Academic Psychiatry 22:135-137, June 1998
© 1998 Academic Psychiatry
Pharmaceutical Companies and Academic Departments of Psychiatry
A Call for Ethics Education
Richard C. Christensen, M.D. and
Michael J. Tueth, M.D.
Dr. Christiansen is assistant professor of psychiatry, University of Florida College of Medicine; and Dr. Tueth is associate professor of psychiatry, University of Florida College of Medicine, Gainesville. Address reprint requests to Dr. Tueth, University of Florida College of Medicine, Geriatric Psychiatry Residency Program, P.O. Box 100256, Gainesville, FL 32610.
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ABSTRACT
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Pharmaceutical companies contribute over $13,000 per physician for promotion and advertisement of products. Psychiatrists and psychiatric residents are influenced by these interactions. Two recommendations to psychiatric residency training programs are offered: Incorporation of ethics education into teaching forums and the establishment of specific ground rules that would govern the interaction of pharmaceutical companies with psychiatric residents.
Key Words: ethics • pharmaceutical companies
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INTRODUCTION
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Pharmaceutical companies mean business. In the United States alone, pharmaceutical manufacturers spend in excess of $10 billion dollars per year on promotion and advertising (1). In 1988 they spent an estimated $5,000 per physician, and in 1993 this amount swelled to more than $13,000 (2). Coffee mugs, pens, and free lunches are only some examples of the largess bestowed on physicians. In academic psychiatry, for instance, drug companies underwrite educational symposia, provide stipends for speakers at Grand Rounds presentations, sponsor continuing medical education seminars and teleconferences, and fund university-affiliated researchers to undertake company-sponsored clinical trials.
Make no mistake about it: psychiatrists, like other physicians, are influenced by these interactions. A number of studies have shown that contacts with pharmaceutical promotions have resulted in the adoption of commercial views of drugs, requests for additions to hospital formularies, and changes in prescribing practices that favor a particular drug company's product (3,4).
Psychiatry residents may be particularly susceptible to the influences of pharmaceutical marketing practices because the residents have assumed the dual roles of learners and practicing physicians. As a consequence, their prescribing preferences have yet to be established and their fund of knowledge, though developing, is limited.
Although industry-supported educational trips, free gifts, and expensive dinners may be particularly irresistible to physicians in training, it should not be overlooked that these marketing practices are commonly linked to the promotion of new and expensive psychotropic medications. However, as in other medical specialties, the one who writes the prescription is not the one who pays for it. As a consequence, when industry is inserted into the physician–patient relationship the potential for inherent conflicts of interest is arguably high.
Obviously, interactions between residents and drug companies should not be universally prohibited. However, we do believe they warrant increased ethical examination and monitoring. The focus of this commentary, therefore, is to neither to pillory pharmaceutical companies nor chastise departments of academic psychiatry. Rather the aim is to propose that ethics education in academic departments of psychiatry formally address the issue of pharmaceutical company interactions with house staff.
Although ethical guidelines regarding this issue currently exist (5), there remains a serious question about how familiar psychiatry residents are with these specific directives. Moreover, ethical guidelines mean little if they are either irrelevant to an individual's situation, inadequately disseminated, or generally ignored, as evidenced by the practices of the resident's department.
To address the issue of pharmaceutical company interactions with residents, we offer two recommendations to directors of residency training. First, we propose that each department make an attempt to formally incorporate this topic into the course content of the teaching forums usually attended by psychiatry residents. Educating house staff about the established professional guidelines is the necessary first step to enhancing an awareness about potential moral conflicts in medical–industry interactions. Didactic seminars in psychiatric ethics are the logical settings for introducing this important, but frequently unarticulated, ethical issue.
By using selected readings on the topic, as well as case studies, encourage residents to carefully reflect upon the relevance of professional codes of ethics in their day-to-day interactions with pharmaceutical companies. However, other forums for ethics education could also be pursued that would involve all members of the academic department. For example, a Grand Rounds presentation could be an exceptional opportunity to highlight the issue for medical students, residents, and faculty alike. Additionally, a department-sponsored panel discussion, involving representatives from the pharmaceutical industry, faculty, and residents, has the potential of creating a lively and highly interactive examination of the pertinent ethical dimensions of this complex issue. Finally, department-based journal clubs, which are usually organized by senior residents but open to faculty, could be tapped as a forum for reviewing the current ethical literature on this topic.
Second, we recommend that each department consider the establishment of specific ground rules that would govern the interactions of pharmaceutical companies with residents. Department-specific guidelines have been successfully developed in a number of different specialties and have the advantage of being specifically tailored to meet the needs of particular resident populations (6,7). Obviously, this approach would involve an ethical examination of a department's relationship with the drug industry and would entail a dialogue that has been instigated by the aforementioned educational forums. The endeavor to develop such guidelines would have to be rooted in a departmental-wide ethical analysis on a topic that has received scant formal attention in most academic departments of psychiatry.
Pharmaceutical companies do, indeed, mean business. However, as has become abundantly obvious in recent years, the morality of the marketplace is not always consistent with the internal goals of medical education and the provision of patient care. Academic departments of psychiatry ought to be especially mindful of this critical issue when developing their programs in ethics education and assessing their relationship with the pharmaceutical industry.
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REFERENCES
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Heber A: Drug companies and doctors: a troubling alliance. Psychiatric Residency Newsletter 1993; 17:1–2
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Hodges B: Interactions with the pharmaceutical industry: experiences and attitudes of psychiatry residents, interns and clerks. Can Med Assoc J 1995; 153:553–559[Abstract]
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Lexchin J: Interactions between physicians and the pharmaceutical industry: what does the literature say? Can Med Assoc J 1993; 149:1401–1407
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Lurie N, Rich EC, Simpson DE, et al: Pharmaceutical representatives in academic medical centers: interactions with faculty and housestaff. J Gen Intern Med 1990; 5:240–243[Medline]
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American Medical Association, Council on Ethical and Judicial Affairs of the American Medical Association: Gifts to Physicians From Industry. Chicago, IL, American Medical Association, 1997, pp 117–119
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Johnstone RE, Valenzuela RC, Sullivan D: Managing pharmaceutical sales activities in an academic anesthesiology department. J Clin Anesthesia 1995; 7:544–548[Medline]
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Lichstein PR, Turner RC, O'Brien KO: Impact of pharmaceutical company representaives on internal medicine residency programs: a survey of residency program directors. Arch Intern Med 1992; 152:1009–1013[Abstract]
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ABSTRACT
INTRODUCTION
