Conflicted Interests

April 8, 2020

In the early 1980s I was invited to attend an all-expenses-paid medical conference at a resort in Colorado. The event was sponsored to announce a new drug class called angiotensin-converting enzyme (ACE) inhibitors. The drug, generically called captopril, was marketed by Bristol-Myers Squibb under the trade name Capoten. Outstanding medical educators, scientists and researchers were presiding to teach a large number of primary care doctors from all across the United States. I was new to medical practice, very busy and deeply in debt. The opportunity for continuing medical education (CME required by Family Practice for maintenance of board certification), vacation and knowledge seemed too good to resist. The conference was terrific. It included outstanding lectures, clarifying discussions and a variety of entertainment and activity options. I returned to practice a believer in Capoten and began prescribing it regularly.

A few years later I wondered about the cost of that trip and how it could have possibly been profitable for the drug company. I disconsolately realized that my trip expenses were fully paid by my patients. After that initial splash new, better and generic ACE inhibitors became available. I stopped prescribing Capoten after my bill had been paid. ACE inhibitors are indeed remarkable and useful drugs, but the zeal of my prescribing after the gala was undoubtedly excessive.

In a 2007 article 94% of 3,167 physicians reported some type of “relationship” with the pharmaceutical industry (http://www.nejm.org/doi/full/10.1056/NEJMsa064508). Although some changes have occurred since my experience in Colorado Springs and this 2007 article, it is still obvious that doctors are influenced by sales people. Sometimes this influence is detrimental to patients. An ER doctor from Washington DC became concerned when she discovered that her mother was being treated by an oncologist who was earning extra income as a spokesperson for the company that manufactured her mother’s chemotherapeutic agents. Dr. Wen did not assume that this was an inappropriate treatment, but she did think that the doctor’s relationship should have been revealed to the patient and her family. She is promoting a “Total Transparency Manifesto” that doctors can sign to inform patients of their sources of income. (http://blogs.bmj.com/bmj/2013/10/21/leana-wan-announcing-the-total-transparency-manifesto/). Not surprisingly, this pledge has been strongly resisted by many doctors.

During a recent discussion a colleague remarked that doctors’ patient care reimbursements have not been increased for several years. However, doctors have responded by doing more procedures and have increasingly tapped in to “alternative income streams”. Alternative income streams can include paid speaking engagements; salary bonuses based on “productivity”; entertainment gifts and paid perfunctory positions. Thus doctors’ total incomes have increased. Sometimes the incomes from the alternative streams dwarf a doctor’s patient care revenue. In the early 1990s I stopped accepting sample drugs, quit meeting with pharmaceutical sales representatives, walked by free food and refused gifts sent or handed to me by drug companies. Each of these “relationships” has been shown to increase a patient’s healthcare costs. This was long after I enjoyed several free trips up a ski lift and donned a bandana to dress for the dramatic hoedown that climaxed the ACE inhibitor conference. I have never fully thanked my patients.

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