No such thing as a free lunch, pen, folder, or bag
Students and doctors are at risk of being influenced by drug companies
“You can borrow my pen, but make sure you give it back or I could lose my job.”
This was the curious remark of a drug company representative who had seen me fumbling for my biro. His company was sponsoring a lunchtime educational meeting at my primary care placement. Intrigued, I went on to quiz him in between mouthfuls of the organic crayfish and rocket sandwich that he had generously provided.
Apparently, the prohibition of giveaway pens is representative of progressive limitations in the way that the industry is allowed to promote its products. The exact rules on stationery distribution are complicated—reps can’t hand out such items, but can enclose them in packs given to delegates at conferences. These items may be branded with a company’s name but not with the names of their products. Other “freebie” promotional items may now be given to clinicians only if they are intended to be used for patients, such as peak flow meters, and then only if they cost less than £6 (€7.20; $9.40) each. The practice of giving prizes for competitions and quizzes is also now disallowed.
These rules are part of a code for drug companies, the latest version of which came into effect in January 2012. This code was created and is enforced by the Association of the British Pharmaceutical Industry (ABPI), an industry funded body that is responsible for regulating practice and representing the industry’s interests. Most major drug companies in the United Kingdom are members of ABPI. Roche, a Swiss global healthcare company, is a notable exception. The company decided not to renew its membership after being suspended for unethical practice in 2008. All drug companies and their representatives are expected to comply with the code, and suspension represents the strongest action that can be taken by the ABPI for not fulfilling this obligation. Most sanctions for non-compliance are largely non-punitive and aim to rectify the company’s wrongdoing. Individuals found at fault might be disciplined internally. Some groups, such as Nofreelunch, have questioned whether the ABPI is capable of acting as an impartial regulator given its close association with the industry.
The ABPI code of practice covers all aspects of drug promotion, including giveaway items, hospitality, sponsorship, and advertisements in journals and on the internet. Medical students and junior doctors are not mentioned specifically, but the code discusses appropriate relationships with healthcare professionals and patient groups.
Hospitality supplied by drug companies can be provided only at educational or scientific meetings and in appropriate environments (ie, not restaurants), and must cost the same as what recipients would normally pay. The hospitality can be provided to healthcare professionals only and not to friends, family, or administrative staff.
Drug companies can sponsor healthcare professionals to attend meetings by reimbursing food and travel expenses limited to economy class. Speakers and other contributors can also be reimbursed for their time.
Relations with industry
Many students will be familiar with tutors recounting the old days of relations with drug companies; extravagant wining and dining and all expenses paid trips to exotic conferences. This marketing of products directly to prescribers alongside the provision of expensive private gifts is an activity that has been extensively scrutinised. More cynical observers have equated it to bribery.
This is not a new problem. There has been public concern about relations between drug companies and healthcare professionals for decades. It has been a prominent enough issue since the turn of the millennium to prompt a parliamentary report in 2005. An update to the ABPI code of practice in 2011 reflected an attempt to deal with this ongoing distrust, and its importance was highlighted by an impressive collection of signatories including politicians, the British Medical Association, and the royal college leaders. In spite of this, it is unclear whether recent changes will be enough to restore public faith in relations between doctors and the industry.
Up to now, the focus of reform has primarily been to rectify a lack of public trust, and steps have been taken by many parties to deal with this problem. The promotion of drugs continues to exist in a more subtle way, however, where a low level of influence is subverting the philosophy of evidence based practice and potentially introducing extra costs to the NHS from more expensive prescriptions.
Pharma’s role in medical education
Is drug company sponsorship a necessary evil? Some educational opportunities might not exist without the financial support of drug companies. A general practice where I’ve worked said it was unlikely they would pay for any educational meetings aside from resuscitation and other mandatory training, passing the baton on to drug companies instead.
In 2007 the Royal College of Physicians commissioned a working group report on doctors’ relationship with the industry, and there was particular focus on education. The group concluded that “continuing professional development programmes are too dependent on industry support,” and “doctors too must take greater financial responsibility for their own postgraduate education.” But who will foot the bill in reality? In an established culture of industry sponsorship, it is not realistic to expect a cash strapped NHS to pay out.
Many consultants already provide teaching without charge at educational meetings. One such consultant suggested I should “look at the consultant and GP pay scales on the BMA website and speculate about whether you think they should be expected to provide education as part of their job.”
Drug companies often describe the role of their representatives as educational, rather than promotional, but their ability to act without bias is questionable. Yet it is important not to dismiss the industry’s educational role altogether. Continuing medical education could be externally funded without promotion if companies contribute to a central fund that could then be distributed without the influence of individual representatives. This has been suggested in the past by the Royal College of Physicians. Although it did not mention this proposition specifically, the ABPI reports that it will “consider a number of options” for the future of industry involvement with medical education, informed by a large opinion survey and further discussions with professional bodies (ABPI, personal communication, 19 January 2012).
Many free resources are made available to doctors to satisfy educational requirements, and careful decisions need to be made about the additional value of sponsored events. Those making decisions might acknowledge a potential influence on prescribing, but believe the educational benefit will provide an important enough improvement on patient care to make the venture acceptable. These decisions could be flawed, however, because promotional influence could be underestimated.
As individuals we believe we are less susceptible to marketing than others. The power of marketing is in its ability to subtly and subconsciously alter our consuming habits, and this applies just as much to drugs as it does to fizzy drinks and cars.
The doctors at my practice thought that talking about drugs with representatives could alter prescribing behaviour, particularly in juniors or those who might be unfamiliar with the topic, an assertion that has support in the literature. It is difficult to make generalisations about which groups of doctors are more liable to be affected by drug promotion; juniors could be influenced to a greater extent, but they are usually confined to a relatively dictatorial hospital formulary. Senior specialists and general practitioners might have more experience, but probably spend more time with representatives, comparatively. Considerable variation will occur between individuals at different staffing levels.
The drug industry is commonly and unhelpfully accused of villainy. These companies invest considerable energy in innovating new treatments and trialling their efficacies. Competition in the industry drives not only innovation, however, but also a pressure to increase market share by promotion. This is key to how the industry works, and therefore, although industry regulation is useful, the ultimate responsibility for removing marketing influence should lie with prescribers.
The General Medical Council’s Duties of a Doctor states that “You must not . . . accept any inducement, gift, or hospitality which may affect or be seen to affect the way to prescribe for, treat, or refer patients.” In the past five years 116 cases have been opened by the council against doctors who may have acted in breach of this principle (GMC, personal communication, 16 January 2012). Public records exist for the more serious infringements—less than 20% of these cases. Of these, none relates to dealings with drug companies. This indicates that there might be few, if any, doctors receiving unacceptable largesse from the industry, although a current lack of transparency could conceal such interactions.
A library of literature exists on how industry promotion affects prescribing behaviour (healthyskepticism.org/global/library), and it is possible that many doctors are not acting in accordance with the General Medical Council’s Duties of a Doctor, albeit in a way that does not bring their professionalism into question.
The Royal College of Physicians has its own recommendations about the appropriate relationship that doctors should have with industry as do other colleges, all of which echo the ABPI code and Duties of a Doctor. The BMA’s advice to doctors is similar and happily states that “it is a legitimate quid pro quo that drug company representatives pay for the costs of a meeting in return for access to the health care professionals attending.”
How are students involved?
Medical students are well known for indulging in hospitality and freebies. Most of us understandably believe little harm, if any, can come from gorging on sandwiches and pocketing pens, but many students have said that they are uncomfortable with the associated promotion of drugs. We will be among the first generation of doctors to have grown up with evidence based practice, and we should be informed of issues that affect this philosophy.
Medsin is a student group that campaigns on international issues. Their campaign Pharmaware, which focuses on the influence of the drug industry, has been successful in informing the policy of national bodies including that of the Royal College of Physicians, and their website has links to numerous informative resources.
Students who feel compromised might want to discuss with their tutors or hospital pharmacists the appropriateness of lunchtime meetings sponsored by drug companies. They might be surprised to find sympathetic ears. Advice for medical students is also provided by the BMA (tinyurl.com/bmaguidance).
It is important to acknowledge that freebies and hospitality represent the tip of the iceberg; the government’s parliamentary report concluded that the drug industry influences healthcare at every level, from prescription pad to clinical trial. Beyond evidence and guidelines, there is a need to be vigilant about industry influence in the political communities that shape healthcare, as recently highlighted by Iona Heath.
A fundamental question that needs to be addressed is what is the place of drug promotion in the age of evidence based medicine?
- Coombes R. Should drug industry staff teach students? Student BMJ 2009;17:84
- Flegg A. Introduction to pharmaceuticology. Student BMJ 2007;15:45-88
1Hull York Medical School, UK
Correspondence to: firstname.lastname@example.org
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer reviewed.
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Cite this as: Student BMJ 2012;20:e1719