New Study Highlights Docs' Denial Calls for Ban on Reps

Troyen Brennan and colleagues fired a major salvo across the bow of the pharmaceutical industry last January with a paper published in JAMA, calling on academic medical centers to adopt strict policies to police (and generally to prohibit) interactions between their staff physicians and drug detail people. The same group, affiliated with the Center on Medicine as a Profession at Columbia, now has published a study (lead author, Susan Chimonas) which extends their earler arguments and adds some suggestive data to back them up.

This new study consists of responses obtained from focus groups, involving 32 physicians in 3 U.S. cities. (Watch for defenders of the status quo to attack this study as having too small and non-representative a sample. But also note that a similar study by Prosser and Walley in the U.K. in 2003 came up with very similar findings. Chimonas and colleagues, why didn't you have the courtesy to cite this earlier study?) The Journal of General Internal Medicine thought the paper worthy of on-line publishing in advance of its print edition.

Chimonas and colleagues show that these physicians were very aware of the notion and meaning of conflict of interest, but that as soon as the issue of their relationship with drug detail people, and their acceptance of company gifts, was rolled out, they refused to apply what they knew about conflict of interest and instead retreated into extensive denials and rationalizations.

The Chimonas study, whatever its limitations, seems to support two major themes I address in HOOKED--the omnipresence of rationalization in physicians' thinking about relations with the drug industry; and the deeply entrenched "culture of entitlement" that convinces us docs that we have all these goodies coming to us, and no spoil-sport had better get between us and those free dinners and other gifts.

I most liked the focus groups' responses to the PhRMA code of ethics on gifts--the document that the industry defenders roll out to show, first, that there may have been abuses in the past but everything now is all fixed; and second, that if we will just let the drug reps and the docs alone, they will figure out good ethical behavior on their own. One disgrunted physician, upset at the goodies that he supposedly could no longer have (such as tickets to sports events or free golf games), called the PhRMA code of ethics the "Doofus Code." Another respondent objected strenuously to the code's disallowance of docs' spouses coming to the free "educational" dinners. Said this fellow, "I think it's ridiculous, insulting...not to be able to spend an extra hour or two with our wives while we're getting an education." (Earth to Physician: please feel free to spend as much time with you want with your wife, and to engage in any activity, educational or otherwise, while doing so. But where in the name of whatever did you get the idea that a drug company should pick up the tab for that time, and add the cost to your patient's prescription prices?)

Chimonas and company conclude their paper with the draconian conclusion that this denial and rationalization tendency runs so deep that no voluntary code of ethics will ever do the trick. Docs will have to be banned, somehow, from seeing reps and taking gifts. Period.

Chimonas S, Brennan TA, Rothman DJ. Physicians and drug representatives: exploring the dynamics of the relationship. J Gen Inter Med 2007; 10.1007/s11606-006-0041-z (e-published ahead of print).

Brennan TA, Rothman DJ, Blank L, et al. Health industry practices that create conflicts of interest: a policy proposal for academic medical centers. JAMA 2006; 295:429-33.

Prosser H, Walley T. Understanding why GPs see pharmaceutical representatives: a qualitative interview study. Br J Gen Pract 2003; 53:305-11.