Should Physicians Avoid Interaction With the Drug Industry?

Robert W. Donnell, MD; Désirée Lie, MD, MSEd; Brian Haynes, MD, PhD, MACP; Roy M. Poses, MD; Charles P. Vega, MD, FAAFP; Bradley Fox, MD

Disclosures

December 02, 2008

In This Article

Introduction

Robert W. Donnell, MD

Years ago, doctors had difficulty accessing new information on drug therapy, many relying on pharmaceutical sales representatives for updates. Modern information technology now puts reliable information at doctors' fingertips. Although few would argue that today's doctors need help from drug representatives to stay current, many still interact with them.

The relationship between doctors and industry is controversial. A groundswell of opinion holds that doctors should avoid interaction with the drug industry.[1] One activist, Robert Goodman, MD, New York internist and founder of No Free Lunch,[2] urged doctors to sign a pledge against accepting any gifts or support from the drug industry and would like to see the pledge elevated to the status of board certification.[3]

Although those expressing such opinions are probably in the minority among physicians, their voices can be shrill. A culture of ridicule and shame has arisen as rank and file doctors find themselves accused of accepting bribes and characterized as minions of the industry.[4,5] How should we respond? I would argue for moderation. Let physicians set their own individual boundaries. Let's examine some anticipated objections to my proposal.

Pharmaceutical company pitches are biased. Doctors are influenced by drug company promotions. These points can be conceded, but by themselves, they do not support a case for condemning other physicians' individual choices to interact with drug representatives. Additional questions must be examined.

Interactions between physicians and drug representatives create conflicts of interest. This knee-jerk reaction suffers from oversimplification. Given that apparent conflicts exist, how real are they? Detractors have moved the concept from one of healthy skepticism to unhealthy cynicism. Drug company interests are not, as they imply, invariably conflicted with a doctor's duty to act on behalf of the patient. In fact, companies have a proprietary interest in producing good outcomes for patients.

When conflicts of interest do result from interacting with drug representatives, they pale in comparison to others that doctors face daily. Doctors who receive fee-for-service compensation are rewarded for exposing patients to unnecessary procedures. Those who practice under capitated reimbursement plans are incentivized to underserve patients. Such conflicts are about real money and they expose patients to real risk.

Drug representatives are trying to sell a product; therefore, doctors should ignore what they say. This is an ad hominem fallacy. It attacks the person or persons making the claim rather than the claim itself. With primary source information just a few mouse clicks away, doctors can critically examine drug company promotions on their own merits.

Promotional influence on doctors harms patients. Convincing, generalizable evidence for this statement is lacking. Critics have cited the heavily promoted drug rofecoxib (Vioxx®), which was found to be associated with cardiovascular events. Rofecoxib's comparator in The Vioxx Gastrointestinal Outcomes Research (VIGOR) trial[6] was naproxen, which is singular among nonsteroidal anti-inflammatory drugs (NSAIDs) for its cardiovascular safety.[7] However, in real-world practice, rofecoxib was promoted as an alternative to multiple older NSAIDs (cyclooxygenase [COX]-1 inhibitors) that have been shown repeatedly to be associated with cardiovascular harm. In fact, data have indicated that they may be at least as dangerous as COX-2 inhibitors.[8,9,10] There is no convincing evidence that industry promotions result in patient harm.

Drug detailing sways doctors away from evidence-based practice. Studies in support of this argument do not give a balanced view. Surveys of the effects of drug detailing on doctors' prescribing have focused selectively on areas of overuse, such as antibiotics in the ambulatory setting and new expensive drugs compared with equally effective generics. Although some promotions undermine evidence-based practice, others may enhance it. Because promotional literature is a mix of good and bad information, the net effect on patient care is not known. Many heavily promoted treatments are evidence-based and known to be underutilized by doctors. A good example is the inadequate use of low-molecular-weight heparin for thromboembolism prophylaxis.[11] The promotion of statin drugs[12,13,14] and angiotensin-converting enzyme inhibitors for appropriate patients[15,16,17] is another example. Such a promotion toward best practice has been ignored in published studies. Research in a broader range of clinical situations is needed before conclusions can be made about the overall effect on evidence-based practice.

Acceptance of food and gifts from drug representatives drives up medication costs. In effect, doctors are taking money out of patients' pockets. This argument is superficially appealing, but wrong. Because fewer doctors accept gifts from drug representatives, the industry is diverting its marketing resources to direct-to-consumer advertising. The money will be spent on promotion one way or another.

Are there solutions? Perhaps, but they're not as simple as vocal detractors would suggest. Doctors should seek unbiased information on drug therapy. Drug company promotion, a mix of good and bad information, cannot be considered reliable, but individual doctors must decide for themselves whether they should allow drug detailing. Broad recommendations must await convincing data on patient outcomes. Transparency about doctors' interactions with industry, along with improved education on drug therapy and the critical evaluation of medical literature, would be more effective than the current finger-pointing and ridicule.[18]

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