A long-time editor of a prestigious medical journal started his editorial on physicians’ conflicts of interest by describing a fantasy: “Doctors treat patients using simply the best evidence and their experience. They are not influenced by money or self-interest.”
“This is, of course, nonsense,” he wrote. There is a reason “pharmaceutical companies spend billions of dollars on the influencing, education, and entertainment of doctors around the world.”
As discussed in my video Find Out If Your Doctor Takes Drug Company Money, the vast majority of physicians in the United States take gifts from the pharmaceutical industry, and, ironically, cardiologists, whose practice centers around diseases that can largely be prevented and treated with lifestyle changes, receive the most payments of all. A previous compilation of surveys from the 1980s and 1990s found that, on average, doctors met face-to-face with drug industry representatives about once a week. Today, your family doctor may meet with drug company employees on average 16 times a month. There are only 20 workdays a month, so that’s nearly every day.
What does the public think about this? Only about half even appear to know what’s going on. Therefore, “if 83% of doctors receive gifts, it is likely that a significant percentage of patients are not aware that their personal physician receives industry gifts.” We’re not just talking about a token Viagra paperweight or soap dispenser. For marketing, pharmaceutical companies spend $15,000 per physician every year, making conflicts of interest one of the most pressing problems in American health care.
How do doctors feel about it? Most generally approve of the gifts. However, tellingly, physicians don’t want gift relationships made public. “Physicians’ disagreement that it is inappropriate to accept gifts, but their reluctance to disclose the gift relationship to the public, suggests that they must recognize that the public would not appreciate the practice.” To analyze how doctors resolve this contradiction, researchers conducted a series of physician focus groups. It turns out physicians use a variety of denials and rationalizations, including avoiding thinking about it, and denying responsibility. Physicians readily acknowledged the inherent conflict of interest, but this didn’t stop them. In fact, some complained that the gifts were getting more modest.
“We [doctors] tend to deny that we have any conflict of interest if a pharmaceutical company buys us a nice dinner. We tend to insist that it won’t affect our judgement in any way”—as if drug companies just like wasting money for the heck of it. Most physicians contend that their colleagues are susceptible to industry influence…but not them.
Though physicians don’t want these gift relationships to be public, that’s just too bad. Thanks to Republican Senator Chuck Grassley, the Sunshine Act was inserted into Obamacare. “For the first time, patients will now be able to see what, if any, financial ties their own doctor has with a drug or device maker.”
Doctors can’t hide anymore.
The Sunshine Act was designed to give patients some insights when choosing a provider, and law enforcement agencies can also use it to see who’s getting money from industry to investigate illegal kickback schemes. Right now, it might just be embarrassing, but this could allow attorneys general to go after doctors to see the kinds of incentives they may be getting for writing a lot of prescriptions. The database is live right now at openpaymentsdata.cms.gov/search/physicians or, for a more user-friendly version, Propublica’s Dollars for Docs page. The drug industry spends billions trying to influence doctors, and, for the first time, you can see if your physician, or any physician, has their hand out.
Senator Grassley hoped this would help save our nation money. It could reduce healthcare costs if patients viewed such doctors as less trustworthy and chose doctors less in bed with industry. It could also change physician behavior: Physicians may want to avoid financial relationships with companies to guard against patient distrust or becoming the target of an exposé or investigation.
Or they could just try to cover it up.
The American Academy of Family Physicians advised physicians how to “avoid getting burned” by the Sunshine Act. For example, drug companies now have to report when they give doctors free meals valued over $10. So, should family physicians just stop accepting free food from drug companies? No way! You just have to give the drug sales reps the right head count to ensure that the meal cost dips below $10 per person.
The former long-time editor of the New England Journal of Medicine said it best: “Although the spotlight has been on the failure to disclose (or adequately disclose) financial relationships with industry, the problem with [conflicts of interest] is not the lack of disclosure but the existence of the conflict itself.” Rather than just disclosing them, the best approach to financial conflicts is to have none.
No wonder physicians undervalue lifestyle interventions! See The Actual Benefit of Diet vs. Drugs and Why Prevention Is Worth a Ton of Cure. Inundated by Big Pharma without so much as a free mug from Big Broccoli, Physicians May Be Missing Their Most Important Tool. And, even worse, sometimes the drugs can do more harm than good. See my video on How Doctors Responded to Being Named a Leading Killer.
Financial arrangements can affect prescribing behavior for more than just drugs. See my video Should We All Get Colonoscopies Starting at Age 50?.
PS: I have never knowingly accepted gifts from the pharmaceutical industry, but “knowingly” is an important caveat. If you search for my name in the Dollars for Docs database you’ll see I apparently accepted money from a vision care company five years ago. I was giving a continuing medical education lecture at an optometric physicians conference and unbeknownst to me they had the corporation pay for my travel and lodging.
Michael Greger, M.D.
This content was originally published here.