In Defense of Legitimate Relationships Between Physicians and Industry

Dear Readers,

There has been a great deal of negative attention lately to relationships between physicians and industry. A front-page story in the Chicago Tribune in October was devoted to a list of all physicians in the Chicago area who received over $100,000 in compensation from the pharmaceutical industry in the past year.¹ It does seem that something is awry when an individual practicing physician earns $250,000 from a drug company, but the reactions by the media, legislators, and some professional medical associations (PMAs) have demonized all relationships between physicians and industry. Last year, the Journal of the American Medical Association (JAMA) published a proposal for controlling conflicts of interest between PMAs and their relationships with industry.² It described several underlying principles and premises, and provided some valid suggestions. Most of these are intuitive. For example, most physicians would agree with the following:

1. “The pharmaceutical and medical device industries make important contributions to medical progress.” No one in the highly technology-dependent field of electrophysiology can argue against this. The pacemakers and defibrillators we implant, the tools that we use during catheter ablation procedures, and the antiarrhythmic drugs that we prescribe have all been developed by industry. Often these devices were found to be effective through industry-sponsored clinical trials involving practicing electrophysiologists. 2. Physicians should fully disclose financial relationships with industry. Full disclosure and transparency is now widely endorsed. However, “resolving issues of conflict of interest is not best accomplished by avoiding all relationships.” 3. Physicians should not receive gifts from industry. “Research demonstrates the power of gifts to bias physicians’ choices.” There have been rules against physicians accepting gifts for several years now. 4. “Funds from industry (to PMAs) should be unrestricted.” Physicians are able to easily identify when industry support comes with strings attached. 5. “Physicians and medical societies should avoid marketing industry products.” Academic institutions and physicians who are involved in industry-sponsored educational activities have defined which activities are related to product marketing and should be avoided, and which activities are supported by unrestricted industry funding and are acceptable.

However, the JAMA article makes recommendations to restrict who can serve on PMA Professional Guideline and Scientific Session committees that are unnecessary and fail to recognize that most relationships are legitimate. They state that “disclosure of industry relationships by committee members is not sufficient protection. … At a minimum, PMAs must exclude from such committees persons with any conflict of interest ($0 threshold) involving direct salary support, research support, or additional income from a company whose product sales could be affected by the guidelines.” These zero tolerance recommendations regarding committee membership fail to differentiate two very separate types of relationships between physicians and companies: those that are real conflicts of interest and those that could be perceived. Not all relationships with industry are created equal. A real conflict of interest should be defined as one where the person or a member of the person’s household, has a reasonable potential for financial, professional, or other personal gain or loss as a result of the issues or content addressed by the committee. Obvious examples are when physicians are company employees, receive direct salary support, own company stock or stock options, or receive royalties. In these cases the physician has potential for future additional income based on the success of the company. In contrast, physicians who provide legitimate advice to a company, participate in industry-sponsored clinical trials, or are involved in an unrestricted industry-sponsored educational activity are not in a position to directly gain personally in the future based on the financial success of the company. The latter activities should be encouraged, fostered, and promoted, and physicians involved in these activities should not be restricted from being involved in leadership positions and roles in medical societies. It only makes sense that physicians should continue to work directly with companies to develop better products used for patient care. And it only makes sense that these physicians should be compensated for their efforts. These activities are not the same as making an investment in a company. Restricting leaders in our field from participating in legitimate activities with industry only perpetuates the misperceptions in the media and by the public that all relationships between physicians and industry are illegitimate or suspect, and that physicians can be persuaded to deviate from the best possible medical care. It is clear that receiving gifts has been shown to influence physician prescribing patterns, but where is the evidence that consulting for a company alters clinical decision making? Perceptions are important, but inaccurate perceptions should be addressed by education and awareness. Physicians should discourage real conflicts of interest, but also be proud of the accomplishments that have been made for patients as a result of productive and honest relationships with industry. It is important for the public to know that if they ever have to undergo a heart rhythm procedure, there will likely be a company representative in the procedure room. This person will be there to provide inventory, optimize device programming, facilitate cardiac mapping, and provide expertise. It is also important that the public understands that it is critical that physicians continue to work with the companies that make these devices to improve the care of patients with heart rhythm disorders.

References

1. Graham, Judith. "Doctor-drug company database adds to confusion for consumers." Chicago Tribune, October 28, 2010. Accessed November 17, 2010.

2. Rothman DJ, McDonald WJ, Berkowitz CD, et al. Professional medical associations and their relationships with industry: A proposal for controlling conflict of interest. JAMA 2009;301:1367-1372.