AMA Journal of Ethics^®

Case

Dr. Mathews is director of the internal medicine residency program at a large teaching hospital. The department chairman asked him to seek sources of funding for the weekly noontime conferences, adding, "With all those drug companies out there wanting time with physicians, you shouldn't have a problem finding someone to buy us a sandwich and chips once a week."

Dr. Mathews asked, "That's okay with you and the department, allowing a drug company to buy lunch once a week?"

"I think so," the chairman said. "Everyone knows by now that each drug rep is going to tout his own wares. It's a wash, in the end. Most 6-year-olds know how to discriminate among fast-food ads on television; I think residents can make sound independent decisions, don't you?"

Dr. Mathews had, in fact, been talking with a rep from Melissima Inc who was trying to push Melissima's ACE inhibitor. If any product message could be neutralized by the sheer number of competing ads, an ACE inhibitor ad would be it. The rep okayed the plan. She would be there at the weekly conferences, but only in case someone had a question, she explained.

Dr. Mathews thought that, with a few words from him to the residents before the Melissima sponsorship kicked off, everything would be okay. After a while, he'd switch companies and let a Melissima competitor buy lunch. Or if it turned out that the Melissima rep was being too chatty, having too much to say to the residents, he'd switch. These things needed to be judged on a case-by-case basis, Mathews thought. All company sponsorship cannot be condemned as bad. By rough calculation, though, Melissima would be spending about $650 to $700 on the food per week. He wasn't sure that information would pass the "how would it look in the headlines" test.

Commentary 1

There are several reasons why Dr. Matthews and his chairman ought to rethink their decision to allow a pharmaceutical representative to buy lunch for their housestaff once a week.

First, while perhaps it is true that a 6-year-old can distinguish among fast food ads (though I doubt this), there is ample evidence in the medical literature that physicians are influenced by promotion and that physicians who practice on the basis of promotion are more likely to prescribe inappropriate or expensive medication.¹ If all ACE inhibitors are the same, than we can hope that the housestaff will prescribe the least expensive and most convenient one, not the one made by the company that provides the best lunch.

A second reason for rejecting the offer is that someone is paying for this supposed free lunch, and arguably it is patients, in the form of higher drug prices. Pharmaceutical companies spend billions of dollars every year in the US on research and development; they also spend billions of dollars each year on promotion. The industry maintains that one reason for the high cost of pharmaceuticals is the high cost of R & D that goes into each product. If this is so, then must not the high cost of promotion also go into each product? It is true that residents work hard and don't make all that much money, and perhaps their hospitals or departments should be buying them lunch; but certainly their patients—many of whom earn far less than they do—should not be buying it for them.

But the third and most important reason why the department should turn down this lunch is that the department is serving as a very bad role model for its residents if it accepts. The doctor-patient relationship is a fiduciary relationship. Fiduciaries, because of their specialized knowledge and the trust that is placed in them by the public (in this case, patients), have an obligation to avoid conflicts of interest. Gifts—whether large or small, educational or not—influence behavior, create relationships, and thus create conflicts of interest. Physicians, like judges, journalists, and basketball referees, must avoid even the appearance of conflict of interest and therefore should accept no gifts from drug companies. Residency programs, as well as faculty entrusted with the training and development of future physicians, must take the lead in role-modeling this behavior for trainees.

Last year, the Accreditation Council for Graduate Education (ACGME), which establishes the standards for the more than 7000 residency programs in the United States, produced a White Paper entitled Principles to Guide the Relationship between Graduate Medical Education and Industry.² The paper acknowledges the "proven" potential for conflict of interest resulting from pharmaceutical promotion, the "proven" influence on medical decision making, and the well-documented inability of physicians to recognize this influence. While the council found itself unable to follow its own arguments and prohibit interactions between trainees and industry representatives altogether (as it could and should have), it did state that "programs and sponsoring institutions must determine through policy, which contacts, if any, between residents and industry representatives may be suitable, and exclude occasions in which involvement by industry representatives or promotion of industry products is inappropriate" (italics added).

Programs must do more than this; to transmit to trainees without interference the core value (and competency) of professionalism, training programs—like individual physicians—must wean themselves entirely of pharmaceutical industry largesse and the conflicts of interest that come with it. Dr. Matthews and his chairman should, therefore, just say no to this free lunch.