No more free lunches
BMJ 2003; 326 doi: https://doi.org/10.1136/bmj.326.7400.1155 (Published 29 May 2003) Cite this as: BMJ 2003;326:1155All rapid responses
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I have been unsuccessful in tracing back to the time when the
decision was made to extract the information on the declaration of
competing interest, conflicting interest or by whatever other name one
calls it. I have intended raising this issue for some time but was at a
loss to find a suitable peg to hang it on.
Having very recently installed broad band technology, one of the
luxuries I decided to treat myself to was to browse throught the BMJ site.
I thus stumbled on theme issues and ended up with this editorial, and that
was the moment of inspiration to express my concern about declaration of
competing interests.
Clearly there is no room for debate on the requirement to declare
interests, but what is debatable, is the requirement to have to admit to
competing interest every time one has to declare an interest. There seems
to be a need to plead guilty without a trial, or if you like to sign a
forced confession. Although there would be many an occasion when the
submission could be influenced by one's own interests, commercial or
otherwise, it should not be assumed that any personal interest is
necessarily a competing interest.
It may well be that this subject has been debated in the past, before
the editorial decision was taken, but some preliminary inquiries indicate
that there may be room for reopening the debate on the subject of
competing interest.
May I therefore suggest a more open expression of interest and that
competing interest be relabelled just declaration of interest, or relevant
interests. This would continue to provide all the protection afforded by
the requirement to declare one's interests while leaving the readers, who
are perfectly capable of making up their own minds, to draw their own
conclusions.
Any other competing or conflicting thoughts?
Competing interests:
None declared
Competing interests: No competing interests
I feel that trying to distance drug companies from doctors is as hard as teaching an old dog new trick.
I do appreciated that we need to be aware of the implications of being influenced by drug companies. But, just imagine how boring medical life will be without any drug company influence in present medical profession.
1. Medical journals will be very boring with no pictures in them (pictures of adverts). Printed on cheapest possible paper. ( so very few people who are addicted to reading journal will only read them ).
2. Subscription prices of these medical journals will definitely go up as they won’t get funding from pharmaceutical companies. ( so very few of us can read them )
3. The number of journals which are being published might come down. (As they wont get money from authors for publishing their articles )
4. There will be hardly any lunch OR dinner meetings. ( because hospitals will not fund them, neither regional PCTs will fund them. Which will affect social interaction among doctors, who meet at these meetings, they might get depressed! )
5. As the number of educational meetings will reduce, doctors will struggle to find required PGEA /CME points / hours for their appraisals / PDP /assessment.
6. As there will be no free lunches, doctors might end up becoming underweight after eating hospital canteen food OR might need to leave hospital for lunch, so fewer hours for patient care.
7. As there will be very few speakers / professors / consultants who teach / speak at meetings for charity. It will curtail down drastically the culture of educational teaching. ( seriously risking CPD / updating with latest medicines in market )
8. If drug companies are not funding any new research, than there will be very few new studies which will be published. (DOH might need to seriously consider increasing funding for medical research /audit and for CME, which eventually might increase the tax everybody pays!! – like you and me ( so govt might have more say in research if not drug companies and funding might vary on ruling party in power!)
9. Studies which will be done will be small due to funding problem. ( so might end up in prescribing some medicines which are less effective ! ?ethical )
10. If there are no drug representatives, than GP’s might end up in seeing only those who are sick. They will be denied to refresh their mood OR a small break of seeing some smiling faces in between their surgery. (this might contribute to increasing stress in GP’s )
11. As there will be no free lunches and no free pens, than doctors monthly budget will increase for spending on lunches and stationery items required for doing NHS job.
12. GP’s who participate in drug trials in surgeries (some consultants in hospitals), their annual budget will be hit if the distance between doctors and drug companies.
13. If holiday conferences sponsored by drug companies are stopped, means, physicians may not get their deserved break, from nerve racking NHS work. ( might increase stress / depression / early retirement ! )
These are only 13(lucky) reasons (there are some more) for why we should not distance ourselves from drug companies. Until and unless we are aware that pharmaceutical companies are not saints OR doing charity work, they are there to push their product. Than it is up to us to decide which anti-depressant and which analgesic to prescribe.
Competing interests: Have attended scores of drug company sponsored lunch and dinner meetings.
Competing interests: No competing interests
Dear Sir & colleagues:
I am not against drug companies and a flashlight pen that once in a
while they can give me as a gift; I am against the novel model of
blackmail that has currently taken place. One of these models is a kind of
a “friend´s club” from a milk-formula company from the USA; this exclusive
membership is only for “high ranking doctors” (they rank them) with a lot
of private practice. And maybe has its advantages, like free all-inclusive
trips to the best paediatric meetings around the world. Perhaps this is
not unethical at all… but what I do consider unethical is the bullying and
blackmail (literally) from the drug representatives if the “member”
decides to recommend another milk formula for his patients... at that
moment, they discharge the member and retrieve all the help and support
that was once “awarded”. This, of course, has several implications, like
the wrath of the ex-member and the sad and unethical behaviour of
“applicants” to the club who are yearning for the free trips and other
gifts (I have to admit, they are good at it).
Nobody, in an economic interest, can dictate a treatment or recommendation
to a patient from a doctor. For me, this is degrading the image of our
profession.
Sadly, but true, the unethical behaviour of some drug companies exists
around the world.
Competing interests:
I am not in one of these clubs, an I truly hope never will.
Competing interests: No competing interests
although it seems to be an intricate problem but what is the harm in
accepting free lunches unless one is too greedy about them?why should it
be impossible to maintain one's ethics even if one accepts some kind of
favor from a pharma company?one needn't overprescribe to show favor to a
company while one can very legitimately prescribe those drugs to a needy
patient.undue emphasis on a single product is a reprehensible act and
should be discouraged.accepting gifts from pharma cos. while making it
clear to them that no special favor will be bestowed to them shouldn't
pose to be a moral problem
Competing interests:
None declared
Competing interests: No competing interests
The relationship between Doctors and drug companies needs to be
strengthened but better regulated, and not severed as some are suggesting.
In an ideal world, Doctors should not have to rely on sponsorship by these
companies. In reality and as well in practice health care and medical
research is grossly underfunded by the government at all levels! We must
promote healthy competition amongst pharmaceutical companies in order to
ensure high standards and timely solutions to medical counundrums.
Doctors will continue work with one another to minimise bias arising from
any such relationship above.We shall continue to practice within the
framework of medical ethics to improve the nations health without
compromising on public trust.
Competing interests:
None declared
Competing interests: No competing interests
A young friend of mine has Leukemia. AML which is more serious and
harder to cure. He takes many of the same drugs my grandson took for his
cancer, Burkitts's Lymphoma, 16 years ago. He has the same side effects-
maybe worse because of the protocol he is on.
Where did all the money go for research on Cancer/Leukemia? Not much
has changed and I believe that the connections with organizations like The
National Cancer Institute and the big gun hospitals (Sloan Kettering) and
research institutes and that is doctors ultimately are responsible for the
lack of progress. The drug companies benefit from this circle of people
who control research and development. I do not say that individual
doctors are not compassionate and concerned but as long as "money" is
involved and these diseases are like an industry how much control do they
have.
I wrote a paper in college many years ago and what has changed? Yes
some cancers are more curable, yes detection is better but children are
still suffering and I see these childhood fatal diseases still hold
families in their grip.
Competing interests:
My husband is a doctor.
Competing interests: No competing interests
Thank you for your theme issue (1) on potential unhealthy alliances
between prescribers and the pharmaceutical industry.
Providing independent drug information using scientific principles
may counteract detrimental results of such alliances. This is one of the
purposes behind the establishment of Institute for Rational
Pharmacotherapy (IRF) in 1999 as a department under the Danish Medicines
Agency.
Our definition of rational pharmacotherapy signifies the treatment
that has:
- The largest effect
- The least serious adverse effects
- The fewest number of adverse effects
- The lowest possible expenses
IRF publishes a monthly medical journal (in Danish) and arranges
postgraduate training for G.P.s in relevant pharmacotherapeutic areas
(i.e. antibiotics, type II diabetes, psychopharmacology, cardiovascular
pharmacology, and rational treatment of obstructive lung diseases,
gynaecological endocrinology and analgesics). In addition, IRF arranges
public meetings on rational pharmacotherapy. In 2002, the title of this
meeting was "Perspectives and Achievements with Rational
Pharmacotherapy"; a conference organised under the Danish presidency of
the European Union.
On the Internet (2) IRF publishes reviews that critically evaluate
newly authorised medicinal products relevant to a large population. These
reviews are given in both Danish and English. IRF also prepares
pharmacotherapeutic guidelines for selected areas in co-operation with
scientific societies. Examples are guidelines for the treatment of
obstructive lung disease, for the use of TNF-alpha inhibitors in rheumatic
diseases and for the prevention of malaria. Moreover, IRF provides survey
statistics on the consumption of selected medicinal products in Denmark,
sponsors independent research and participates actively in the discussion
on rational pharmacotherapy in highly ranked international, peer-reviewed
media (3,4).
Based on suggestion by IRF, governmental medical representatives are
appointed locally in each county. These employees, who are typically
pharmacists or part-time G.P.s, monitors the use of drugs in Denmark and
advises G.P.s on their specific pattern in order to optimise
prescription patterns. It is also possible for the G.P.s to study their
personal prescription-pattern in relation to the use in the county as a
whole and in Denmark (5).
Thus, IRF aims to improve rational prescribing. Institutes such as
IRF and NICE may not only reduce the possible deleterious influence of
industry-driven marketing activities upon prescription, but can also be an
asset to the drug companies with the best products. We welcome a debate on
the possibility to initiate comparable initiatives in other countries.
References
1. Time to untangle doctors from drug companies. BMJ 2003; 326: 1155-1222
2. www.irf.dk
3. Thirstrup S, Kampmann JP. Adjustment of Europe��s drug regulation
to public-health needs. Lancet 2001; 358: 1734.
4. Bjarnason NH, Kampmann JP. Selection bias introduced by the
informed consent process. Lancet 2003; 361: 1990.
Competing interests: �
None declared
Competing interests: No competing interests
I work at a local restaurant delivery service. Our day business
consist of about 90% of doctors offices getting free food from drug reps.
From what I have experienced it's not even the drug rep who places the
order. It's the doctors office. In fact I think the doctor office's are
the one's who are sucking the marrow from the everyday person who has to
pay the price for prescription drugs, and the drug companies are letting
them do it. As if they don't get paid enough already...
Example: I made a delivery to a doctor's office that only had five
employees yet they ordered enough food for each employee to eat three
meals. How can you justify that? Talk about milking the cow to death...
After reading a lot of articles about the free lunch policy of these
companies I feel that I must add my two cents worth.
Many people say that these free lunches don't affect the overall cost
of prescription drug costs. I would have to disagree. The delivery company
I work for makes approximately 20 deliveries everyday, 5 days a week. The
average cost of one delivery ranges from $200-$500.
Now let's see... 20 deliveries a day times a mean average of $250
equals about $5,000 a day. Take this figure and multiply it by 5 days a
week... That's $25,000 a week and $100,000 a month. Wow! That's roughly
1.2 million dollars a year being spent on free lunch for doctors offices
within our delivery company alone.
If you take that figure and multiply it by 60,000 drug reps, well I
won't get my calculator out or anything but it's roughly 7 billion dollars
a year. How can you say that it doesn't impact the market cost of drugs?
Granted I liked getting those $25 gratuities plus the $20 add-on tips
but that doesn't make it right so I quit my job and became an advocate for
the reform of drug rep perks. I think it is good that legislators are
trying to restrict this area of the drug field.
Not to wreck my own career or yours but I would love to see the
bottom drop out of the perks business... I think it would have a definate
impact on the cost of prescription drugs. Doctor education is not even
close to a good excuse for this practice
Competing interests:
None declared
Competing interests: No competing interests
Dear Editor
Your theme issue on the drug industry and the “embrace of avarice and
excess” must serve as a mirror to see ourselves in.
The relationship between the pharmaceutical industry and the medical
profession is a natural one .As natural as that between the arms industry
and armies the world over. It can be one of constructive co-operation and
the health benefits are for all to see.
But it can be, as several robust studies and investigations have shown,
dishonourable and damaging.
So why do we indulge in such messy liaisons, full of biros, M&S
sandwiches, business class travel and lavish conference holidays? There
are the obvious reasons -pleasant sales persons, a sponsored break from
the drudgery of work and well, why not? The bigger factor is the global
and unflinching faith in the free market. Any debate on this influence of
marketing on decision-making and health outcome is considered too old
style and doctrinaire to be worthwhile. The rather subdued response to
your editorial 1and the issue in general from hospital practioners is a
testimony to what they think of it all. A waste of time. This mind set is
increasingly pervasive with students, junior doctors indoctrinated into
the free lunch way of life. The market has us all in its grip. The medical
profession, it appears will only see and believes what it chooses to.
Apart from the problem of potential influence in prescription, of the
devil quoting the scriptures to suit its purpose, there is the issue of
priority setting.
Decisions in cancer care, for example, are in the main, grounded in
evidence where it exists. Despite the army of reps set out to preach their
respective gospels, the existence of guidelines, protocols and consensus
statements make it difficult to influence the influential. There are
problems even here. So often the press will have stories of another cure
for cancer. The Health service is time and again accused of not providing
a “life saving drug” .The industry thrives on this publicity. Denying drug
treatment is a charge hard to bear, even for the rather stoic NHS.But
while there have been advances in cancer chemotherapy, the publicity and
promotion is often out of proportion to its real benefit. Surrogates of
outcome such as response rates, which even non-purists amongst us would
consider inadequate, may be quoted in an effort to create a niche for a
drug. The distortion of the agenda goes beyond this. Radiotherapy, an
important single modality of cancer treatment is considered just another
tool2. In comparison to other European and North American countries where
high quality radiation research and technology based studies are
encouraged, there are few departments in the UK that are able to retain a
commitment to this area of work. This is probably at least in part to the
lack of backing from an ambitious industry and the marketing that goes
with it. Achievements in radiotherapy, equivalent and often more
significant, hardly ever receive the fuss and attention that goes with a
drug.3
Disentanglement is the key.The University of California in San Francisco
(UCSF) and the American Medical Student Association need to be commended
for their work..
It is crucial that that the U.K. moves in that direction starting with the
creation of blind trusts for education.. Apart from decanting the
influence of the brand, access to funds would be certainly fairer than it
is now. All health professionals, not just doctors, can than have access
to grants without having to court salesmen.
We are easily reassured by our own integrity. And I’m sure few of us doubt
the honour of our colleagues within the health system. But that is hardly
enough. Our increasing knowledge from this world of competition demands
that local codes and national ones such as those of the Association of the
British Pharmaceutical Industry (ABPI) are constantly scrutinised. The
industry-health service relationship needs re-configuring. The medical
profession so often challenges politicians on issues of conflict of
interest. The existing environment makes our position duplicitous and
untenable.
Ref
1.Abbasi K,Smith R.No more free lunches bmj 2003;326:1155-6
2.Burnet et al Improving cancer outcomes through radiotherapy BMJ
2000;320 198-199
3.Saunders M et al Continuous hyperfractionated accelerated
radiotherapy(CHART) versus conventional radiotherapy in non small-cell
lung cancer:a randomised multi-centre trial.Lancet 1997;350:161-165
Competing interests:
Free lunches.
Competing interests: No competing interests
Re: A hungry student's view
It saddens me that a person with the ethics and compassion of "hungry
student" has been programmed into thinking that what developing nations
need is cheaper, safer drugs. The most clever thing that the drug
companies have done is to make the people who want to be healers believe
that drugs are what healing is all about.
There are small clinics in South Africa and Mozambique that are
successfully converting HIV+ patients to HIV-, and TB and bilharzia are
very successfully treated by what has become known as "alternative"
medicine. The suppression of herbal and homoeopathic medicine began in
1911. Before that homoeopathic medicine was regarded as "orthodox" in
North America. The financial arrangements that nowadays exist between
doctors and drug companies are just a symptom of a much bigger problem in
world health.
Competing interests:
I am an author who promotes non pharmaceutical types of medication.
Competing interests: No competing interests