Conflicts of Interest: An Issue That Will Not Go Away

Last month in Health Letter, we discussed conflicts of interest in science and medicine that manifest themselves in the most fundamental sources of scientific knowledge. We described evidence of such conflicts in the gatekeepers of medical knowledge: the National Institutes of Health (NIH), institutional review boards, and major medical journals. This month, we continue with a different twist on the same theme.

I’m sure that the pen I have in my pocket has an ad for one of the big drug companies, but I don’t know or care what it says and that would never influence my prescribing,” said my physician when I told him that I worked for Public Citizen. I replied that, while he was speaking only for himself, the drug companies have done their research and have confirmed that their advertising campaigns and ‘freebies’ do pay off. Moreover, name recognition is all-important in any purchase. Given a choice between an unknown drug and one that is heavily advertised, physicians are more likely to go with the one they know. It is not coincidental that mentions of “the name you know, the brand you trust” are recurring motifs in much contemporary advertising.

Recent data confirm that drug manufacturers are also savvy marketers, and that they consider physicians to be a prime target. In 2004 drug companies spent a total of $7.8 billion influencing physicians. This computes to an average of $10,000 for every practicing doctor in the United States. If these companies gave each doctor a check for this amount, we would be duly outraged. But the monies are doled out in dribbles, and take a variety of pathways, shapes, and venues: they include gifts, consulting contracts, meals, sponsorship of trips and professional conferences, and advertising in medical journals.

Moreover, the companies appear to have adopted the concept of “give early, give often” as their motto. Physicians-in-training are wooed and courted in both subtle and obvious ways. Some receive outright fellowships, or take advantage of research opportunities offered by the companies. Last year, some drug companies paid professional organization dues for doctors finishing their residencies and invited graduating medical students to lavish meals, thereby establishing a pattern to win and cement the young physicians’ allegiance. And, while all self-respecting doctors will argue that they will not sell their soul for a steak dinner, the acceptance of such gifts will establish a relationship that can only compromise their independent judgment in future prescribing.    

Some academic medical centers, increasingly aware that the physicians they train model their professional behavior on that of their mentors and peers, have adopted new rules to limit the contact between researchers and practitioners, on the one hand, and pharmaceutical representatives, on the other. Yale and the University of Pennsylvania were the first to institute clear policy guidelines to stem potential conflicts of interests. More recently and with greater fanfare, Stanford Medical Center has followed suit. Following a series of press exposés revealing that the more than 700 members of the medical faculty reported 299 potential conflicts of interest related to their research and that more than one-third of the medical school’s administrators and department chairs also acknowledged having outside research-related financial interests within the past four years, Stanford University adopted a “no pens or pizza” policy that is being criticized as both too strict (because of its ban on inexpensive trinkets) and not strict enough (because it allows faculty members to serve on corporate boards of companies that do business with the institution).  

Those who feel that the no-freebies policy is too strict need to hear the words of bioethicist Arthur Caplan. Small gifts, he writes, are the most powerful. They catch recipients unaware, whereas big gifts raise physicians’ conflict-sensing antennae. Supporting this, Stanford Medical School Dean Phillip Pizzo cites the example of Lyndon B. Johnson. Ever the consummate politician, Johnson gave voters toothbrushes with his name on them because he “wanted people to think about him morning and night.”