Conflicts of Interest in Medicine

The relationship between pharmaceutical companies and physicians, nurses and/or other medical personnel has become an alarming concern in the medical field.  Doctors become involved with these companies by creating financial ties with an individual company. “Pharmaceuticals Industries have deliberately and/or unintentionally created an interlacing network with willing physicians, physicians’ professional organizations, nurses, celebrities… to market their prescription drugs.”[1] They market through these agents because it is very effective. It is effective because this relationship is very profitable for both the doctors/medical personnel involved as well as the industry. Pharmaceutical companies communicate and/or network among an enormous amount of physicians. Their commercials are advertised directly to physicians. They go out of their way to make face-to-face encounters, offer gifts such as samples for patients and/or treat the physicians to lunch, dinner etc. The most alarming thought is the fact that they create financial incentives for doctors. Physicians, who are willing, make financial arrangements with drug companies for their patients to participate in activities such as clinical and basic research studies. A practicing physician may also find free medical education as an incentive to market that particular company’s product.Only certain medical personnel appeal to pharmaceutical companies’ salesmen. They look for individuals, who are considered to be respected in their community, so called “opinion leaders”, leaders in clinical and basic research and/or well-placed academic physicians. The salesmen that represent the drug companies tend to choose wisely because they want the best known doctors/authors to publicize their product. In particular, they will seek out doctors that normally write for the New England Journal of Medicine or other medical publications or doctors with special connections such as knowing the ins and outs of the FDA. These high, powered and/or respected doctors are the ones we suppose to trust with our lives, so how do we know when a doctor is being truthful and not have a financial gain?“A new national survey finds nearly all physicians (94%) have some type of relationship with the pharmaceutical industry – from receiving drug samples or food in the workplace, to being reimbursed for professional meetings, to receiving consulting fees.”[2]  Much of the medical publication authors tend to have some financial gain for either disapproving or approving a drug. Websites, testimonies to the FDA, company-sponsored brochures are just a few more ways the public as well as other doctors get to know about the new drugs in the market. Some of these publications may come from doctors, who carried out their research with biased methods to achieve favorable outcomes in other words slanting clinical tests. Examples of such publications are:

• Lipid Letter, Lipids Online and Lipid Management are publications to promote statin drug use for high blood cholesterol. The authors have financial ties with statin manufacturers.
• Quick Consult: Guide to Clinical Trials in Thombrosis Management – the authors also had financial ties to Aventis. Aventis sponsored the book in order to promote their drug, Lovenox (a thinly veiled advertisement).
• There is a difficulty to find an author for the New England Journal of Medicine, who does not have financial conflicts with a drug companies.

The list goes on and on with many examples due to the enormous amount of physicians and academic doctors involved with the pharmaceutical industry. Physicians acknowledge the fact that the interactions between them and drug companies are used to influence their clinical decisions. They also acknowledge that the information received is not always balanced. Physicians are aware of the conflicts of interest they may have[3], so why do they continue this relationship? In response to this question doctors truly believe their conversations with representatives allow them to stay current with new products, new formulations of old products, new combinations of medications etc. Physicians are oblivious to any bias that sales representatives introduce. “They are convinced that their knowledge of the medical literature makes them impervious to industry influence.”[4] One doctor said that he is “…more influenced by having enough medication to give my patients some so they can try and see what within that class of medication is effective,”[5] and this doctor in particular continues to deny any influence from drug companies on his prescription methods. He claims to just listen to their spin, in turn receiving free samples. Who do we blame for this blow up of industry and physicians relationship? The U.S government plays little role in influencing physicians’ prescription habits, since it is a free-based market. Physicians are not pressured to save money on prescriptions and see no reason to do so. Pharmaceutical companies charge more in the U.S for most medications than elsewhere (high prices due to huge political lobbying). The rising cost of healthcare is of little concern among doctors because some of them perceive healthcare as a business not a public good. Academic physicians feel a strong, psychological urge/need to make more money. The industry creates a source of relatively easy money: they pay them to enroll patients as well as treat them like stars with hotel accommodations, dinners, plane tickets etc.

Patients trust their local physicians to prescribe the best medication for their condition and not the most expensive. Doctors are so influenced by the incentives from drug companies’ representatives that it is hard to say that they are truly unbiased. As a patient, I find it vexing that a physician would just be in the business to make money. Doctors should have a ‘fiduciary obligation’ to their patients and/or community. (Fiduciary refers to a heightened duty of commitment or devotion that comes with ones profession.)

So how do we fix this relationship? As a patient, initially, I would want all ties to be cut between physicians and industry; but how would they know about new drugs? When I think about it further, I would suggest limits on the interactions and a various amount of companies that present to doctors rather than one drug company. A doctor suggests that universal health coverage as a solution. He claims that expensive medications would lead to larger federal deficit, so that would lead the government to have more control over the industry. Some medical universities all over the world currently have strict laws about their students conducting business with industry. Everyone is alarmed by this relationship but it is still growing as you read this paper. Conflicts of interests is not unique to medicine, in happens in most high powered careers such as an accounting firm (aka the Enron Scandal). This conflict of interest is more alarming to me because these are the people we trust to sustain healthy lives. If we cannot trust them, who can we trust?          Additional Articles: “Conflict in the Corporation: A Review of Corporate Physicians: Between Medicine and Management”, Robert A. Brenson; (The Hastings Center Report)“Opinions and testimony of expert witnesses and independent medical evaluators”, J. Schofferman; (Pain Medicine)“Conflicts of Interest in health care – who guards the guardians?”, Richard A Epstein; (Perspectives in Biology and Medicine)