E-8.061, as even a cursory glance will show.
Many gifts cited by Campbell et al., such as reimbursement for admission and travel to continuing medical education (CME) meetings and tickets to cultural and sporting events, are clearly prohibited under the AMA code. The AMA calls on pharmaceutical companies and physicians to abide by their respective codes of conduct and to neither offer nor accept inappropriate gifts, for the benefit of patients and the public.
Robert M. Sade, M.D.
American Medical Association
Chicago, IL 60610
Campbell EG, Gruen RL, Mountford J, Miller LG, Cleary PD, Blumenthal D. A national survey of physician-industry relationships. N Engl J Med 2007;356:1742-1750. [Free Full Text]
American Medical Association. Opinion E-8.061: gifts to physicians from industry. In: Code of medical ethics. Chicago: AMA Press, 2006:212-24.
To the Editor: Voluntary guidelines issued by the pharmaceutical industry in 2002 addressing interactions with health professionals include a ban on direct payments to physicians for attendance at CME or other conference events. According to the guidelines, any industry support for conferences or courses should be provided indirectly through event organizers.1 Despite this guideline, Campbell et al. state that 35% of the physicians in their survey reported receiving reimbursement for “costs of travel, time, meals, lodging, or other personal expenses for attending meetings,” “free or subsidized admission to meetings or conferences for which CME credits are awarded,” or both. These findings suggest low compliance with voluntary industry guidelines and provide support for a renewed focus on addressing commercial influence in medical education. The Charter on Medical Professionalism requires that physicians and the profession take responsibility for our education and competence.2 Current reliance on industry support threatens this fundamental professional responsibility and undermines public trust. Leadership from academic institutions and medical societies is needed to address this undue influence in medical education.
David Grande, M.D., M.P.A.
University of Pennsylvania
Philadelphia, PA 19104
Pharmaceutical Research and Manufacturers of America. PhRMA code on interactions with healthcare professionals. Washington, DC: PhRMA, July 1, 2002. (Accessed July 12, 2007, at http://www.phrma.org/files/PhRMA%20Code.pdf.)
Medical professionalism in the new millennium: a physician charter. Ann Intern Med 2002;136:243-246. [Free Full Text]
To the Editor: Campbell et al. report that an increase in physician-industry relationships may be due to a dependence on “industry representatives as the source of medical information.” If this is true, then physicians need to be aware of the validity of that information. One report stated, “A recent study of the advertising material and marketing brochures sent out by drug companies to GPs [general practitioners] in Germany has shown that about 94% of the information in them has no basis in scientific evidence.”1 Although I have never, in more than 30 years of practice, met a drug-industry representative I did not like, it is important that we obtain our medical information from nonbiased sources.2,3
Arnold L. Gorske, M.D.
Health Education Program for Developing Countries
San Diego, CA 92112-2683
Tufts A. Only 6% of drug advertising material is supported by evidence. BMJ 2004;328:485-485. [Free Full Text]
Topol EJ. Failing the public health — rofecoxib, Merck, and the FDA. N Engl J Med 2004;351:1707-1709. [Free Full Text]
Avorn J. Dangerous deception — hiding the evidence of adverse drug effects. N Engl J Med 2006;355:2169-2171. [Free Full Text]
The author replies: Sade and Grande raise a very important issue regarding the effectiveness of the voluntary codes of conduct of the AMA and the PhRMA regarding interactions between physicians and drug companies. Our survey was not designed to test adherence to these codes. Thus, we did not think it appropriate to comment on this issue in the article. However, Sade, the chair of the Council on Ethics and Judicial Affairs of the AMA, feels that more than one third of physicians do not adhere to the AMA’s code of conduct regarding the acceptance of reimbursements for attendance at meetings and tickets to cultural and sporting events; this is certainly a cause for concern. Taken together, these letters clearly question the ability of the profession of medicine to regulate relationships between physicians and drug companies by using voluntary codes of conduct.
Gorske’s point regarding the scientific accuracy of the promotional materials that pharmaceutical companies provide to physicians is also a cause for concern. A number of others have expressed similar concerns regarding bias in industry-sponsored activities.1,2 Since our study did not directly assess this issue, we chose not to mention it in our article. However, it does seem reasonable for physicians to remember that the information that drug companies provide to physicians may not always meet the scientific standards of the peer-reviewed literature.
Eric G. Campbell, Ph.D.
Massachusetts General Hospital
Boston, MA 02114
Angell M. The truth about drug companies: how they deceive us and what to do about it. New York: Random House, 2004.
Kassirer JP. On the take: how Medicine’s complicity with big business can endanger your health. New York: Oxford University Press, 2005.
For more information on this subject, please refer to our section on Medical Malpractice and Negligent Care.