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Narrative Matters

A Matter Of Influence

About ten years ago I served on a committee in our department that decided that our residency site should make no effort to eliminate contact with drug reps or their gifts. We argued that part of residents’ training was learning how to deal with the reps’ blandishments to prepare for their presence in later professional practices. I remain sympathetic to our resident’s educational arguments.

Still, if our committee were voting today, I would advocate a policy that made our residency program—and indeed, the whole hospital—a "drug-rep-free zone." I would justify this draconian action by pointing to how much has changed in the past decade. The pharmaceutical industry has drastically, if incrementally and therefore often invisibly, upped the ante. Too much is now at stake.

Evidence is steadily mounting that we physicians are, in fact, influenced by the industry’s largess. The proof does not by itself matter. What matters is how blind we are to the fact that we are being influenced. This lack of critical awareness seems to demand regulatory oversight. Today it is naïve to claim that each of us can make our own informed decisions about this matter. Very likely, those who deny the loudest that we are influenced and who are most insulted by this poor reflection on our professional integrity are precisely those who are most influenced and whose prescribing patterns are most deleterious to patients’ well-being.

Also, we must be aware of the growing scope of the problem as it extends its tentacles into every aspect of medicine. In the past I could entertain the impression that although I might get biased reports if I spoke with drug reps, I could always find the truth by consulting my professional publications. Today I have no such confidence: Even the most prestigious journals have published numerous papers by authors with serious, undisclosed conflicts of interest; and when a study reveals facts that are deemed unfriendly to the sales of a drug, the sponsoring company may use intimidation to prevent or delay publication of the results. Knowing how the few scientists who have dared to anger their company sponsors have been vilified, slapped with nuisance lawsuits, and had their research careers shattered, I conclude that a good many investigators whose studies revealed information unfavorable to a drug company quietly buried their data and never sought to publish at all.

The disparate pieces of this puzzle are interconnected. At first glance, whether our residents get to gobble down nice lunch sandwiches provided by the drug reps seems unrelated to whether a study’s authors misrepresent their findings because of a financial conflict of interest. But why are residents so angry if a policy is proposed that will limit their free meals? Why is Harvard Medical School willing to look the other way with a policy that its faculty receive only $10,000 annually in consulting fees or $20,000 in stock?

Culture Of Entitlement

 
What the residents and the harvard faculty have in common is a culture of entitlement. Since the first day of medical school, we have been primed by the drug reps to believe that we had all of this coming. We work hard, we stay up long hours, we put up with a lot of grief and misery to become physicians. Moreover, at least during our long years of training, the people for whom we supposedly make all this effort—our patients—seldom express gratitude for what we do. Certainly it is only small recompense that we get a few goodies now and then from friendly people who stroke our egos and make us feel desirable and important. The drug firms start the process of convincing us of our entitlement, but then we ourselves pick up the ball and run with it. The result is residents who think they are entitled to the tasty sandwiches, practitioners who feel entitled to dinner and drinks at the best steakhouse in town, and research scientists who think they deserve a lot more than their medical school salaries—and who, the school fears, will jump ship and go elsewhere if the school cracks down too hard on their perks. In an era of managed care, declining physician incomes, and ever-expanding hassles and paperwork, our sense of unfulfilled entitlement increases proportionately.

Regaining Integrity: A Better Lesson

Top Culture Of Entitlement Regaining Integrity: A Better...

 
Those of us in medical education cannot afford to let residents decide for themselves how to handle relationships with the pharmaceutical industry. Instead, we need to take firm action to reverse this culture of entitlement as thoroughly and rapidly as we can. Some of my colleagues think that it is already too late, that the culture of greed, entitlement, and profit is here to stay. "Live with it," they advise. Moreover, a recent effort in Toronto to change the culture by banning contact with drug reps produced less-than-stellar results: Although residents trained at the program before the ban took effect today have about eleven contacts per month with drug reps, residents who trained after the ban have about nine per month—hardly a dramatic difference.

Yet I find myself unwilling to go down without a fight. Admittedly, once you have sold your soul, it can be a hard item to retrieve. But the medical profession today is not without financial resources. We physicians can afford to pay fees to attend unbiased continuing medical education (CME) programs, rather than allowing for-profit firms that are closely affiliated with drug companies to organize our CME for us. We can afford to buy medications for ourselves and our families rather than dipping into the sample cupboard that (we tell ourselves) we keep only for the benefit of our indigent patients. If occasional nice lunches improve residency morale, surely the hospital and the medical staff can scrape together the funds. If our professional organizations now depend too heavily on donations from industry and our journals are held hostage to advertising, perhaps we can finance both through dues and subscriptions.

It’s not clear what hurts more—that we have been so willing to bargain away our professional integrity, or that we have let it go for a bunch of ballpoint pens and a few sandwiches and doughnuts. A strong effort to regain our integrity as a profession is a much better educational lesson for our students and residents than any number of "free" lunches and visits with drug reps.

Editor's Notes

 
Howard Brody, <brody{at}msu.edu >, is professor of family practice and also works in the" is professor of family practice and also works in the Center for Ethics and Humanities in the Life Sciences at Michigan State University in East Lansing.

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