Residents should probably say ‘no’ to swag

As part of the Affordable Care Act, the Physician Payments Sunshine Act required the pharmaceutical industry to report any gifts given to physicians, starting in 2014. As the American Academy of Family Physicians (AAFP) observes, this strict, legally required reporting—along with policies by various national organizations calling for increased boundaries with regard to physician-industry interactions—means that the heyday of physician gift giving has likely passed.^[] To date, the provision of samples, gifts, and direct payments by pharma has decreased, and interaction between physicians and pharma is also down, from 84% in 2009 to 72% in 2017. In addition, 55% of practices reported accepting samples in 2017 compared with 64% in 2009.

Residents and fellows also interact with pharma, not only attending physicians. It’s a good idea to understand the influence that industry wields.

What professional organizations have to say

The AMA does see the value in limited gift giving.^[]

“Many gifts given to physicians by companies in the pharmaceutical, device, and medical equipment industries serve an important and socially beneficial function. For example, companies have long provided funds for educational seminars and conferences. However, there has been growing concern about certain gifts from industry to physicians. Some gifts that reflect customary practices of industry may not be consistent with the Principles of Medical Ethics,” the AMA stated.

The AMA’s list of acceptable gifts include the following:

• Subsidies to underwrite the cost of continuing medical education

• Legitimate conferences or meetings (but not travel costs, meals, and sundries)

• Individual gifts of little value, like pens and notepads

• Drug samples for patients and personal use

Ultimately, gifts should either be small and inconsequential or hold educational value. Meals, textbooks, and so forth must serve a genuine educational function and a benefit to the patient. Physicians should not accept compensation for prescribing practices. Other ethical guidance precludes the acceptance of cash payments or the payment of conference costs by conference sponsors. If drug samples are used for personal purposes—such as family—the recipient must ensure that patient needs for these samples are met first. 

The AMA also provides input on how medical students and postgraduates should interact with pharma.

“Scholarship or other special funds to permit medical students, residents, and fellows to attend carefully selected educational conferences may be permissible as long as the selection of students, residents, or fellows who will receive the funds is made by the academic or training institution. Carefully selected educational conferences are generally defined as the major educational, scientific or policy-making meetings of national, regional, or specialty medical associations,” the AMA writes.

Although the AMA may be a bit more permissive with regard to gifts, the AAFP advises physicians and trainees to refuse such gifts, in recognition of the insidious nature of pharma gift giving.

“The high cost of prescription drugs in the United States is a major public health challenge,” the AAFP writes. “This high cost is driven by prescribing of expensive brand-name medications, which is influenced heavily by the pharmaceutical industry spending billions of dollars to market directly to physicians. Physicians should refuse gifts, samples, direct payments, and other industry interaction to avoid perpetuating an unjust health system,” the AAFP claims.

“It is the professional responsibility of a physician to promote social justice, commit to a just distribution of finite resources, prioritize patient welfare, and not compromise integrity with conflicts of interest,” they added. 

In particular, family medicine residency programs have clamped down on industry interaction. In 2008, only 26% of programs did not permit the use of samples, the acceptance of food/gifts, or industry-sponsored residency activities vs. 64% eschewing such dealings by 2019. Moreover, 84% of family-residency programs forbade visits with pharma reps by 2019, up from 43% in 2008. For their part, program directors attribute this trend to ethical concerns and institutional policy.

“Restricting contacts with industry during physician training is especially important to promote evidence-based prescribing because practice habits form during this important time in a physician's career,” the AAFP notes.

Ethical quandaries explained

The AAFP cites a number of ethical dilemmas associated with the acceptance of gifts from pharma.

Drug samples. Drug samples “do more harm than good,” with medications in sample closets usually expired or inappropriately utilized by physicians and staff, as well as being distributed to patients who already have health insurance and not those in greatest need. From an ethical perspective, brand-name samples heighten sales of more expensive further-line treatments vs. superior and cheaper generics with first-line indications. Non-rational prescribing is the result. Patients who initiate treatment with more expensive brand-name drugs face increased total and out-of-pocket costs. In sum, the $13.5 billion that pharma spends annually on samples increases sales of the brand-name drugs, with no help to the patient.

Time-consuming detailing. Time spent with pharma reps is prodigious and entails listening to a spiel that is false, according to the AAFP. Ethical physicians must go back and read up on drugs in unbiased peer-reviewed sources to truly learn about the evidence underlying the drug’s use.

Physician influence. Baubles, breakfasts, and snacks provided by pharma reps—who are professionally trained to influence doctors—are effective at yielding low-value prescribing that lacks evidence basis. Although physicians may claim that these things don’t influence prescribing patterns, they do, and result in cognitive dissonance, or psychological conflict secondary to incongruous beliefs/attitudes held simultaneously.

Authors of a study among U.S. prescribers in Washington, D.C., published in PLOS ONE found that industry gifts do, indeed, influence prescribing behavior.^[] The researchers concluded that  “Gifts from pharmaceutical companies are associated with more prescriptions per patient, more costly prescriptions, and a higher proportion of branded prescriptions with variation across specialties. Gifts of any size had an effect and larger gifts elicited a larger impact on prescribing behaviors.” Their final conclusion: “Industry gifts influence prescribing behavior, may have adverse public health implications, and should be banned.”

Remember the patient. The physician’s obligation is to the patient—first and foremost—and research cited by the AAFP shows that patients are uncomfortable with the idea of physicians receiving gifts from industry.

It should be noted that no physician would actively prescribe a non–evidence-based treatment because they received a gift from pharma, but the pull of such gifts is insidious, according to the non-profit Health Action International (HAI).^[]

“Only a deeply corrupt doctor or pharmacist would consciously and deliberately prescribe a medicine to patients when that medicine is known to be sub-optimal. Virtually all health-care professionals (and trainee professionals) feel confident that they are not corrupt in this way.” Unfortunately, however, social science research provides substantial evidence that “even when individuals try to be objective, their judgements are subject to an unconscious and unintentional self-serving bias.”