Friday, April 30, 2010

What Do Patients Think of Docs' Financial Ties?

Adam Licurse, leading a team primarily from Yale, has contributed to our understanding of patient attitudes toward physicians having financial ties to industry (subscription required). Licurse et al. attempted a systematic review of the available literature on this subject. They identified 20 studies, most of decent or better quality, that addressed their questions. Let me quote their key conclusion: "When asked about the importance of disclosing certain [financial ties], patients and research participants largely want to know about physician and researcher [financial ties]. In clinical care, many patients believed that industry gifts of a personal nature to physicians are unacceptable, whereas fewer found professional gifts to be unacceptable. Patients are concerned that these gifts affect the cost and quality of care and that these gifts influence clinical judgment." The situation seemed less clear in research; most studies wanted to know whether people would be less likely to participate as subjects in research if they knew that the investigator had financial ties, but several studies seemed to indicate that this would not be a very big factor.

People coming at the subject from my own bias would tend to wish that the research would show massive distrust of physicians if patients found out about financial ties. The research that is available hardly shows that univocal or extreme an answer. However, neither does it support a claim one now hears from our friends the pharmapologists-- that there are simply no compelling data that the issue of financial ties and disclosure has anything to do with public trust in medicine at all. For example, here is Dr. Thomas Huddle, replying to his critics in a January article that I blogged about previously ( "Surveys have repeatedly shown that large majorities of patients do not regard the promotional items and food involved in typical detailing to be ethically problematic."

Dr. Huddle is strictly correct, but his assessment tells only a piece of the story. Plus he cites only three sources for his claim, all published before 2000. The Licurse review includes several surveys conducted within the last decade. One of them, by Jastifer and Roberts, notes in passing that more recent reviews appear to show patients as more critical of financial ties than surveys done in the 1990s (as would be very reasonable given recent publicity, and findings in some early studies that few patients were even aware of the nature of these ties).

Here is how I would summarize the Licurse et al. review: There is sufficient evidence to believe that a significant number of patients are concerned about financial ties between physicians and industry, in ways that implicate public trust in medicine.

Licurse A, Barber E, Joffe S, Gross C. The impact of disclosing financial ties in research and clinical care. Archives of Internal Medicine 170:675-82, April 26, 2010.

Jastifer J, Roberts S. Patients' awareness of and attitudes toward gifts from pharmaceutical companies to physicians. International Journal of Health Services 39:405-14, 2009.

1 comment:

Tom said...

Hard to know what to say here—Dr Brody cites my statement to the effect that patients do not, by and large, disapprove of the promotional inducements of pharmaceutical detailing as an example of a very different belief—that there is no empirical support for the proposition that physician financial ties affect public trust in medicine. I am at a loss as to how my statement as cited exemplifies the latter belief.

Dr Brody does not dispute the truth of what I did say, and I am grateful for being made aware of more recent data that bears on the issue; the only recent study cited in the Licurse paper that bears directly, so far as I can see, is the Jastifer study mentioned by Dr Brody; that study indeed suggests that public attitudes may have become more sceptical than they were; a 54% disapproval rate of pens as gifts per the Jastifer survey perhaps indicates a shift in public attitudes toward routine detailing inducements (I advisedly avoid calling them “gifts”)—if indeed the results of the study can be generalized, which seems doubtful. I have not yet gotten access to the paper but the abstract states that the response rate for the survey was 10%--not particularly inspiring of confidence. I am aware of so far unpublished data from a well-done recent survey that is much more consistent with the 1990s studies I cited as noted by Dr Brody.

In any event, it will not be surprising to see shifts in public attitudes toward detailing and its inducements if the sermons preached by the pharmascolds take hold in public consciousness. That will be a sad outcome if, as I believe, detailing offers a net benefit to the public—a virtually unalloyed benefit if doctors engage with it properly. That physician financial ties may affect public trust in the profession I take as a given. The hard work is in determining which ties ought to be accepted and which discouraged—believing as I do that academic-industry relationships are shoals to be navigated rather than swamps to be drained. The usual pharmascold prescription, for simply severing any tie that might be construed as a conflicting interest, is doubtless comforting in its simplicity and moral certitude to those who offer it. They live in a different world than I do, however.