To the Editor: Campbell et al. (April 26 issue)1 present disturbingevidence that many physicians accept inappropriate gifts fromindustry. Physicians should not accept such gifts, because thereciprocity they engender is known to affect prescribing decisions,which may harm patients and increase the cost of care.
The authors should have known, however, that an American MedicalAssociation (AMA) policy has addressed the ethics regardingindustry gifts to physicians since 1990,2 more than a decadebefore the Pharmaceutical Research and Manufacturers of America(PhRMA) code was implemented in 2002. In fact, the PhRMA codewas based largely on the AMA's opinion E-8.061, as even a cursoryglance will show.
Many gifts cited by Campbell et al., such as reimbursement foradmission and travel to continuing medical education (CME) meetingsand tickets to cultural and sporting events, are clearly prohibitedunder the AMA code. The AMA calls on pharmaceutical companiesand physicians to abide by their respective codes of conductand to neither offer nor accept inappropriate gifts, for thebenefit of patients and the public.
Robert M. Sade, M.D. American Medical Association Chicago, IL 60610
References
Campbell EG, Gruen RL, Mountford J, Miller LG, Cleary PD, Blumenthal D. A national survey of physician-industry relationships. N Engl J Med 2007;356:1742-1750. [Free Full Text]
American Medical Association. Opinion E-8.061: gifts to physicians from industry. In: Code of medical ethics. Chicago: AMA Press, 2006:212-24.
To the Editor: Voluntary guidelines issued by the pharmaceuticalindustry in 2002 addressing interactions with health professionalsinclude a ban on direct payments to physicians for attendanceat CME or other conference events. According to the guidelines,any industry support for conferences or courses should be providedindirectly through event organizers.1 Despite this guideline,Campbell et al. state that 35% of the physicians in their surveyreported receiving reimbursement for "costs of travel, time,meals, lodging, or other personal expenses for attending meetings,""free or subsidized admission to meetings or conferences forwhich CME credits are awarded," or both. These findings suggestlow compliance with voluntary industry guidelines and providesupport for a renewed focus on addressing commercial influencein medical education. The Charter on Medical Professionalismrequires that physicians and the profession take responsibilityfor our education and competence.2 Current reliance on industrysupport threatens this fundamental professional responsibilityand undermines public trust. Leadership from academic institutionsand medical societies is needed to address this undue influencein medical education.
David Grande, M.D., M.P.A. University of Pennsylvania Philadelphia, PA 19104 dgrande{at}wharton.upenn.edu
References
Pharmaceutical Research and Manufacturers of America. PhRMA code on interactions with healthcare professionals. Washington, DC: PhRMA, July 1, 2002. (Accessed July 12, 2007, at http://www.phrma.org/files/PhRMA%20Code.pdf.)
Medical professionalism in the new millennium: a physician charter. Ann Intern Med 2002;136:243-246. [Free Full Text]
To the Editor: Campbell et al. report that an increase in physician–industryrelationships may be due to a dependence on "industry representativesas the source of medical information." If this is true, thenphysicians need to be aware of the validity of that information.One report stated, "A recent study of the advertising materialand marketing brochures sent out by drug companies to GPs [generalpractitioners] in Germany has shown that about 94% of the informationin them has no basis in scientific evidence."1 Although I havenever, in more than 30 years of practice, met a drug-industryrepresentative I did not like, it is important that we obtainour medical information from nonbiased sources.2,3
Arnold L. Gorske, M.D. Health Education Program for Developing Countries San Diego, CA 92112-2683 ag{at}hepfdc.org
References
Tufts A. Only 6% of drug advertising material is supported by evidence. BMJ 2004;328:485-485. [Free Full Text]
Topol EJ. Failing the public health -- rofecoxib, Merck, and the FDA. N Engl J Med 2004;351:1707-1709. [Free Full Text]
Avorn J. Dangerous deception -- hiding the evidence of adverse drug effects. N Engl J Med 2006;355:2169-2171. [Free Full Text]
The author replies: Sade and Grande raise a very important issueregarding the effectiveness of the voluntary codes of conductof the AMA and the PhRMA regarding interactions between physiciansand drug companies. Our survey was not designed to test adherenceto these codes. Thus, we did not think it appropriate to commenton this issue in the article. However, Sade, the chair of theCouncil on Ethics and Judicial Affairs of the AMA, feels thatmore than one third of physicians do not adhere to the AMA'scode of conduct regarding the acceptance of reimbursements forattendance at meetings and tickets to cultural and sportingevents; this is certainly a cause for concern. Taken together,these letters clearly question the ability of the professionof medicine to regulate relationships between physicians anddrug companies by using voluntary codes of conduct.
Gorske's point regarding the scientific accuracy of the promotionalmaterials that pharmaceutical companies provide to physiciansis also a cause for concern. A number of others have expressedsimilar concerns regarding bias in industry-sponsored activities.1,2Since our study did not directly assess this issue, we chosenot to mention it in our article. However, it does seem reasonablefor physicians to remember that the information that drug companiesprovide to physicians may not always meet the scientific standardsof the peer-reviewed literature.
Eric G. Campbell, Ph.D. Massachusetts General Hospital Boston, MA 02114 ecampbell{at}partners.org
References
Angell M. The truth about drug companies: how they deceive us and what to do about it. New York: Random House, 2004.
Kassirer JP. On the take: how Medicine's complicity with big business can endanger your health. New York: Oxford University Press, 2005.
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