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| Is There Really a Difference Between a Ball Point Pen With a Logo On It and Two Tickets to a Football Game?
"Cartoons and Poems following each article are created and copyrighted by Dr. Ackerman and cannot be copied or reproduced without his permission."
I am going to list several items in increasing order of value. I would like each reader to choose the point at which you believe that you would feel indebted to someone who gave you that item as a gift.
0 = Business card
1 = Ball point pen with company logo
2 = Colorful eyeglass clip without company logo
3 = Reflex hammer with company logo
4 = Penlight with company logo
5 = Sandwich
6 = T-shirt with company logo
7 = Lunch at a local restaurant
8 = Dinner at an elite restaurant
9 = Certificate for a massage at a spa
10 = Two tickets to box seats at the Super Bowl
Suppose now that we increase the ante. Let us assume that you are a physician who has been solicited by an area representative of a large pharmaceutical company. Okay, now pick the point at which you would be willing to try prescribing a new medicine in order to please the individual who gave you the gift. Finally, suppose you try choosing the level at which you might be inclined to switch your allegiance from the medication that you are accustomed to prescribing to the new one. One more question: If you have picked a switch point, would you continue to adhere to that choice if it turned out that your patient's results were inferior, or side effects more pronounced with the new product?
Some doctors had to make a similar choice as much as several times every day. They were being inundated with representatives from pharmaceutical corporations seeking their attention and plying them with gifts. And now, an increasing number of them are starting to object. Proponents of the system are lining up against the opponents. More and more articles are appearing in the medical journals and newsletters. I would like to review some of the recent background including arguments - pro and con - during the remainder of this presentation.
All articles came from the American Medical News starting with an editorial for the October 22/29, 2001 edition called "Industry gifts to physicians: Less is more." No author's name was supplied. Placing the medical profession one notch above most others, the writer notes that industry gifts "raise a conflict with the standard that's supposed to apply in medicine, of what's in the best interest of the patient." It's implied that patients will tend to lose faith in their doctors. However, the barrier suggested does not seem to be lowered to zero on our list because it still allows for certain gifts to be acceptable. Some ideas of the more blatant type were family take-out dinners, books, Christmas trees, over-the-top meals and entertainment, honorariums, and travel expenses. In 1990 the AMA Council on Ethical and Judicial Affairs provided guidelines - updated in 2000 - but most doctors, especially younger ones, were unaware of them. Once again, the ban is not at level zero in deference to the belief that pharmaceutical and other medical corporations have the right to advertise their products, which, after all, do benefit patients. The key to proper gift giving includes keeping gift values modest, designed mainly to benefit the patient, and with no strings attached. A campaign was put in motion to advise physicians, and ironically one of the main contributions came from nine pharmaceutical companies. An article by Jay Greene in the September 17, 2001 issue entitled "AMA launches education drive on drug industry gifts" helped bring this campaign to the attention of American Medical News readers whose organizations were to receive informational packages along with information sent by companies to their representatives. It must be assumed that a good deal of this effort and that of a trade industry group in April of 2002, similar to that of the early 1990s, was to blunt any effort towards federal regulation. The trade group, Pharmaceutical Research and Manufacturers of America, ruled out such things as free tickets to entertainment venues and theater tickets, but okayed others like stethoscopes, medical books, pizzas and boxed lunches according to Andis Robeznieks in the May 27, 2002 AMNews issue. They also set down guidelines for physician consulting positions. Robeznieks also noted in a brief article published on June 24, 2002 that the American Medical Students Association provided guidelines for their members.
The story took a bizarre turn when a company called Time-Concepts LLC was formed to arrange for drug reps to be given time with physicians for a fee. Tyler Chin reported this in an article on May 6, 2002 called "Drug firms score by paying doctors for time." The price for 10 minutes was $105. The doctor gets $50, Time-Concepts gets $50, and the remaining $5 goes to charities chosen by the doctor. Doctors have to complete an "impact analysis" online in order to be paid. A second company called Physician Access Management Ltd charges $65. Finally, a report on June 14, 2002 mentioned that one physician-owned polyclinic was charging sales reps $30 per hour just to come in, whether they got to see a doctor or not, and that Vermont became the first state to require that gifts over $25 be reported to the state by the company. Probably the drug companies will find this approach to be much cheaper, but is this really a way to avoid conflict of interest? Richer companies will still have more access to the doctor's office, and most of them are avoiding the idea because they can afford to continue heavy gift giving. Furthermore, if the idea is to educate the doctor to new products, then why should he or she be paid for it? Proponents feel that it's okay so long as details of the transaction are fully disclosed and there's actual educational exchange.
Eventually the answer as to what is right and what is wrong should rest with the patient who stands to be benefited or harmed. Educating doctors and companies is fine, but new regulations, ethics, and laws have a way of being circumvented. If the patient is not educated as to the implications of potential conflict of interest, it's not certain that the practice of buying a doctor's attention and allegiance can be properly modified.
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If you think you can bribe me,
You are sorely mistaken;
There are far richer gifts,
That I've always forsaken
Our time is divided with greatest precision,
Carefully parceled into gems of advice.
Be ye pauper or king, you must be prepared,
To pay an extremely generous price.
Did I hear you say dinner at seven,
Then to the opera at eight?
Go right in my dear, the doctor awaits you,
And I'll see you tonight - but don't you be late.
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Cartoons and Poems following each article are created and copyrighted by Dr. Ackerman and cannot be copied or reproduced without his permission.
Copyright © 2007 by Marvin Ackerman, M.D.
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Relax! It’s Only Your Doctor’s Waiting Room, Not the ER: Or How to Get Along With and Understand Your Doctor is an insightful but irreverent intrusion into the complexities of modern day medicine. Listen to an interview with Dr. Ackerman
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