Should all doctors publicly declare payments from drug firms?
A new database listing the financial gifts paid to healthcare professionals in the United Kingdom has sparked an interesting debate
You may have enjoyed a free lunch from a drug company while you were a medical student, but would you continue to accept gifts once you’ve qualified?
A publicly available website called Disclosure UK has been launched by the Association of the British Pharmaceutical Industry, which lists the payments made to UK doctors from the drug industry. We now know that in 2015 drug companies paid out over £340m (€400m; $440m) to doctors and other healthcare professionals.
Two thirds of this was spent on clinical studies and trials, with the remainder accounted for by “events” (including travel, accommodation, and registration fees) and “services and consultancy”—for example, training and chairing or speaking at meetings.
How much does the database really tell us?
Criticism of the scheme has been made because participation by health professionals is entirely voluntary. The drug firms making the payments are listed in the database, but the individuals receiving the payments are named only if they give their consent. As 30% of healthcare professionals who did not agree to have their data disclosed were in receipt of 52% of the payments registered, it is not surprising that the exercise has been described by Margaret McCartney, a general practitioner and columnist for The BMJ, as having “all the thrust of a dead jellyfish.”
Another criticism is that the database covers only drug company payments, which Fiona Godlee, editor in chief of the BMJ, says “represent only part of the overall picture of financial competing interests in healthcare.” She considers the database to be “a useful step towards greater transparency and public accountability, but it serves mainly to show just how far we have yet to go.”
What are financial competing interests?
A financial competing interest (or conflict of interest) exists if a doctor’s medical decision making could be influenced, either consciously or unconsciously, by payments or gifts they receive. These inducements may come from a wide range of sources including drug companies, medical device or medical education companies, private practice, private healthcare companies, or patent ownership. A conflict of interest is said to exist whether or not the doctor is influenced by the payment they have received.
Why does this matter?
Gifts and payments from the drug industry have been shown directly to influence medical decision making.  A study by an investigative journalism group in the United States found that doctors who received money from drug or device makers prescribed a higher percentage of brand name drugs compared with doctors who did not. Even doctors who receive just one industry sponsored meal are more likely to prescribe the drug the sales representative is promoting instead of a cheaper, generic alternative.
Financial conflicts of interest are said to “have repeatedly eroded the credibility of both the medical profession and [medical] journals.” And financial conflicts can also be harmful to the doctor-patient relationship and the confidence the public has in the medical profession. The General Medical Council warns doctors that the trust that is so essential to an effective professional relationship may be damaged “if your interests affect, or are seen to affect, your professional judgement.” Doctors are advised by the General Medical Council not to “accept any inducement, gift, or hospitality which may affect or be seen to affect the way you prescribe for, treat, or refer patients.” It sets out clear guidance for doctors faced with a financial conflict of interest. “You must be open about the conflict, declaring your interest formally. If you are in doubt about whether there is a conflict of interest, act as though there is,” it says.
Why is it important to be open about conflicts of interest?
Godlee says that transparency is necessary for fair, effective, and accountable healthcare. Ben Goldacre, academic lead at the Evidence Based Medicine DataLab at the University of Oxford, points out that a financial conflict of interest does not necessarily mean someone is biased. “There are good reasons to work with the industry, but it does introduce risks. That’s why clearly declaring your conflicts matters, so we can all judge for ourselves,” he says.
Even if a doctor has acted professionally and with the best of intentions, there is the risk of a perception of a conflict of interest if they have accepted any financial inducements. It is therefore in the best interests of doctors to be, and be seen to be, open and transparent.
Are there any downsides to disclosing this information?
Doctors may be concerned about the release of their personal data and about sharing private information about their income. As one of the most trusted professions, doctors may also think that they should be trusted not to be conflicted in the advice and treatment they recommend to patients. They may be concerned about how the data may be interpreted and whether they could be taken out of context or lead to inaccurate conclusions. The cost of setting up, maintaining, and monitoring a register of wider financial interests, and who will be responsible for this, must also be considered.
What happens elsewhere in the world?
In the US, concerns about industry influence on medical decision making led to the introduction of the Sunshine Act in 2013, and it is now mandatory for doctors to declare all payments greater than $10 from both drug and medical device companies. In France, a publicly accessible searchable database has been in place since June 2014. In the Netherlands, doctors declare their interests on an online public platform, which is funded by the medical associations. Disclosure is mandatory but is self regulated by a professional code of conduct and not legislation.
What next in the UK?
The General Medical Council is currently consulting on whether to include details of doctors’ conflicts of interests on the medical register. It does not have the legal power to make doctors participate in the Association of the British Pharmaceutical Industry’s database or in any similar scheme, and to make it mandatory would require a change in the law. A voluntary system may not be effective: an independent online register that offers doctors the opportunity to declare their conflicts of interest (www.whopaysthisdoctor.org) lists the details of just over 300 of the 195 367 doctors licensed to practise medicine in the UK. In October 2014, a joint meeting of the Royal College of Physicians and The BMJ concluded that doctors should be obliged to adhere to a code of conduct on relationships with industry and to declare their interactions with drug and medical device companies on a publicly accessible, searchable database maintained by the profession. Godlee has called for this to be delivered by the General Medical Council.
What can medical students do to bring about change?
The American Medical Students Association campaigns for US medical schools to introduce regulations governing relations with the pharmaceutical industry to ensure that teaching remains focused on the best patient care. The association has called on medical schools to teach students how to interact with the industry in a way that protects patients, promotes public health, and preserves the public trust in medicine. Similar schemes have been set up in Australia, Canada, and France.
In the UK, PharmAware, an organisation run by doctors and medical students, aims to raise awareness around how healthcare professionals can interact ethically with the pharmaceutical industry. Nathan Cantley, a foundation year 1 doctor working in Inverness, Scotland, and a member of the national steering committee for PharmAware, says, “Lots of medical students love a free sandwich from a drug rep talk thinking they are saving a day’s lunch money.”
But Cantley says that explaining the evidence that there is no such thing as a free lunch to students and doctors can be challenging. “Some are insulted at the suggestion that they could be ‘duped.’ Many others say they don’t think their prescribing could ever be influenced by accepting something as simple as a free lunch,” Cantley said.
Many of the studies that have looked at the interaction between drug companies and medical students have been carried on outside the UK. However, in November 2016 PharmAware and Universities Allied for Essential Medicines will be launching the PharmAwareness Student Survey to find out more about UK medical students’ experience and opinions of interactions with drug companies. Any medical student based in the UK or studying on an intercalated degree is eligible to participate, and all responses will be kept anonymous.
“When PASS [PharmAwareness Student Survey] is complete, we will have a dataset that can be included in any future reviews of the evidence surrounding medical students and drug reps that represents the views of UK medical students,” Cantley said.
More information is at www.PASSstudy1.co.uk and the study will be live from 1 November for 12 weeks.Marika Davies, medicolegal adviser, Medical Protection
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.
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