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Editorial
Why I No Longer Accept Pens (or Other "Gifts") from Industry (and Why You Shouldn't Either) RICHARD S. PANUSH, MD,
Professor and Chair, Department of Medicine, Saint Barnabas Medical Center, 94 Old Short Hills Road, Livingston, New Jersey 07039, USA. E-mail: rspanush@sbhcs.com Address reprint request to Dr. Panush. If market research by large industrial companies had suggested that the returns were not adequate, these activities would not take place...doctors were either unwilling to admit to the powerful influence of commercial pressure or unconscious of it... some...declared that they would retain virgin intellectual purity...such a belief may preserve self-respect, but it is a delusion1. The degree to which the profession, mainly composed of honorable and decent men, can practice such self-deceit is quite extraordinary. No big company gives away its shareholders' money in an act of disinterested generosity2. We have already established what you are. We are only quibbling about your price. — Anonymous What choice should a man make? That which leads to honor...Where there are no men, strive to be an honorable man. Talmud, Avot 2:1 and 2:5 There's really not much I'd change if I could do my career over again. But there are a couple of things. Like most of us, perhaps, there are some things I would do differently and some memories that still haunt me, which I wish I could exorcise. One is of the horrible, unconscionable operations we performed as second-year medical students on dogs, in the labs: I still have nightmares about this, wish I then had the courage to protest that aspect of our curriculum, and now do what I can in my way to make amends. Another regret is the naivete with which I interacted with drug companies as a younger academician. There was a time when I eagerly accepted gifts from drug companies. It began early in my professional life. I was running a division, training fellows, getting government and industry grants to find the causes and cures for rheumatic diseases, presenting my data at national and international meetings, and generally doing the things that advance an academic career. I was flattered by the attention of the drug reps. I felt entitled to whatever they handed out; after all, I had worked hard to be in a position to take those perks (also they were neat and my kids often had stuff that non-physicians' kids didn't). At one point a colleague photographed some of the Pfizer memorabilia we had proudly accumulated (following the introduction of Piroxicam) which included calendars, note pads, pens, watches, gym bags, hats, umbrellas, t-shirts, backpacks, calculators, calendars, paper clips, magnets, and of course slides. The company even featured this (Figures 1a and b) in some of its promotional material. I collected these as if they really reflected meaningful achievement, as if stature could be measured by the number and value of gifts awarded by drug companies, and I don't think my attitude was unique (I hope it wasn't!). In those days one of the desirable "prizes" was an invitation to speak at a drug company-sponsored extravaganza ("meeting"), accompanied by first-class travel for one's spouse, at a luxurious resort abroad (e.g., Monaco) with a continuing open invitation to serve on the company's "advisory board" (with additional financial rewards). The accompanying speaking invitations and number of frequent-flier miles were considered (by some) as equivalent to being identified as someone important in rheumatology, and everyone important, it seemed, was "on the circuit," not only in rheumatology but in other specialties too. Of course I knew that more fundamental achievements really defined academic/professional accomplishment, but industry gifts and perks seemed almost like a surrogate for these. I am now profoundly embarrassed by the prominence of industry-related influences in my activities and by what I now consider the misguided, immature, unprofessional sense of values they reflected.  Figure 1. My one-time accumulation of drug company gifts.
I evolved to a very different perspective, albeit slowly. My epiphany occurred at the October 2003 American College of Rheumatology (ACR) meeting. It may have been when, walking to an early evening activity at one of the headquarter hotels, I passed a limousine at the entrance-way whose driver was holding a sign with the names of two prominent leaders in rheumatology (and I am confident these rheumatologists do not normally travel by limo). Or it may have come later that same night when, returning to my hotel and walking through the lobby, I passed a group of other distinguished rheumatologists being extravagantly entertained by a pharmaceutical company in one of the off-the-lobby restaurants. Perhaps it was when virtually none of my rheumatology colleagues was ever free for dinner during the meeting because of invitations to lavish industry-sponsored affairs. Or maybe it was when, at the Journal of Rheumatology reception (which many internationally-recognized rheumatologists visited), the Editor lamented that none of the post-doctoral fellows would come and avail themselves of an opportunity to meet leaders in their field because fellows' time was preempted by the company sponsoring their attendance at the meeting. Not only did I find these events intellectually and emotionally repugnant but also viscerally disturbing. A character in Brecht's Galileo asks, "why should we go out of our way to look for things that can only strike a discord in this ineffable harmony?" Why rail at industry gifts? Are not most trivial? Are they not necessary for our research and education? Do they not subsidize our meetings? Are they not essential for many academic programs? Do we not have codes of conduct to sanction and satisfactorily regulate these activities? Are we not impervious to their (implied) blandishments? Colleagues say, "C'mon, Rich, you're overreacting; don't we deserve to enjoy an occasional nice meal or accept a trifle at industry largesse? Are we not capable of making unbiased decisions?" I think the correct answer is a resounding "No" to all. Let me explain. Accepting industry gifts is unethical, unprofessional, and pernicious. And unnecessary. Gifts differ from contracts or grants. Gift exchange exemplifies the potentially problematic individual and professional relationships with industry. "Gifts," in this context, is used to reflect relationships from which personal or organizational benefit may accrue. Medicine is humane science inextricably bound to an ethical lattice. It is a moral enterprise3. Individual physicians and their professional association(s) must be committed to promote the welfare of those we serve. They should affirm the moral imperatives from which authenticity and integrity derive by conforming to the highest possible standards of ethical and professional conduct. Opportunities for professional associations and their individual members to accept monetary support and/or gifts, to generate income, and to partner with industry in order to promote their interests, perceived privileges, and sense of entitlement challenge our ability to recognize moral dilemmas and to subordinate self-interest to that of our patients. Medicine, however, is not about physicians, our practices, institutions, organizations or individual organization, needs, research, careers, prerequisites, prerogatives, agendas, or perceived entitlements. It is about dedication and devotion to our patients and to their welfare even at personal and professional risk to profit, pride, and position4-16. Gifts are powerful symbols throughout cultures used to initiate and sustain relationships. Gifts are used ubiquitously to seduce and influence physicians. Companies are motivated by profit, not altruism. Contemporary society has lost sight of — or ignored — the importance of gifts as regulators of human relationships. Offering a gift proffers friendship. Accepting a gift initiates or reinforces a relationship. Accepting a gift assumes social obligations of grateful conduct, grateful use, reciprocation, and response. While gift-giving is an act of apparent generosity it serves the self-interest of the giver. Formal contracts can be dissolved but gift relationships are subtle and less well defined. Remember, companies' ultimate goals are to increase profit to shareholders. "If market research by large industrial companies had suggested that the returns were not adequate, these activities would not take place...doctors were either unwilling to admit to the powerful influence of commercial pressure or unconscious of it...some...declared that they would retain virgin intellectual purity...such a belief may preserve self-respect, but it is a delusion."1 "The degree to which the profession, mainly composed of honorable and decent men, can practice such self-deceit is quite extraordinary. No big company gives away its shareholders' money in an act of disinterested generosity."2 A recent editorial, by a former editor of the New England Journal of Medicine, called for more stringent, not softer, conflict-of-interest guidelines, emphasizing grave concern that "close and remunerative collaboration...naturally breeds goodwill...and the hope that the [beneficial relationship] will continue. This attitude can subtly influence...judgment...Can we really believe that clinical researchers (or individual physicians or organizational leadership or organizations/institutions) are more immune to self-interest than other people?"13 Gift exchange absolutely reflects relationships with reciprocal obligations, even though many do not consciously recognize this. The act of accepting gifts of any value violates fundamental bioethical and professional precepts. What are these? They are simple, really; profound, too, but simple. Several ethical problems arise for individual physicians with regard to gifts (Table 1). Gifts obligate. Gifts influence behavior. And gifts violate the ethical precepts of distributive justice (unfairly allocating resources without patients' knowledge or consent), beneficence (eroding physicians' fiduciary relations as trustees of patients' welfare above all else), non-maleficence (transferring costs to patients and increasing costs of care), fidelity (obligating physicians to companies), and of self-improvement/professionalism (presuming an entitlement for subsidies or gifts as incentives for continuing education)4-16. Also, we learn much about drug (product) prescribing, our most common activity, from sources that stand to profit from our choices. We abdicate our responsibility to educate ourselves impartially. We sell access to our young (students, residents, and fellows) when they are most impressionable in exchange for institutional and personal prerequisites. We risk losing the trust of society and our patients through ethically inappropriate relationships that other fiduciaries (i.e., bankers, judges, journalists, or purchasing agents) would not accept. And we invite outside regulation to curb perceived excesses and costs if we don't do this ourselves. A recent editorial noted that quantity or quality of gifts was irrelevant. Individuals adopt those "notions that favor their own interests...[and] drastically underestimate how strong their bias would be." "Disclosure may have perverse effects"; "the implication for industry gifts is straightforward: they should be prohibited."17
But surely we are not susceptible to outside influences. Others, perhaps, but not us. Nonsense. Compelling and considerable scientific data document that this notion is delusional. So do the pervasive industry marketing practices. Once again, all together now, "No big company gives away its shareholders' money in an act of disinterested generosity."2 These data are briefly summarized in Table 2 and have been reviewed extensively elsewhere by myself and others, and they don't change4,5,8,9. Selected examples from a growing and robust literature include the following. Physicians' prescribing habits reflect a preponderance of commercial over scientific influence. Physicians' requests to add drugs to formularies were strongly associated with physicians' interactions with companies manufacturing the drug. Of articles published in literature, more articles with drug company support than without were likely to favor the drug of interest. Authors supporting calcium channel blockers during a recent controversy were more likely to have financial relationships with manufacturers than other authors. Significant increase in physician prescribing followed all-expense-paid educational meetings at luxury resorts, etc.4,5,8,9.
Many professional societies have adopted positions about this. The interested reader is referred elsewhere for details. In general, these variably discourage or recommend limitations to acceptance of industry gifts that others might perceive as inappropriate, recommend disclosure of any relationships, caution about clinical trials methodology and objectivity, and urge that control of continuing medical education activities not be compromised4,5,8,9. Virtually all tolerate some degree of gift acceptance and are therefore ethically unacceptable. There is an extensive array of additional opinions well worth reading4,5. While there is a growing literature about ethical behavior for individual physicians, there is substantially less pertaining to the ethics of professional societies. Guidelines for medical organizations have been suggested3. These are quite stringent and would not be met by most societies. They include admonition about dangers of focusing unduly on the economic concerns of members to the detriment of transcendent obligations to patients and the public, warning against being self-serving and subordinating patients' interests to those of members, expecting financial support solely from members' dues (as support from or deals with the healthcare industry inevitably risk and create unacceptable conflicts of interest), and having scientific meetings free of industry sponsorship, even if that sponsorship is offered as unrestricted and for general education purposes. How did we get here, so seemingly inextricably involved with industry? The seduction began subtly in medical school, continued during residency and fellowship, and was complete thereafter. We learned from our elders and peers and, for the most part, came to expect that it was our due to get free pens, notepads, calendars, samples, meals, educational events, trips, and then grants, stipends and honoraria. From whence came this sense of entitlement, the arrogance to presume that we physicians should expect these things — particularly so-called educational events and subsidizations of meetings — that no other self-respecting professionals would claim? Where and when did we learn that we needn't pay for meals or our own continuing education? From naivete, ignorance, lack of education and sensitization, a sense of entitlement, and probably some degree of greed. Do we want our behavior to recall the story of the Hollywood producer attempting to buy the favors of a beautiful movie star for a trivial sum, which offer she refused indignantly; however, when the producer was prepared to pay her as much as a million dollars, she was ready to accept. He then opined, "We have already established what you are. The only thing we are quibbling about is your price"? Have things changed? I think so. Editorialists, opinion leaders, the public, the government, some organizations, and increasing numbers of physicians are beginning to recognize the improprieties of our relationships with industry. Continuing medical education requirements are becoming more stringent. Mine is not the only department, or medical center, to have a strict code of conduct eschewing all gift relationships with industry. Organizations like No Free Lunch have sprung up with a growing voice18. The May 2003 issue of the British Medical Journal was devoted entirely to this topic, and extremely critical of the cozy relationships that had evolved and been accepted between physicians and industry19. Recent editorials in The Lancet addressed continuing medical education ("what is of most concern here is the fact that so much continuing medical education comes through the filter of industry"20) and the "corrosive example of...commercial influence," and concluded by asking how tainted by commercial conflicts has medicine become? Heavily, and damagingly so, is the answer and they challenged "do those doctors who support this culture for the best of intentions...have the courage to oppose practices that bring the whole of medicine into disrepute?"21 Former editors of the New England Journal of Medicine have argued compellingly against industry relationships. I quote them at some length because, for good reason, they are articulate thought leaders in medicine. Kassirer wrote, "... nearly all...went into medicine with high-minded motives and that financial gain was only a secondary consideration. ... nearly all had been exposed in medical school to lectures and small group discussions about appropriate professional behavior. Yet the culture in academic medical centers becomes a major determinant of professional behavior once students enter the clinical years and later when they become house officers. Some of this acculturation is promoted by faculty members who themselves are exploiting their academic status for financial gain. But much of it, I suspect, is a consequence simply of inattention to the issue. Most students and house officers have not been challenged to consider that their relations with pharmaceutical companies might compromise their judgment...Some resist, but others develop a sense of entitlement...A colleague who graduated from medical school almost 30 years ago once told me he never forgot that a certain company had given him his very first medical bag. Deans of medical schools and training program directors must do a better job of addressing conflict of interest. Where professionalism is concerned, they must teach that there is no free lunch. No free dinner. Or textbooks. Or even a ballpoint pen."14 Relman wrote, "To its shame, the medical establishment tolerates...continuing education programs [which] accept grants from the pharmaceutical industry and frequently allow the industry to suggest topics and speakers and help with preparation of the programs. They are reluctant to do anything that would jeopardize the industry's support...As for the doctors attending these industry-sponsored education programs, they like the slick presentations, which often use industry-supplied teaching materials. They also like the low or nonexistent fees, the free food, and the numerous small gifts given out at the commercial exhibits that often accompany big education events. And naturally they are confident that their own independence is wholly unaffected by all of this — although surveys reveal that they are less sanguine about other doctors' ability to resist industry's blandishments. But the companies providing the support wouldn't pour money into education unless they were confident of a return on their investment...Until the Medical Schools (and hospitals) insist that the pharmaceutical industry stick to its own business (which can include advertising but not education) we are unlikely to get the help we need from our doctors in controlling runaway drug expenditures."22 The issues have been framed eloquently. It is not unreasonable to consider gifts broadly and together with industry-sponsored continuing medical education, as the issues are certainly overlapping if not identical. Accepting gifts coarsens our sensibilities and declares our values. Some have suggested that the way to consider these issues is to ask how we would feel if our patients or the public were aware of what we did. I reject that approach: real character is reflected by what we do when no one is watching. Some in leadership at my medical center used to remonstrate with me from time to time about the potential cost savings, in the era of budget deficits, of not having to buy pens, note paper, lunches, bagels, coffee, prescription pads, and the like if I would but relent and accept these ubiquitous industry gifts. I remained steadfast in my refusal (and also remained employed, as of this writing). I suggest that the challenge is to uphold our ethics, our professionalim23, our pride, our integrity, our image, our identity, our fiduciary responsibilities, our commitment to patients' and public welfare, indeed our very soul, especially in difficult circumstances. Character is also reflected in how we respond to adversity. Every gift we accept, every item, every paper clip, every meal, every speaker, every event erodes these and diminishes us. Every act of refusal, every pen not taken, every notepad not used, every dinner forgone is an emphatic statement affirming of our collective ideals. It is past time to reclaim our honor, our dignity, and our self-respect, and to remember why it is we chose our profession. May neither avarice nor miserliness, nor thirst for glory or for a great reputation engage my mind; for the enemies of truth and philanthropy may easily deceive me and make me forgetful of my lofty aim and doing good for thy children. — Prayer of Maimonides ACKNOWLEDGMENT Some drafts of and notes for the manuscript were written with generic pens and pencils on generic paper, perhaps to the disappointment of some industry companies or representatives. I have delivered presentations on this topic at Grand Rounds settings, but received no honoraria or even travel reimbursements (the talks were local, though). My medical center still accepts occasional unrestricted grants for certain educational activities, but we're working on that. My wife would like to see our mortgage paid off and my parents would like to see me driving a car that isn't 11 years old, but I think they understand, as it was they who instilled in me the belief that one should aspire to high standards. 2. Rawlins MD. Doctors and the drug makers. Lancet 1984;2:276-8. [MEDLINE] 3. Pellegrino ED, Relman AS. Professional medical associations. Ethical and practical guidelines. JAMA 1999;282:984-6. [MEDLINE] 4. Panush RS. Introduction to miscellaneous topics. In: Panush RS, editor. Yearbook of rheumatology, arthritis, and musculoskeletal diseases. St. Louis: Mosby; 2001:349-59. 5. Panush RS. Not for sale, not even for rent: just say no. Thoughts about The American College of Rheumatology adopting a code of ethics. J Rheumatol 2002;29:1049-57. [MEDLINE] 6. Panush RS. [Reply to letter]. J Rheumatol 2003;30:202-3. [MEDLINE] 7. Panush RS. Professionalism — it's all about the patient. And respect. Rounds. Saint Barnabas Health Care System. Winter 2003:1-2. 8. Panush RS, Kavanaugh A, Romain P. Ethical issues in rheumatologic practice and investigation. In: Smolen JS, Lipsky PE, editors. Biological therapy in rheumatology. London: Martin Dunitz Publishers; 2003:639-51. 9. Dendi P, Desai S, Jacobs FM, et al. Why ethics are important to the busy practitioner caring for patients with rheumatologic and musculoskeletal disorders. Bull Rheum Dis 2003;52:1-7. 10. Panush RS, Sergent JS. A rude awakening. JAMA 1997:277:515-6. [MEDLINE] 11. Relman AS. Separating continuing medical education from pharmaceutical marketing. JAMA 2001;285:2009-12. [MEDLINE] 12. Hadler NM. Hubris for sale or rent. Rheuma21st Archived Reports [Internet]. 1999 [cited April 5, 2004]. Available from: http://www.rheuma21st.com/archives/ACR99.html 13. Angell M. Is academic medicine for sale? N Engl J Med 2000;342:1516-8. [MEDLINE] 14. Kassirer JP. Financial indigestion. JAMA 2000;284:2156-7. [MEDLINE] 15. Korn D. Conflicts of interest in biomedical research. JAMA 2000;284:2234-6. [MEDLINE] 16. DeAngelis CD. Conflict of interest and the public trust. JAMA 2000;284:2237-8. [MEDLINE] 17. Dana J, Loewenstein G. A social science perspective on gifts to physicians from industry. JAMA 2003;290:252-5. [MEDLINE] 18. Carrasquillo O, Goodman RL. Pharma's bad karma. Resistance is not futile. J Gen Intern Med 2003;18:315-6. [MEDLINE] 19. Time to untangle doctors from drug companies [theme issue]. BMJ 2003;346:1155-210. 20. Just how tainted has medicine become? [editorial]. Lancet 2002;59:1167. [MEDLINE] 21. Drug-company influence on medical education in USA [editorial]. Lancet 2000;356:781. [MEDLINE] 22. Relman A. Your doctor's drug problem. New York Times 2003; Nov 18. [MEDLINE] 23. Stobo JD, Cohen JJ, Kimball HR, LaCombe MA, Schechter GP, Blank LL. Project professionalism. Philadelphia: American Board of Internal Medicine; 1995:1-29. |
