Can Doctors Avoid Conflicts of Interest?

As editor-in-chief of JAMA for 11 years, Dr. Catherine DeAngelis was known for her outspoken views about the deficiencies of U.S. health care and the drug industry. Her recent commentary, “Conflicts of Interest in Medical Practice and Their Costs to the Nation’s Health and Health Care System,” continues her campaign to expose what’s wrong with our medical care.

“Many, if not most physicians practicing today have, or have had, conflicts of interest that clearly do not result in their patients’ best interest,” she writes in the Milbank Quarterly, a health policy journal. She defines conflicts of interest as “a conflict between the private interests and the official responsibilities of an individual in a position of trust.”

That sorry situation, as summarized by, has become widespread over the last couple of decades, largely driven by pharmaceutical companies whose marketing and scientific divisions seem to be one and the same.

We’ve blogged about the slimy intersection of these two forces, and their harmful effect on patient safety. DeAngelis traces their roots back to medical school, with “the free black bags, instruments or books given to medical students by a pharmaceutical company, or even the doughnuts, coffee, soft drinks and free lunches provided at teaching conferences.”

It’s not long before those … kindnesses … escalate to “the free food, tickets to sporting and other events, sponsored trips to resort locales and the shower of other gifts given to physicians by the pharmaceutical representatives assigned to them,” says DeAngelis.

Often, the recipients of this largess claim that their clinical and prescribing practices are not influenced by it, but if that were true, DeAngelis wonders, “[W]hy would pharmaceutical companies spend billions of dollars on these items, and why would they partially reimburse their marketing representatives according to the number of prescriptions written by the physicians to whom they are assigned?”

Sunlight is spreading over this smarmy practice of drug and device manufacturers showering practitioners with attention and treats – ProPublica’s Dollars for Docs is one site where you can track how the industry greases practitioners’ palms – but DeAngelis explains how much more disinfectant is required to clean up the mess.

“What about the free drug samples provided to physicians for their patients?” she asks. Some people say free samples help patients who otherwise can’t afford the drugs they need. If so, she asks, “[W]hy are the vast majority of these free samples for new (meaning those still under patent protection) and expensive drugs that are almost exclusively for illnesses that require the drug’s frequent or continued use?”

She’s concerned as well about academics who conduct research and/or write practice guidelines or review papers who are subsidized by Big Pharma. “Most Americans are surprised to learn that the clinical research funded by Big Pharma dwarfs the annual investment by the National Institutes of Health. Moreover, much of this industry-sponsored research is tainted by bias that is not always clearly stated.”

If you’re not happy to name the members of your team, doesn’t that suggest there’s something sordid about the game you’re playing?

DeAngelis decries the practice of physicians, biomedical and health-care researchers working for a pharmaceutical company’s marketing division instead of its scientific division. One example is “expert physicians” serving as industry-sponsored speakers using data provided by the pharmaceutical company. “Invariably” she writes, “such ‘chaperoned’ presentations accentuate the positive and downplay the negative (including price differentiation) aspects of the drug being promoted.”

Then there’s the common but illegal habit of promoting a drug for off-label use. DeAngelis describes how insidious drug companies and their willing medical partners operate in this arena:

Imagine the following and, unfortunately, common scenario: At a major clinical or health-related lecture, a physician paid by the pharmaceutical company is “planted” in the audience. The “plant” raises his or her hand and supposedly innocently asks the presenter if he or she has ever used the drug for an illness for which the drug has not been approved by the … FDA. The presenter then discusses off-label uses of the drug for this or that illness or symptom. Remember that physicians in the United States can write prescriptions for any drug, whether or not it has been approved by the FDA for that illness. So why not add a few more uses, which can translate into multiple sales and millions of dollars in unexpected revenue?

Later this year, as we’ve noted, the Physician Payment Sunshine Act, a provision of the Affordable Care Act, requires drug and medical device manufacturers to report what they pay individual physician on a website accessible to consumers.

Will that public disclosure persuade physicians to uphold their Hippocratic oath to do no harm, to always act in the best interest of their patients and reject the free meals and trips, the lucrative speaking and consulting fees Big Pharma offers?

Says DeAngelis, “We can only hope.”

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