We’re entrusted with life, but not dinner or a pen?

The dinner invitations from industry start coming in medical school, even before we earn our MDs. To be sure, these dinner meetings offer a wonderful opportunity to meet with colleagues and enjoy a good meal at the end of a long day.

In the interest of integrity, I will say I often travel the country as a speaker for these events. At home in Kansas City, I frequently attend these dinner programs. But as we’re all aware, they have come under great legislative scrutiny, which resulted in the Sunshine Act and Pharma guidelines. So, are they beneficial?

GIVE US SOME CREDIT

Historically, these events were lavish affairs, often hosted in country clubs that included a round of golf. Even more dazzling venues were used, such as yachts and hot air (yes really) balloons.

Yet did these marketing events ever truly sway the pendulum of product market penetration? I would argue strongly that they did not.

Physicians are driven by outcome measures and their patients’ best interest. At the end of the day, there is no profitability in whether we prescribe one antibiotic or anti-inflammatory or another. It is offensive that physicians are not trusted to make clinical decisions regarding product use based solely upon outcome measures rather than a meal accompanying a lecture.

When I lecture on behalf of a company, I make it clear that I speak (in the case of a pharmaceutical product) on behalf of the molecule. The stipend I receive for lecturing does not begin to cover the lost revenue from missing clinic. Yet I am passionate about the molecules I discuss, based upon their efficacy and the potential benefit our patients receive. If this didactic discussion occurs in an appealing venue, it certainly does not detract from the importance of the conversation, nor do I expect that physicians’ use of a given product is the result of the meal they enjoyed.

Ironic, isn’t it, that politicians permit and encourage such activity in their milieu, while regulating and penalizing physicians and industry for doing likewise in theirs. We call it continuing medical education, and they call it lobbying, but in truth, it is about the dissemination of information, and it is up to each of us to interpret and use or discard in an ethical manner.

PER PHARMA GUIDELINES

“Prohibition on Entertainment and Recreation: Company interactions with health-care professionals are professional in nature and are intended to facilitate the exchange of medical or scientific information that will benefit patient care. To ensure the appropriate focus on education and informational exchange and to avoid the appearance of impropriety, companies should not provide any entertainment or recreational items, such as tickets to the theater or sporting events, sporting equipment, or leisure or vacation trips, to any health-care professional who is not a salaried employee of the company. Such entertainment or recreational benefits should not be offered, regardless of (1) the value of the items; (2) whether the company engages the health-care professional as a speaker or consultant; or (3) whether the entertainment or recreation is secondary to an educational purpose. Modest, occasional meals are permitted as long as they are offered in the appropriate circumstances and venues as described in relevant sections of this Code.”¹

A CLOSER LOOK

Several studies, of course, have looked at this potential bias suggested to exist between “gifts/meals/entertainment” and physician prescribing behavior and product utilization.^2-5 But, these studies are blatantly flawed. In the ones I’ve cited, some of the investigators recognize the limitations of their conclusions, though others have seemingly convinced the authors that such a relationship exists and that physician bias is genuine.

In at least one, the sample size is remarkably small.⁴ In another, despite the large sample size, changes in prescribing habits were considered significant — even though 11 of 19 academic medical centers in the survey sample that adopted new industry contact regulations showed a change in prescription habits.²

In general, the authors do not take into consideration that these branded products may be preferred by doctors because of enhanced efficacy and excellent clinical experience relative to the generic equivalent, for example. These studies often are regional and do not account for differences in patient demographics, severity of disease, or differing payer mix/regulations. Certain high-volume pharmacies (i.e., Walmart) are typically not included in these studies because of the difficulty in obtaining prescription data. Differences between academia — where reps are frequently not permitted into clinic or dinner programs are not offered or allowed — and private practice is not considered. High-volume versus lower-volume practices are not split out, and there is often no accounting for products used in the absence of “gifts” or dinner programs and those that may or may not have reps available to visit an office as the primary interaction between the company and the physician. Direct-to-consumer marketing, which influences patient demand, is typically not analyzed in these studies. Finally, differences in pharma plans are not sorted. The cause-and-effect relationships that the study authors presume exist are at the heart of pharma guidelines.

Continuing medical education is never-ending and hails from many sources. Journals and meetings are certainly important. But visits to our offices from industry reps add to our knowledge fund, especially between meetings when new technology frequently emerges. So, too, are educational dinner meetings, when information is shared and wonderful discussion ensues.

Like most colleagues, I am offended by the intent of pharma guidelines. We are trusted with life and death, hospital admissions, anesthesia and surgery, but not a pad of sticky notes, a 39-cent pen, or a dinner meeting above a specific dollar value. OM

REFERENCES

1. Code on interactions with healthcare professionals. http://phrma-docs.phrma.org/sites/default/files/pdf/phrma_marketing_code_2008-1.pdf . Accessed July 6, 2017.
2. Larkin I, Ang D, Steinhart J, et al. Association between academic medical center pharmaceutical detailing policies and physician prescribing. JAMA. 2017;317(17):1785-1795. http://jamanetwork.com/journals/jama/article-abstract/2623607 . Accessed July 6, 2017.
3. Grochowski Jones R, Ornstein C. Matching Industry Payments to Medicare Prescribing Patterns: An Analysis. ProPublica. March 2016. https://static.propublica.org/projects/d4d/20160317-matching-industry-payments.pdf?22 . Accessed July 13, 2017.
4. Wang Y, Adelman RA. Interactions between pharmaceutical industries and ophthalmology trainees. Investigative Ophthalmology & Visual Science May 2007, Vol.48, 2415. http://iovs.arvojournals.org/article.aspx?articleid=2385061 . Accessed July 13, 2017.
5. Taylor SC, Huecker JB, Gordon MO, et al. Physician-industry interactions and anti-vascular endothelial growth factor use among U.S. ophthalmologists. JAMA Ophthalmology Online First, published online June 23, 2016. Accessed July 13, 2017.

Steven M. Silverstein, MD, FACS, is a cornea-trained comprehensive ophthalmologist in practice at Silverstein Eye Centers in Kansas City, Mo. He invites comments. His e-mail is ssilverstein@silversteineyecenters.com.