Should Doctors be Banned from Accepting Gifts from Pharma Companies?

Virtually, all US doctors take freebies from drug companies, and a third take money for lecturing, and signing patients up for trials, reports recent survey published in New England Journal of Medicine. The study of 1,662 physicians found that 94 per cent reported ‘some type of relationship with the pharmaceutical industry', with more than 83 per cent receiving food in the workplace and 78 per cent receiving free samples. And the more influential a doctor was, the greater the likelihood that he or she would be benefiting from a drug company's largess. The situation is not very different in India. So, we ask experts whether doctors should be banned from accepting freebies from pharma companies...

'Competition has Brought in a Growing Unscrupulousness'

"Ethics, like beauty, lie in the eye of the beholder. In the end, it is up to the individual doctor to decide the 'Lakshman Rekha'" - Dr Narottam Puri Executive Director New Business Development Max Healthcare, New Delhi

Let me quote from American College of Physician Executive Journal of Medical Management (March-April, 2005): "No profession is more fundamentally rooted in an ethic than medicine". There is general agreement that there exists an "inherent
conflict of interest between the physician's role as a trusted healer and the physician's role as a breadwinner—earning a living from the medical knowledge and ministrations applied".

The 1976 Gallup Poll in the US concluded that doctors were first in the public's
perception of honesty and ethics; today they are fifth. No such poll has been conducted in India, but one thing I am sure of, doctors will not be in the first three. The whole business of medicine in the market-driven healthcare delivery involves motivations that are less than clinical.

I hate to admit this, but in our country there are major issues developing which point to a problem with physician integrity —accepting of gifts, free travel for the family and hotel for the family from the pharma industry are only a small part. These are akin to a bribe. Who is the guilty party in this? The bribe giver or the taker? In my view, both.

My first contact, as a doctor, with a medical representative was in the year 1969—and too much water has flown in these 38 years. Those days, there were few pharma companies and much fewer drugs and their combinations. With a host of products and a huge number of pharma companies, competition brought in a growing 'unscrupulousness'.

From samples of medicines for the poor patients and sometimes for the doctor's family, writing pads and ball pens came in. Then Diwali and New Year gifts of small denominations were supplanted with money to hosting tea/coffee parties and then lunch for the clinical meeting.

Then came dinner, but who will come for dinner till cocktails and liquor were added! The buck didn't stop here—air ticket and hotel stay for conferences first to the doctor and then to the whole family followed. I have heard of some 'new, small, local type' companies handing over microwaves, fridges and cars to doctors in return of a monthly support to the drugs being prescribed.

If that number is not reached, the company doesn't pay the EMI and the doctor becomes a defaulter!

Ethics, like beauty, lie in the eye of the beholder. In the end, it is up to the individual doctor to decide the 'Lakshman Rekha'.

The pharma company and their medical representatives have an important role to play - their visits and support for continuing medical education are vitally important, but the route employed needs to be re-examined.

In the end, let me quote Richard Johnson in the ACPE Journal - "Yes, there is a problem with physician integrity but it is not of epidemic proportions. For every doctor on the take, there are several who abhor these stains on the honour of the medical profession. Is honest physician an oxymoron in the 21st Century? The answer is NO”.

Dr Narottam Puri

'Pressure is Building Against Gifts to Doctors'

"Pharma industry has intense competition, which can skew balance. It can either reach to exploitative situations or 'no effect' situation" - Dr RB Smarta Founder and Managing Director Interlink Business Consulting Mumbai

Relationships are always mutual. There has been no model in pharmaceuticals where you can avoid one-on-one relationship building. It may be through medical service or detailment or organisational representatives with the prescribers. As relationships
need nurturing, you tend to build them on the basis of 'give and take' or 'take and take'. It could be an exchange of knowledge, token gifts, dining together, obliging patients with free samples or providing intellectual as well as emotional support for the mutual benefit of both.

In case of professional relationship between pharma companies and prescribers, it
becomes complex. Pharmaceutical industry has intense competition. Competitive processes can skew balance. It can either reach to exploitative situations or 'no effect' situation.

In January-February 2006, Pharma Marketing News, a monthly electronic newsletter published from Newton conducted an online survey on 'Pharma gifts to physicians'. The areas of conflict in the context of free gifts to doctors were identified and responses were invited. Gifts were classified in many areas such as attending conferences, expenses on travel, ghostwriting services, free meals, sponsorship of speakers, research grants, drug samples, and continuing medical education. It was observed that there are few conflicts in the context of these offerings. They were depicted as follows: You will observe that there has been a great conflict on account of attending conferences, travel expenses, and ghost writing services. It is typical to the US culture, while in India we may have different nuances for such offerings.

A press report emanating from New York published on February 13, 2007 pointed out that free lunch delivery to medical offices, along with that drug company's logo pens have come to symbolise extensive financial ties between doctors and the drug industry. Pressure is building against such gifts and other potential conflicts. Last year, a group of influential doctors condemned financial arrangements between doctors and drug companies as highlighted in the journal of American Medical Association.

Recently, a new initiative was announced by Community Catalyst, a healthcare consumer advocacy group in Boston, the institute of medicines and a research group at Columbia University. The organisation has got $6 million grant from the Pew Charitable Trust. It plans a national campaign calling for restrictions on the interaction between doctors and drug companies and to urge doctors to base their prescription writing more on medical evidence than on marketing.

As reported in Scrip, dated March 30, 2007, in Vermont 12,227 payments totaling $2.2 million were publicly disclosed. Of these payments, 68 per cent were in the form of food and only 4 per cent were in the form of books or grants. Many of these payments were for education (28 per cent), physicians detailing (26 per cent) and speakers (14 per cent).

International Federation of Pharmaceutical Manufacturers and Associations (IFPMA) a global non-profit NGO representing research-based pharmaceutical companies and national industry associations has developed a code of pharmaceutical marketing practices.

The code has been recently revised in 2006. The code has developed detailed guidelines relating to pharmaceutical companies' interaction with healthcare professionals. It has developed specific norms relating to payments for speakers, hospitality, entertainment, gifts and items of medical utility.

While gifts cannot completely be done away with taking into consideration ground realities, they have to be reasonable and promote professional education and efficacy.

The leading industry associations namely Organisation of Pharmaceutical Producers of India (OPPI) and Indian Drug Manufacturers Association (IDMA) who together cover almost 90 per cent of the pharmaceutical companies in India, have developed their own codes on pharmaceutical marketing practices. They define norms, discipline and values of pharmaceutical marketing practices. They have also developed sanctions for breach of practices. An exercise has been initiated to define the limits on the value of the gifts. Acceptance of the code is mandatory for all the member companies.

This is a welcome initiative, as it is self-regulatory in nature and as such is expected to be more effective. The industry associations have also designed a mandatory mechanism to receive and deal with complaints relating to the breach of guidelines.

These initiatives in India will streamline the professional relationship. In Interlink's assessment, it will have the following positive impact on the industry, prescribers and patients.

• A healthy and ethical relationship with prescribers will evolve.
• Industry will keep upgrading its focus on patients through prescribers.
• Promotion of pharmaceutical products will really become ethical.

While on a high moral ground, non-acceptance of any gift by any doctor can be advocated, the reality is that gifts are given many times rampantly to the doctors. If the gifts are intended to promote education or scientific character of doctor's practice, they should not be objected. If the gifts are excessive which run counter to this basic purpose, they should not be acceptable. Regulating the gifts and minimising the commercial aspect is a workable solution to the ranging controversy of gifts to the doctors.

Dr RB Smarta

'The Pharma Industry is to be Blamed than Doctors for the Menace'

"The price of free gifts or free holidays or free excursions, which is quite exorbitant, has to be borne by the poor patient" - Dr Digambar Naik Founder, Vrundavan Hospital Goa

Give and take is a way of life. But should we consider gains as only material gains? Definitely not. A doctor with good work and dedication gains respect and a position of pride in the society which is not comparable to any material gains. Then why
should he be lured by the free gifts offered by the pharmaceutical companies to favour writing their drugs?

I feel it is a big menace today and the ever growing pharmaceutical industry is more to be blamed than the doctors.

Most doctor still works with his ethics, integrity and self pride. But the virus of 'Gifts to Doctor' in the pharmaceutical companies is so virulent that they themselves compete with each other to give more to the doctors. Fortunately, many doctors do not fall a victim to this trap, but many more do. The result is costlier medicines!

The price of free gifts or free holidays or free excursions, which is quite exorbitant, has to be borne by the poor patient, about whom nobody thinks. Nearly half of our patients still find it difficult to pay for the medicines they have to take throughout their lives. Needless to say, the doctors who fall a victim to these become greedier as time goes by. Hence the competition to give more from the pharmaceutical companies.

Mind you, there is no free lunch. Somebody has to pay for this and in this case it is the poor, non-affording sick and helpless patient.

All these companies have a promotional budget, which I think basically should go in educating the doctor about the newer developments in the field of medicine. Many a companies do this by supporting various conferences and medical workshops. This is definitely necessary. Simultaneously, there should be a proper thought from the pharmaceutical companies to curtail costs by avoiding a number of unnecessary gifts and trying to subsidise the medicines as much as possible.

There is also a need of giving free medicines for the benefit of some poor patients. I am aware of pharma companies who do this regularly. But the menace of free gift must be stopped. Many of these gifts are of no use to the doctors or their families.

They may be even thrown out in the dust bins. What can a doctor do if at the beginning of a year, 10 companies give him 10 costly calendars or 10 pen stands or paper weights? There are better ways for the pharma companies to spend their promotional money, keeping in view the research, development, education of doctors as well as the end user—the patient.

Dr Digambar Naik