AAMC Reporter: February 2006
A Word from the President:
"Gift Horses Expect a Ride for Their Money"
My mother told me never to accept gifts from strangers. At first I wondered, why not? If someone wanted to give me something just for being me, why not be grateful? Ahh... now I understand; turns out that's precisely what my mother was worried about. If a stranger gives you something, he or she most likely wants something in return, and if you feel grateful, you're likely to respond.
Like most things my mother told me, this admonition has stood the test of time. Unfortunately, it was a lot easier to adhere to that admonition in the uncomplicated world of childhood than it is in the complex world of medicine. Gifts from strangers have become
so much a part of the everyday practice of medicine
that they are seen by many not as inducements to be shunned but as entitlements to be counted on. I'm talking, of course, about the gifts and other financial inducements showered on physicians by industry, especially pharmaceutical companies and medical device manufacturers.
Does anyone doubt that the reason industry targets physicians with gifts is to curry their favor? And does anyone doubt that it works? Certainly drug companies have no doubt; they spend billions of dollars each year on blandishments directed at doctors. And why shouldn't they? Put yourself in the position of a drug company executive. You have a roster of FDA-approved products that cost millions of dollars to develop. You know that the only way your drugs can make money (and reach people who might benefit from them) is if doctors write prescriptions for them. You don't have to be a rocket scientist to conclude that it makes good business sense to do everything you can to persuade doctors to prescribe your drugs. And what better way than by giving them gifts so they feel obliged, consciously or not, to reciprocate (and to keep those gifts coming!)
We're not talking old wives' tales here. Solid social science research has demonstrated that gifts of any size elicit a strong impulse in people to reciprocate. And doctors are no exception. Numerous studies have documented that physicians' attitudes and behaviors are influenced by gifts from industry. And the belief that small gifts don't matter is simply wrong. The problem is that the result of gift-induced behavior is not necessarily what's best for patients. Anything that poses a risk to physician objectivity — to the use of the best available evidence for the benefit of patients — is just cause for concern by the profession.
But let's be clear. To the extent that doctors are biased in their decision-making by industry largess, the fault lies not with industry for doing its job too well but with the medical profession for failing to do its job well enough. The job of industry is to promote its products. The job of the profession is to protect the welfare of patients and the public. For the profession to depend on government directives (e.g., FDA, OIG) or voluntary guidelines (e.g., AMA, PhARMA) to adequately
constrain the promotional practices of a sophisticated industry is to abdicate its responsibility. Professions, by definition, are obliged to discipline themselves in fulfilling their oath of public service.
The evidence is incontrovertible: current industry practices that use gifts and other financial inducements to curry favor with physicians can, and often do, undermine objectivity in the provision of both medical care and medical education. Left unchecked, this situation will not only continue to threaten the welfare of patients and the integrity of medical science; it will also continue to breed mistrust of the profession and of individual physicians. For this reason, the profession must adopt and implement much more effective policies than those that currently prevail.
Toward that end, the American Board of Internal Medicine Foundation and the Institute on Medicine
as a Profession assembled a working group to consider what steps might be taken to reverse the current trend.
I was privileged to be a part of this effort, which culminated in the publication in January in JAMA of an
article entitled "Health Industry Practices That Create Conflicts of Interest: A Policy Proposal for Academic Medicine" The working group chose to focus its recommendations on academic medical centers (AMCs) for several reasons.
First, AMCs are highly respected by industry and the public for their expertise and leadership. Others are likely to follow the lead of AMCs. Second, AMCs are the cradles of professionalism; they are responsible for inculcating in future health professionals the ethical norms of medicine. Third, AMCs
are, in general, organized sufficiently well to adopt and implement new policies relatively quickly. Finally, given the central role of AMCs in evaluating new technologies, their adherence to high standards of objectivity is especially critical.
The working group's recommendations are uncommonly demanding and reflect the urgency of reversing present practices. The following are likely to be the most challenging to implement:
- Ban all gifts (large and small) from drug and device makers, including free meals
- Prohibit direct support of CME programs (including faculty and trainee travel) by industry or any industry subsidiary; establish instead a central fund for pooling contributions from multiple sources to be distributed by the AMC according to its priorities
- Prohibit direct provision of drug samples to physicians; create instead an arm's-length system (e.g., vouchers) to meet the needs of indigent patients
- Limit membership on formulary committees to individuals without financial relationships with any drug or device maker
- Prohibit faculty from serving as members of industry speaker's bureaus, which are avowedly components of a company's marketing system
- Prohibit faculty from publishing anything that is ghostwritten by industry employees
The lesson that our mothers taught us about the dangers of accepting gifts from strangers has never been more germane. As stewards of medicine's future, leaders of medical schools and teaching hospitals must reinforce that lesson by ensuring the adoption of and rigorous adherence to appropriate institutional policies and procedures governing relations with industry. Gift horses expect something in return for their money. We should be traveling on a higher road.
Jordan J. Cohen, M.D.
AAMC President
Editor's note: The article Health Industry Practices That Create Conflicts of Interest is available on the Journal of the American Medical Association (JAMA) Web site.
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