“Many, if not most physicians practicing today have, or have had, conflicts of interest that clearly to do not result in their patients’ best interest,” charges Dr. Catherine DeAngelis, former editor of the Journal of the American Medical Association (JAMA), in an op-ed article in the June issue of the Milbank Quarterly.

And those conflicts of interest — which DeAngelis defines as “a conflict between the private interests and the official responsibilities of an individual in a position of trust” — have become rampant over the past two decades or so, she says, as pharmaceutical companies merged their marketing and scientific divisions.

The conflicts begin in medical school with “the free black bags, instruments, or books given to medical students by a pharmaceutical company, or even the doughnuts, coffee, soft drinks, and free lunches provided at teaching conferences,” writes DeAngelis. The ante is then raised by “the free food, tickets to sporting and other events, sponsored trips to resort locales, and the shower of other gifts given to physicians by the pharmaceutical representatives assigned to them.”

“Some people maintain that such gifts do not influence physicians’ prescribing practices,” she adds. “But if that were so, why would pharmaceutical companies spend billions of dollars on these items, and why would they partially reimburse their marketing representatives according to the number of prescriptions written by the physicians to whom they are assigned?”

A widespread practice

But the conflicts of interest that compromise the doctor-patient relationship are often much more insidious than free meals or trips, as DeAngelis points out:

What about the free drug samples provided to physicians for their patients? It has been argued that these free samples help patients who cannot afford them. But then why are the vast majority of these free samples for new (meaning those still under patent protection) and expensive drugs that are almost exclusively for illnesses that require the drug’s frequent or continued use? . . .

What about academic physicians who do research or write practice guidelines or review papers funded by Big Pharma? Here the association between research sponsorship by pharmaceutical and medical device companies and pro-industry conclusions is clear. Most Americans are surprised to learn that the clinical research funded by Big Pharma dwarfs the annual investment by the National Institutes of Health. Moreover, much of this industry-sponsored research is tainted by bias that is not always clearly stated.

And then there is the problem of physicians and biomedical and health care researchers who work for a pharmaceutical company’s marketing division, rather than its scientific division. An obvious example occurs when “expert physicians” serve as industry-sponsored speakers and use the slides and data provided by the pharmaceutical company. Invariably, such “chaperoned” presentations accentuate the positive and downplay the negative (including price differentiation) aspects of the drug being promoted. 

Finally, there is the promotion of a drug for off-label use. Imagine the following and, unfortunately, common scenario: At a major clinical or health-related lecture, a physician paid by the pharmaceutical company is “planted” in the audience. The “plant” raises his or her hand and supposedly innocently asks the presenter if he or she has ever used the drug for an illness for which the drug has not been approved by the US Food and Drug Administration (FDA). The presenter then discusses off-label uses of the drug for this or that illness or symptom. Remember that physicians in the United States can write prescriptions for any drug, whether or not it has been approved by the FDA for that illness. So why not add a few more uses, which can translate into multiple sales and millions of dollars in unexpected revenue?

Law promises transparency

Starting later this year, thanks to the Physician Payment Sunshine Act (which is part of the Affordable Care Act), consumers across the country will be able to access information online about payments made by drug and medical device manufacturers to individual physicians.

But, asks DeAngelis, will that very-public disclosure persuade physicians to “uphold their professional promise to act in the best interest of their patients” and turn down the free five-star meals and trips, the lucrative speaking and consulting fees, and other compensation from Big Pharma?

“We can only hope,” she says.

You can read DeAngelis’s op-ed on the Milbank Quarterly website.