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;326:1155
All rapid responses
I found this theme edition very encouraging. For years I have been
amazed by the naivety of my colleagues as they accept yet another free
lunch / pen / foreign trip. They fail to recognise the sophistication of
pharmaceutical marketing and excuse their behaviour on various grounds.
One favourite is “It doesn’t influence me”. If this were true, they
would find that the reps would lose interest in them and move on to
another colleague who is more easily influenced.
Another excuse is that the NHS could not afford to fund postgraduate
education without sponsorship. It must be remembered that the money that
provides sponsorship started in the NHS coffers. It was paid to the
companies in exchange for expensive drugs and a small proportion is being
reinvested. If we got some discounts on drugs, perhaps we could afford to
provide education. In any case, colleagues who provide courses that do not
ultimately result in increased drug sales will inevitably find sponsorship
hard to obtain.
Many doctors do not realise that this behaviour is not the norm in
modern society. I have a number of non-medical friends who work in various
organisations within the public and private sector. They are generally not
permitted to accept significant hospitality from those who sell products
to their organisation and are horrified at the willingness of doctors to
see sales reps and accept lavish hospitality.
There are a number of possible answers to the problem of
inappropriate drug company sponsorship and promotion. I suggest that a
code of openness and disclosure would be a good start. Every healthcare
organisation – hospital trust, GP practice, etc – should develop a code of
conduct. This should include the introduction of a register of interests
listing all hospitality, sponsorship and significant gifts (over £5). The
code and the register should be available to patients and the public.
Doctors who do not abuse their position should have nothing to fear from
this. Our MPs already have to adhere to such a code and it seems to work
for them.
Annual appraisal also provides an opportunity for the doctor to
reflect on the appropriateness of his/her relationship with the
pharmaceutical industry. If the doctor lists gifts, hospitality and
sponsorship under the probity heading of the appraisal form, the annual
appraisal can include a discussion on how this has influenced practice and
whether they need to change their behaviour in the future.
Competing interests:
I am responsible for provision of advice and support on prescribing to the 400+ GPs in the Eastern Area of Northern Ireland. I do not accept drug company sponsorship or gifts.
Competing interests: No competing interests
Why just the physician's free lunch? The pharmaceutical industry now
owns worldwide cessation policy – at every level - and is making a
"killing" selling OTC NRT products generating a 93% midyear relapse rate
and using physicians to help.[1] Do you think my summary is how they'll
market the lozenge, gum and patch to physicians over lunch? Not on your
life! In fact, I had a brief online exchange with the study's industry
"consultants" who admitted that OTC NRT isn't half as effective as the
local neighborhood quit smoking program, but then go to great lengths
making childish math and cost arguments as to why a 93% relapse rate is
preferable to vastly superior interventions.[2]
Forget doctors and journals, the pharmaceutical industry owns a
controlling interest in the cessation education presentations of most
major health non-profits, which today are little more than pharmacy
storefronts. And, whether just lazy or hoping for a cozy job later, senior
government health bureaucrats allowed pharmaceutical interests to actually
write U.S. cessation policy.[3] In doing so they have damaged and
destroyed the efficacy of countless short-term (2 to 4 week) community
abrupt cessation programs around the world. Imagine alcoholics wearing IV
bags full of alcohol during AA meetings. NRT and gradual weaning have
transformed once serious programs into bad jokes.
[1] Hughes JR, Shiffman S, et. al., A meta-analysis of the efficacy
of over-the-counter nicotine replacement, Tobacco Control. 2003
Mar;12(1):21-7.
http://tc.bmjjournals.com/cgi/content/full/12/1/21?ijkey=5.ko5/Oz4yutI
[2] Tobacco Control eLetters, Shiffman, S, et. al. OTC NRT 93%
Midyear Relapse Rate, 10 Mar 2003 -
http://tc.bmjjournals.com/cgi/eletters/12/1/21#89
[3] U.S. Clinical Practice Guideline (June 2000 USDHHS), Appendix C,
Financial Disclosures for Panel Members, Consultants, and Senior Project
Staff - http://whyquit.com/whyquit/A_GuidelinePanelDisclosure.html
Competing interests:
Abrupt nicotine cessation programs director
Competing interests: No competing interests
No matter what we may think but as clinicians, we remain vulnerable
to the newer and innovaive marketing tricks of the pharmaceutical
industry. It is unimaginable the ways it
can, does and, I'm afraid, will continue to influence us.
Till not very long ago, I used to take pride in refusing lunch and
dinner offers by pharma companies. Instead, I would ask them for
literature documenting their efficacy etc. That lead to some sharp medical
reps identifying my weakness and hunger for the printed word. Realization
slowly dawned on me when I started receiving books and photocopied
journals. Instead of being fed pizza, I was being fed books!
I then came up with a good alternative. Like some colleagues of mine,
I started asking for bulk samples for the non-affording patients (who
frequent all hospitals in the developing countries like Pakistan). The
thought that I was playing a Robin Hood of sorts was a very satisfying for
my conscience. Whatever I got out of these rich companies, I was using for
the poor. Imagine my surprise and shame when a colleague pointed out that
I had been routinely using one specific brand of a drug only because it
had been bulk sampled in my ward!
I wonder if we can ever get out of this tangle and escape their
influence. If not, then does it really matter if this manipulative sway is
used for a little benefit of the poor?
Competing interests:
None declared
Competing interests: No competing interests
Insulting, patronising, anecdotal and ironic: four words I would use
to describe the doctor/drug company entanglement issue of 31 may 2003.
The cover of this conspiracy theorising BMJ pictures doctors [mostly thick
GPs, we assume] as fat pigs, drug reps as snakes and patients as
impoverished, unimportant, rodent-like party voyeurs. Good bit of satire
and pretty insulting. Maybe the BMJ will come to the same sticky end as
other punchy satirical mags.
It is patronising because it presumes that we thick GPs are so
gullible that we do not know that we are being sold products when we see
reps. Get real. I know, you know, we all know that that is what drug reps
do.
Watkins and his co-researchers show us a lot of cross-sectional data of
rep-seeing GP attitudes and behaviour. As they say, the plethora of data
does not show causality. Fine. But to come out with a biased,
unsubstantiated clanger such as ‘For some general practitioners, the
frequency of contact must be greater than their need to know about new
drugs’ is just anecdotal rubbish. I assume that this preconceived idea was
the reason why the authors carried out the study in the first place. In
any case, given the enormous number of products out there, it would
[anecdotally] take a lifetime of posh lunches to know everything about all
drugs – new or old.
But the biggest gripe I have with the BMJ in this issue is the double
standards shown by the BMJ editorial team in their editorial on the
subject. As they say in the ‘competing interests’ epilogue, the BMJ has a
considerable income from the pharmaceutical industry. Bit ironic, in my
opinion. My advice for the editorial team would be to ban all drug company
adverts in their journal before hectoring to the masses. Do as I do, not
as I say.
If a rep wants to see me in my free time to discuss a product, I do not
think it unreasonable to expect a nice lunch or a good dinner. I will eat
and, hopefully, enjoy the meal and I will not feel guilty about it. I will
not feel obliged to prescribe because, for me, the meal is the price to
talk to me, not to bribe me. Only joking, I am a thick, shallow, gullible,
conspiratorial greedy pig.
1. Watkins C, Moore L, Harvey I, Carthy P, Robinson E, Brawn R
Characteristics of general practitioners who frequently see drug industry
representatives: national cross sectional survey. BMJ2003;326:1178-9
2. Abbasi K, Smith R No more free lunches BMJ2003;326:1155-6
Competing interests:
None declared
Competing interests: No competing interests
Editor – In your themed issue, while referring to drug companies, you
omit to mention the potential influence of manufacturers of medical
equipment, implants and other disposables. In my role as consultant
anaesthetist with responsibility for equipment I often meet with
representatives from these companies. As I am clinically very busy and
rarely have time for lunch I am usually unable to take advantage of any
such offer, and I decline any hospitality while a purchase is being
negotiated. The relationship is often the opposite of your suggestion: I
regularly welcome representatives in order to discuss their products and
to show them something of our clinical practice, in recognition of the
need for a dialogue with industry to ensure our needs are provided for.
However your leading article “No more Free Lunches” asks the very
pertinent question “how did we reach the point where doctors expect their
information, research, education, professional organisations, and
attendance at conferences to be underwritten by (drug) companies?” – well,
at least in respect of attendance at conferences I am sure many others
will confirm my personal experience. The only way I have been able to
attend major international conferences has been through industry
sponsorship. For example, I attended the World Congress of Anaesthetists
in Montreal in June 2000 at the expense of an equipment manufacturer, who
paid my (economy) airfare and modest hotel bill, and a pharmaceutical
company who paid my registration fee. My NHS employer is only willing to
contribute a flat rate of £600 towards any overseas conference, which is
almost always insufficient for the purpose, indeed this amount is less
than the cost of most two-day meetings in the UK. I would point out that
my Trust is among the more generous in terms of study leave funding. So I
would suggest that at least part of the answer to the question you posed
is that the NHS woefully undervalues the attendance of its senior clinical
experts at reputable international conferences. Most colleagues in other
specialties can confirm that the only way to attend key meetings in other
countries is to accept industry hospitality. In other developed nations,
for example Australia and New Zealand, paid attendance at one
international meeting per year is included in specialists’ contracts; it
is high time the NHS did the same.
Nigel Puttick FRCA
Competing interests:
None declared
Competing interests: No competing interests
Mr. Antony E Green says:
"In the comments by Wiel Maessen he appears to be missing the point
that the WHO is trying to improve the collective health by raising the
smoking issue and encouraging people to stop smoking."
Is the WHO's real objective to care "genuinely for the patient and
improving patient health or care"? Or is it mainly a political
organisation that first looks where its money comes from and then
determines its main objectives? [1]
If the WHO really cared it would care about the millions of *real*
deaths caused by famine and disease in the underdeveloped countries and
not fighting 'virtual' deaths that are computed by computer models like
SAMMEC.
But it looks like the political analysis on WHO's behaviour explains
much more about the choices they make.
The most important sponsor of the WHO is the US. Smoker demonisation
started first there. Why? Maybe because the pharmaceutical industry is a
better sponsor of the US government and political parties as the tobacco
industry? Pharmaceutical companies donated about 3 times the amount of
money to US political parties in 2002 compared to the tobacco industry.[2]
All other major sponsors are western countries. Doesn't it sound
logical that an organisation like the WHO fights its sponsors' 'problems'
first?
So it's not only the direct funding of the WHO by pharmaceutical
multinationals that dictates their choices but also the American
government receiving ample funds by that same industry.
WHO's choices are not determined by *real* needs but by political
interests....
Orwell's Big Brother has gotten a face and it is obviously the Big
Pharma's one.
-----
[1] http://forces-nl.org/download/whowhat.pdf
[2] http://www.opensecrets.org/industries/contrib.asp?Ind=A02 and
http://www.opensecrets.org/industries/contrib.asp?ind=H04
Competing interests:
None declared
Competing interests: No competing interests
Sir,
One day it will happen that most of the doctors refuse free lunches
and freebies. The day all of us look and analyse our conscious probably we
will achieve. But at the moment the person who doesnot accept and
patronise the drug industry is a fool and a loser [materialistically].
Doctors have gone to the extent of opening their consulting chambers with
the financial help of pharmaceutical company. I strongly believe people
should pay for learning instead depend on free lunches during CMEs. The
day is not far people will realise this.
Competing interests:
None declared
Competing interests: No competing interests
It is amazing that the only ones to protest against the article are
Psychiatrists. Well, well you would expect that. After having declared
that every feeling humans have is a result of depression they have done an
admirable job in promoting anti-depressants. I am just waiting for the day
when Psychiatrists will recommend that we mix anti-depressants in the town
water supply.
Competing interests:
None declared
Competing interests: No competing interests
Dear Dr Smith,
Your inference that my colleagues and I would sell our souls for the
sake of a plastic pen and a slap up lunch at Pizza Hut is, frankly, a bit
wide of the mark.
There are two main criteria that apply to any prescription. The first
is that it should stand a reasonable chance of working. Otherwise the
patient will come back, possibly several times. The second is that it
should be cost effective. Otherwise the local prescribing managers will
come down like a ton of bricks.
Compared to these irresistible forces, the offer of a cucumber and
tuna sandwich will have little impact.
Commenting on your editorial the other day, the Times compared
Richard Smith to Savonarola, a fifteenth century monk who condemned moral
corruption in Florence. For his troubles, he was burned at the stake. Not
a fate that even his sternest critics should wish on Dr Smith.
Yours sincerely,
John Hopkins
Competing interests:
I rarely speak to drug reps
Competing interests: No competing interests
Re: Enough already - Critical Psychiatry Network campaign
Simon Wessely may think that the relationship between the pharmaceutical industry and the medical profession does not matter.1 This might be alright if all doctors took as refreshingly sceptical a view of medical practice as he does. He has agreed to chair a debate at the Critical Psychiatry Network conference on "Antidepressants are no better than placebos" (for details see www.criticalpsychiatry.co.uk/AnnualConference2003.htm). However juvenile he may regard the staging of such a debate, he at least seems to recognise the importance of the academic argument about the effectiveness of antidepressants. There is a genuine issue about bias in clinical trials of antidepressants, as further demonstrated by another article in this theme edition of the BMJ.2
The Critical Psychiatry Network does think that psychiatrists should declare their interests in drug companies.3 It also thinks that all organisations and conferences addressing psychiatric issues should provide full public disclosure of the amount of funding they receive from the psychiatric drug industry. A resolution to this effect was passed by the World Federation for Mental Health at its Membership Assembly, which was held at the Vancouver Conference and Exhibition Centre on 25 July 2001.4 The Critical Psychiatry Network is not receiving any sponsorship from the drug industry for its annual conference. It is dependent on subscriptions from delegates. The day's conference and debate are open to the public and there is a printable booking form at http://www.critpsynet.freeuk.com/form.htm.
Competing interests:
Founding member of Critical Psychiatry Network
I have always kidded myself that any money I have taken from drug companies has been to reduce their profit.
Competing interests: No competing interests