States and Institutions Impose Restrictions on Physician-Industry Relationships

October 13, 2007 By Grendel Burrell [mailto:grendel.burrell@gmail.com]

The New York Times story, October 12, “Minnesota Limit on Gifts to Doctors May Catch On” (http://www.nytimes.com/2007/10/12/us/12gift.html?hp) describes how officials in Minnesota have interpreted rules for interaction between physicians and sales representatives for pharmaceutical companies. However, the “may catch on” part isn’t catching on with all doctors. A survey of users of www.theheart.org, from April 26-May 26, 2007 revealed that when asked, “Do you accept gifts from industry?”, 61% replied YES, and 38% replied NO (792 respondents). When the question, “Do you think physicians should be banned from accepting gifts from industry?”, of the 847 respondents, 60% said NO, and 39% stated YES. While the survey on www.theheart.org isn’t a scientific poll, it might be a pulse check.

Two years after Minnesota officials imposed a requirement that drug makers to not provide doctors more than $50 worth of food or other gifts per year, sales representatives saw Minnesota primary care doctors much less frequently than primary care doctors nationwide, according to a survey by ImpactRx, a New Jersey firm that tracks pharmaceutical marketing, according to the Times. Many companies provided modest meals to doctors, their offices, cath labs, intensive care units, and emergency department because that was often the most efficient time for doctors and other health care professionals to meet with representatives. It’s clearly important for doctors and adjunctive staff to have access to the latest information on drugs, and over the years, many companies and drug reps used time over food or snacks to secure a few minutes of conversation with busy physicians. However, despite the $50/physician/year rule in Minnesota, the NY Times article states, “Food has not entirely disappeared from the marketing efforts of drug makers in Minnesota.”

According to the Times article, companies sponsor dinners and “hire influential doctors to deliver educational talks about drugs during dinner.” The Times goes on to state, “companies now invite nurses and secretaries to dine, drink and listen.” What the Times doesn’t discuss is that the role of nurses, nurse practitioners, advanced practice nurses is critical to the care of patients, and it’s very important that not only doctors, but also nurses remain apprised of the most current developments in drug and device therapies. Minnesota also requires drug makers to report all consulting payments made to doctors. Maine, Vermont and West Virginia have passed similar registry requirements, several states are considering them, and Congress is evaluating this. Companies sponsoring clinical trials are required to record and report all payments made directly to a physician in the roles of clinical trial investigator, steering committee member, advisor, or speaker.

To date, no other state has adopted Minnesota’s limit on free food. New Jersey’s attorney general announced the development of a task force to examine limitations on the gifts and money that drug and device makers give doctors. Do requirements like this help produce therapies to improve morbidity and mortality? The interest in legislation to register or limit the food and honoraria that drug and device makers provide to doctors rises from concerns that these benefits lead doctors to choose therapies that may raise the cost of health care. Nothing however is stated about how new, and sometimes more expensive therapies, can be large improvements over older medications or devices. Most doctors would discard the idea that dinner influences their prescribing choices. Many pharmaceutical companies have implemented their own internal policies of limiting the amount that can be spent on a meal with a physician or nurse.

Authors of a survey published April 26, 2007 issue of the New England Journal of Medicine (1) examined acceptance of gifts, samples, reimbursements, or payments by anesthesiologists, cardiologists, family practitioners, general surgeons, internists, and pediatricians. The objective was to survey physicians to collect information about their financial associations with industry and the factors that predict those associations. Dr Eric G Campbell (Institute for Health Policy, Massachusetts General Hospital, and Harvard Medical School, Boston, MA) and authors surveyed 3504 doctors surveyed in 2003-2004.

For the group of respondents (n=1662), 94% reported some type of relationship with the pharmaceutical industry, and most of these relationships involved receiving food in the workplace (83%). 78% said they have accepted drug samples. 35% received reimbursement for costs associated with professional meetings or continuing medical education, 28% said they'd received payments for various services. Cardiologists had the lowest response rate of all physician specialties surveyed (42%), but cardiologists were more likely to have accepted samples, gifts, or payments than their colleagues in some or all other fields. Cardiologists were more than twice as likely as family practitioners to receive payments. The authors wrote that cardiologists have "prescribing patterns as specialists and opinion leaders [that] are thought to influence the prescribing patterns of nonspecialists." Amongst the medical specialties surveyed, Campbell et al also noted that family practitioners met more frequently with industry representatives than did physicians in other specialties, and physicians in solo, two-person, or group practices met more frequently with industry representatives than did physicians practicing in hospitals and clinics, institutions in which there may be policies outlining physician-industry relationships.

The NY Times article recounts a discussion with Dr. Samuel Carlson, chief medical officer of Park Nicollet Health Services, one of Minnesota’s largest private health systems, in which he said that many of his system’s 20 clinics began asking to bar sales representatives after the food limit went into effect. Park Nicollet is considering further system wide restrictions on sales representatives, Dr. Carlson told the Times.

The Times presents no data about any change in prescribing habits since the $50/doctor/year for food went into effect in Minnesota. Nor does the Times discuss the changes that pharma has imposed on itself regarding food and gifts over the past decade. Clearly physicians need to carefully evaluate messages from pharma and device representatives. They must weigh the body of evidence for new therapies or changes in care. The Times article seems to discount the educational value that smart, ethical representatives can provide.

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 * 1) ref1 PMID 17460228