Scenario 1: You are a medical specialist -- say a pulmonologist -- walking to the intensive care unit to see one of your patients, and you pass a roomful of your colleagues in the hospital auditorium crowding around tables piled with food and drink. Outside in the hall you see a sign on a stand that says, "MEGA Pharma welcomes the attending staff to a Pizza and Pasta Lunch brought to you by GALE FORCE, the new fixed-combination medication for asthma and COPD!" An attractive young woman stands in front of you, asks you to join the luncheon, and hands you a flyer with the program for the talk that will be given.
"Free CME," it says. The other pulmonologist at the hospital is giving a talk that is based on a study in which he had been an investigator. The talk is "The Use of a New, Improved Fixed-Combination Medication as First-Line Therapy for COPD."
Scenario 2: You are attending the annual lung society convention in San Francisco, California, and the conventioneers are walking around with convention bags, pens, programs, inhalers, packages, and even neckties emblazoned with pharmaceutical product names and logos. You notice that these same names and logos are on the placards and signs in rooms and hallways, in the programs, and even on the convention buses.
Prior to the convention, you received letters and postcards for the nightly gala dinners and CME symposia sponsored by pharmaceutical companies with the best-known pulmonology experts as speakers. You notice that there are 3 speakers at each symposium; two of the speakers are giving interesting scientific talks, and one is giving the talk "The Use of a New, Improved Fixed-Combination Medication as First-Line Therapy for COPD."The lung society is providing CME accreditation. You find that many of your clinical colleagues from other countries have been given "grants" from pharmaceutical and other commercial medical and device companies (referred to in this essay as Pharma) to attend the meeting as "consultants."
Scenario 3: A Pharma representative buttonholes you as you enter your office and hands you a free copy of the latest single-sponsored practice guideline from the lung society, and with it an ad slick for GALE FORCE along with free drug samples, peak flow meters, and pens with the GALE FORCE colors and logo. She hands you 3 published, state-of-the-art, randomized controlled trials from the lung society journal written by the top experts in the field and funded by the makers of GALE FORCE that explicitly state the point of view that GALE FORCE is a better choice than the 3 drugs that you currently prescribe.
When I find myself in such ethically questionable situations as those portrayed above, it is natural to wonder what led to their occurrence. A common response to the problems with the US healthcare system is to blame Pharma and their excessive marketing zeal. Several authors have written their perspectives about the events and policies that have crippled US medicine during the past several decades.[1,2,3,4,5,6,7,8] They discuss cutthroat competition within medical coverage providers, the ascension of medicine as a business, predatory marketing practices by Pharma, and the effects of inhumane government policies in damaging US healthcare. Their descriptions of the effects of "corporate medicine" and the inappropriate commercialization of medical practice provide a chilling perspective on some of the problems.
However, except for Dr. Kassirer's article, these works have not emphasized the damaging role of medical professional organizations (MPOs) and their leaders on US healthcare. I believe that it is in large part the dependence of these organizations on Pharma funding that has led them to compromise their professional ethics. Although this influence is also exercised by medical device, biotech, publishing, and diagnostics companies, for simplicity I will include all of these medical commercial organizations in aggregate as "Pharma" because they act in similar ways on MPOs, and the giant multinational pharmaceutical companies wield the greatest influence.
Pharma operates in the realm of business and in accordance with national laws. They are conducting legal businesses regulated by business ethics, whereas physicians and their MPOs are bound by medical ethics. When physicians violate these principles of medical ethics, they lose their professional identity and authority. Although I do not wish to ignore the positive medical and scientific activities of MPOs, in this commentary I lay much of the blame for unduly expensive and inappropriate medical care in the United States at the doors of MPOs. As the above scenarios imply, practicing physicians are constantly bombarded by MPO-abetted promotion from Pharma.
This thesis concerns only those MPOs in which inappropriate Pharma influence can be documented or inferred. In my experience, these tend to be the MPOs that serve the higher-income specialty organizations and are active in governmental lobbying. Their members are prescribers of specific pharmaceutical products relevant to the Pharma that support them. Some MPOs in the United States are not very dependent on Pharma support. Most are, as judged by the listings of the categories of their revenue. I suggest that the largely hidden relationship between MPOs and Pharma enhances the ability of MPOs to promote their specialties' services inappropriately, and it fosters the excessive prescription of expensive, highly-promoted medications. These results would be important factors in the spiraling costs of US healthcare.
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Medscape J Med. 2008;10(7):169 © 2008
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