Interactions between doctors and the pharmaceutical industry are frequent, involve more than just face-to-face visits with company representatives, and have consequences for patients, doctors, and society (1, 2). Such interactions include accepting direct gifts of equipment, travel, or accommodations and indirect gifts through sponsorship of software, textbooks, and continuing medical education. These interactions begin in medical school and persist through a physician’s career, yet data suggest that physicians at various training levels remain unaware of the pros and cons of these relationships or the professional policies guiding their conduct (1, 3).
Psychiatry’s interactions with the pharmaceutical industry have been reported in the academic literature and lay press (4–9). Psychiatric educators have highlighted the problems that arise when industry plays a role in educating trainees about pharmacology and also the pervasive influence of industry-sponsored faculty and research on the practice of psychiatry (4). Others have argued that some interactions between residents and industry are, on balance, ethical and that educators should prepare trainees for future interactions with industry (5). Studies attempting to quantify the relationship between psychiatric residents and industry have found interactions to be common and to include lunches and other gifts (7). Despite this, surveys of psychiatric residency training directors showed that often no formal policies were written and residents received little didactic instruction on the topic (7, 8). These findings are disconcerting given the empirical evidence that shows that free gifts negatively affect physicians’ prescribing behaviors (10, 11).
Psychiatric residents are therefore in the precarious situation of having significant exposure to the pharmaceutical industry but, depending on their training program, little practical advice on how to conduct these relationships. This commentary aims to address this predicament by summarizing five key areas: gifts from the pharmaceutical industry to physicians, detailing between pharmaceutical company representatives and physicians, the relationship between medical academia and the pharmaceutical industry, differentiating industry promotion from medical education, and patient perceptions of physician-pharmaceutical industry interactions.
Gifts From the Pharmaceutical Industry to Physicians
In 2000, the pharmaceutical industry spent $15.7 billion on promotion (12), with significant dollars spent on “gifts” to physicians. Giving a gift creates a social contract and imposes a reciprocal obligation on the recipient. Gifts from pharmaceutical company representatives (who are usually bright, young, and personable) can strengthen the relationship between a doctor and a company representative (13).
Proponents of gift giving from industry to physicians argue that the act maintains goodwill in a relationship that has historically resulted in impressive advances (14); encourages attendance at continuing medical education, which may be reduced without the convenience of an accompanying meal (10); and compensates for the time physicians spend becoming educated about products by industry representatives (15). Opponents of gift giving argue that the act creates opportunities for bias (10), thus creating a conflict of interest for the physician (16); affects physicians’ prescribing negatively, such as through erroneous information about the medication and nonrational prescribing (11); and contributes to the high cost of prescription medications, because the cost of such gifts is ultimately passed on to consumers.
Recent policy changes have resulted in the industry adopting voluntary bans on common gifts and, in many medical schools and residency training programs, implementing formal guidelines. Despite this, psychiatrists continue to be offered gifts from the pharmaceutical industry. Such offers should be critically evaluated with an understanding of the full implications of the offer, especially the offer’s influence on prescribing choices and relationships with patients.
Detailing involves pharmaceutical company representatives visiting physician offices to discuss products. Eighty-three percent of physicians acknowledge such visits (17). Representatives efficiently distribute information about new medications, but prescribing behaviors influenced by detailing may be nonrational and expensive (18). A fundamental conflict in receiving information this way is that industry employees are motivated by business principles, such as ensuring profits, while physicians have a fiduciary responsibility to act in the best interests of patients.
Shaughnessy et al. (19) differentiate between rational reasons to use a drug, such as greater effectiveness, patient convenience, and lower cost, and nonrational appeals voiced by industry representatives, such as appealing to authority (“Dr. X uses this drug”), the bandwagon effect (“everyone is using this drug”), the red herring (giving technical but irrelevant data), and the challenge (“prove me wrong by buying this drug”). Anastasio et al. (20) recommend asking company representatives the following questions: How does this product compare with X, which is what I usually prescribe? What are the medication’s adverse effects? How much does this medication cost per month? Does a well-controlled study compare the new drug with others prescribed for the same condition?
Finally, physicians must consider whether the promoted medication is a “me too” drug—a drug with minor pharmacological difference to one already approved by the FDA that may offer little clinical benefit over the existing medication. Critics argue that some medications are only developed for companies to gain market share and add little to a physician’s armamentarium (21).
Medical Academia and the Pharmaceutical Industry
Academic centers in the United States have partnered with the pharmaceutical industry to bring innovations effectively to market. Relationships vary from individuals, such as faculty members receiving research support through grants or fees for supporting marketing activities, to institutions, such as an academic institution owning stock in research being conducted at the institution (22, 23).
Commercial interests may also influence scientific publication and research. Medical journals receive substantial income from industry through advertising, reprints, and sponsorship of supplements. Furthermore, non peer-reviewed publications, wholly dependent on industry advertising, are sent to physicians on a large scale without charge (24). Many medical journals have strict rules for authors that govern the reporting of sponsorship and conflicts of interest (25).
In the United States 70% of financial support for clinical drug trials comes from the pharmaceutical industry (26–28). Physicians need to critically evaluate studies for undue commercial influence over key steps of the research process: Does the trial test the drug in a healthier population than the one that will actually receive the drug? Is the new drug compared to an insufficient dose of a competing product? Does the study employ surrogate end points or nonvalidated scales, which may not correlate with more important clinical end points or that are more likely to support the study’s focus? Is the process of data analysis compromised? For example, investigators in a multisite trial may have access to only portions of the data, with the sponsor retaining primary control over the entire clinical trial data (26).
Differentiating Industry Promotion From Continuing Medical Education
Pharmaceutical companies are major disseminators of information to prescribers. Examples of “information asymmetry,” in which industry and paid researchers act as “opinion leaders” have been reported (29), including opinion leaders writing one way in a scholarly journal article about a medication and talking about it another way with practitioners in an informal setting (e.g., non-CME dinner talks).
Funding for CME is often inadequate, so industry support can be useful (30). In addition, industry is an abundant source of advances in medicine and technology, and its desire to dispense information furthers the goal of CME (31). Such support can be harmful, however, when the content is inadequately vetted, so that it becomes “ads disguised as educational materials” (32), topics skewed to favor “treatment” versus diagnosis and/or prevention (33); and biased to support the sponsor’s drug and influence physician prescribing (34).
Educational material must be differentiated from industry promotion. The following are markers that CME content is likely free of commercial bias (35, 36): the speaker does not focus on a single company or drug; the CME provider controls the event’s budget; promotional materials are not distributed in the educational session; full disclosure of commercial support occurs; and decisions regarding the topic and content of lectures rests with the physician organizer/speaker, not the sponsor.
Patient Perceptions of Physician-Pharmaceutical Industry Interactions
Negative aspects of the relationship between the medical profession and the pharmaceutical industry receive intense media attention (9). Government regulators are also increasingly interested in these interactions. Gifts from representatives may invoke antikickback laws; physicians and drug companies both are vulnerable, with the possibility of criminal prosecution, civil monetary fines, and exclusion from government programs (37–39). Recent analyses of industry data showing that spending 24% of profit dollars on promotion, versus 13% on research and development, indicate that such marketing activities are likely to continue to attract attention (40).
Studies of patient perceptions reveal that patients are often unaware of the many personal gifts frequently given to physicians by the pharmaceutical industry. When they are made aware, a significant percentage of patients disapprove of gifts that do not benefit patient care (1).
The relationship between the medical profession and the pharmaceutical industry has held the attention of the academic literature and lay press for decades. Academic psychiatry has recently started to introduce formal didactic teaching on the subject, but the presence of institutional policies varies, as does the content of such policies. This review demonstrates that interactions between the pharmaceutical industry and psychiatry are complex. The relationship is dynamic, with constantly evolving parameters and opportunities. Trainees will be better equipped to handle this relationship ethically if they approach such interactions critically rather than adopting a fixed approach, assessing potential advantages and disadvantages at each step.