Despite the potential for conflict of interest, virtually all practicing physicians in the U.S. have some form of relationship with pharmaceutical manufacturers but the nature and extent of those relationships vary, depending on the kind of practice, medical specialty, patient mix, and professional activities, reports a study in the April 26 issue of the New England Journal of Medicine.
In the first national survey to gauge the predictors and depth of relationships between industry and practicing physicians, 94 percent of doctors report that they have at least one type of relationship with the drug industry, mostly in the form of receiving food in the workplace or prescription samples.
However, more than one third are reimbursed for costs associated with professional meetings or continuing medical education (CME), and more than a quarter receive honoraria for consulting, lecturing or enrolling patients in clinical trials, say researchers at Massachusetts General Hospital-Partners Health Care System, Yale University, and the University of Melbourne and Royal Melbourne Hospital in Australia.
“Relationships with industry are a fundamental part of the way medicine is practiced today. The real questions relate to how much is too much and how far is too far. It appears that these relationships benefit physicians and industry but the important policy question is to what extent do these relationships benefit patients in the terms of the care they receive,” says lead researcher and co-author Eric Campbell, Ph.D., an associate professor of medicine at the Institute for Health Policy at Massachusetts General Hospital and Harvard Medical School.
The findings, from a survey of 1,662 practicing physicians conducted in late 2003 and 2004, also show that drug and device manufacturers pick and choose which doctors to form the strongest ties with. For example, cardiologists are more than twice as likely as family practitioners to receive direct payments from drug companies for consulting and other services and are also significantly more likely to be paid honoraria than pediatricians, anesthesiologists, or surgeons. “Cardiology is a highly influential specialty within the medical profession. If the drug and device industry can influence cardiologists, they can likely influence the prescribing practices of other doctors,” says Campbell.
Campbell and his co-authors, including Institute for Health Policy Director David Blumenthal, MD, report that the idea that companies target opinion leaders for marketing is further suggested by the higher frequency of industry payments to physicians who have developed clinical guidelines and who serve as mentors for doctors in training. “I know it?s clich?, but if it didn?t work, drug companies wouldn?t do it,” says Blumenthal. “It appears pretty clear that industry forms tighter relationships with doctors who are really the thought leaders, the ones who are likely to affect the behavior of other doctors.”
Researchers surveyed physicians in six specialties (anesthesiology, cardiology, family practice, general surgery, internal medicine, and pediatrics) to measure the extent of their financial associations with industry and the factors that predict those ties. They looked at what physicians receive from industry; how often they met with industry representatives; and what characteristics determine the frequency and nature of these relationships. The study was funded by a grant from the New York-based Institute on Medicine as a Profession. IMAP has made the study of physician-industry relationships one of its main concerns.
The study found striking differences in the nature of physician-industry relationships depending on the primary practice location of the physician. For example, compared to physicians practicing in hospitals, those in group practices were three times as likely to receive gifts and nearly four times more likely to be paid for professional services. Group practice physicians along with solo or two-person practices also met more frequently with industry representatives such as drug detailers than did physicians practicing in hospitals or clinics or staff model HMOs. The authors suggest that the primary reason for these differences is that hospitals may be more likely to have policies and practices in place that limit physician contact with industry representatives. It may also be that hospitals are more likely to provide physician education through grand rounds and CME events, rendering physicians in these facilities less dependent on industry representatives as the source of medical education and information.
The survey also found that:
Pediatricians and anesthesiologists were significantly less likely than family practitioners to receive samples, reimbursements and payments for professional services.
Family practitioners reported the highest average number of meetings with industry representatives (16 meetings a month), followed by internists and cardiologists (9-10 per month, respectively). Anesthesiologists had only 2 meetings a month.
All specialties except anesthesiology appear to be meeting more frequently with industry today as compared to 2000, when the average was about 4.4 meetings per month. The authors say it could reflect an intensification of industry marketing since the 1990s.
Women physicians are less likely to receive payment than their male counterparts.
Physicians were more likely to receive payments if less than 25 percent of their patients were uninsured or covered by Medicaid.
Motivated by growing concern about physician-industry relationships, a number of groups ? such as the Pharmaceutical Research and Manufacturers of America, the American Medical Association and the American College of Physicians ? have recently instituted codes of conduct that set limits on gifts to physicians from industry. PhRMA recommends that gifts not exceed $100 in value and should be only items that support a medical practice such as a stethoscope. The AMA recommends that any gifts accepted by a physician should primarily entail a benefit to patients and not be of substantial value.
The authors say the findings should raise alarms that more needs to be done. “We have given physicians a lot of freedom to govern themselves and to voluntarily follow guidelines set by the profession. If they are unable to monitor and manage these practices, there will be increasing pressure on government to do it for them,” says Blumenthal.