O’Neil Pyke, MD, SFHM

Dr. Pyke

PRO

Hospitalists’ moral obligation is to protect the patient

In this era of historic budget deficits, wars, and political strife surrounding healthcare reform, one might ask if we can afford to spend valuable time and energy on the issue of reporting physicians who abuse substances.

At first glance, I certainly had skepticism about the subject, but then I dug deeper. To my surprise (and likely yours), studies indicate that physicians develop substance-abuse problems as often or more than the general population does.¹ Recent reports detail horrific patient outcomes at the hands of health providers whose actions are compromised by drug use. With data showing the prevalence of substance abuse among physicians hovering around 10% to 12%, we must accept the reality that hospitalists are not exempt.^2,3,4,5

As medical doctors, our promise to our patients is to provide care in an ethical manner. Even if we try to live in denial, most of us would agree that with great blessing (or power) comes great responsibility. So when the question of reporting a fellow hospitalist who is abusing substances was asked, my response was unequivocally yes.

In my opinion, this discussion can be limited to two overarching principles: First, we are compelled to put our patients first. As hospitalists, we are blessed to be caring for some of the most frail and vulnerable in our society. Fortunately, an overwhelming number of us do so with pride, skill, and integrity.

The task of providing high-quality care to an empowered patient population is difficult enough with us being physically, emotionally, and mentally exhausted. But to add substance abuse to this is just a complete and utter violation of our patients’ trust. We must agree that putting our patients’ well-being beyond reproach requires us to report any colleague who is compromised.

Second, delayed help for a colleague in trouble with substance-abuse issues could be fatal—and for more than just that single colleague. At some point, we are compelled to do more than just raise an eyebrow and shake our head. Usually at the time of discovery, months if not years of substance abuse already have gone by undetected. Deferring to the next person is just not an option. There is too much at stake. It is our moral duty to help our colleagues who are unable to realize the danger they are posing to themselves, the team, and, most importantly, the patients.

Certainly, physicians do not need another lecture about the perils of substance abuse. Whether discussing prescription drugs, alcohol, marijuana, cocaine, or the like, we all have witnessed the devastating effects of abuse. The fact is, any substance that alters our ability to perform our trusted duty must be avoided.

Colleagues, the algorithm is simple: Be vigilant, observe, confirm, and report. It is our moral and ethical imperative.

Dr. Pyke is chief medical officer of Medicus Consulting, LLC.

Dr. Guerrasio

CON

Responsible, helpful action doesn’t always mean official involvement

Recognizing impairment in our colleagues is both difficult and ethically challenging. Despite national trends, medicine remains a largely self-regulated profession, and we have an ethical obligation to report impaired, incompetent, or unethical colleagues. Rarely are the indications for reporting or identifying a colleague clear.

As trained clinicians, we know the signs of substance abuse:⁶

• Frequent tardiness and absences;
• Unexplained disappearances during working hours;
• Inappropriate behavior;
• Affective lability or irritability;
• Interpersonal conflict;
• Avoidance of peers or supervisors;
• Keeping odd hours;
• Disorganized and forgetful;
• Incomplete charts and work performance;
• Heavy drinking at social functions;
• Unexplained changes in weight or energy level;
• Diminished personal hygiene;
• Slurred or rapid speech;
• Frequently dilated pupils or red, watery eyes and a runny nose;
• Defensiveness, anxiety, apathy, and manipulative behaviors; and
• Withdrawal from long-standing relationships.

Yet when it is a colleague, we are often in denial about their substance abuse. Certainly, simple seasonal allergies and allergy medications can cause a number of the above symptoms. We also are aware of and fear the potential impact of licensing board notification on a physician’s career. In fact, in a national survey of physicians, 45% of respondents who had encountered impaired or incompetent physicians had not reported them, even though 96% of those surveyed agreed that physicians should report impaired or incompetent colleagues.⁷

Similar to reporting child or elder abuse, you don’t want to be wrong.

At the same time, impaired physicians are disruptive. They negatively impact the lives of their patients, colleagues, and hospital staff.

It is possible to do both the responsible thing and not go directly to the licensing board. You are not responsible for diagnosing your colleagues, but rather recognizing possible impairment.

Check out the Federation of State Physician Health Programs’ website (www.fsphp.org) to identify a local physician health program. Call them and place a report of concern identifying your impaired colleague. While it’s possibly new to you, they have years of experience working with this situation. Trust these organizations, many of which are independent from licensing, to intervene responsibly and confidentially. They can evaluate your colleague and provide a treatment plan and monitoring, as needed. Their approach is rehabilitative rather than punitive, and they resist reporting to the medical board unless the physician-patient is noncompliant.

Physicians have better outcomes than the general population, with reported abstinence rates of 70% to 90% for those who complete treatment.^8,9 Between 75% and 85% of physicians who complete rehabilitation and comply with close monitoring and follow-up care are able to return to work.^9,10

There is hope for your impaired colleague. Contact your local physician health program.

Dr. Guerrasio is a hospitalist and director of resident and medical student remediation at the University of Colorado Denver.

References

1. Hughes PH, Brandenburg N, Baldwin DC Jr., et al. Prevalence of substance use among US physicians. JAMA. 1992;267:2333-2339.
2. Gold KB, Teitelbaum SA. Physicians impaired by substance abuse disorders. The Journal of Global Drug Policy and Practice website. Available at: http://www.globaldrugpolicy.org/2/2/3.php. Accessed June 27, 2011.
3. Wolfgang AP. Substance abuse potential and job stress: a study of pharmacists, physicians, and nurses. J Pharm Mark Manage. 1989;3(4):97-110.
4. Cicala RS. Substance abuse among physicians: What you need to know. Hosp Phys. 2003:39-46.
5. Berge KH, Seppala MD, Schipper AM. Chemical dependency and the physician. Mayo Clin Proc. 2009;84(7):625-631.
6. Bright RP, Krahn L. Impaired physicians: How to recognize, when to report, and where to refer. Curr Psy. 2010;9(6):11-20.
7. Campbell EG, Regan S, Gruen RL, et al. Professionalism in medicine: results of a national survey of physicians. Ann Intern Med. 2007;147:795-802.
8. Femino J, Nirenberg TD. Treatment outcome studies on physician impairment: a review of the literature. R I Med. 1994;77:345-350.
9. Alpern F, Correnti CE, Dolan TE, Llufrio MC, Sill A. A survey of recovering Maryland physicians. Md Med J. 1992;41:301-303.
10. Gallegos KV, Lubin BH, Bowers C, Blevins JW, Talbott GD, Wilson PO. Relapse and recovery: five to ten year follow-up study of chemically dependent physicians—the Georgia experience. Md Med J. 1992;41:315-319.

Dr. Pyke

PRO

Hospitalists’ moral obligation is to protect the patient

In this era of historic budget deficits, wars, and political strife surrounding healthcare reform, one might ask if we can afford to spend valuable time and energy on the issue of reporting physicians who abuse substances.

At first glance, I certainly had skepticism about the subject, but then I dug deeper. To my surprise (and likely yours), studies indicate that physicians develop substance-abuse problems as often or more than the general population does.¹ Recent reports detail horrific patient outcomes at the hands of health providers whose actions are compromised by drug use. With data showing the prevalence of substance abuse among physicians hovering around 10% to 12%, we must accept the reality that hospitalists are not exempt.^2,3,4,5

As medical doctors, our promise to our patients is to provide care in an ethical manner. Even if we try to live in denial, most of us would agree that with great blessing (or power) comes great responsibility. So when the question of reporting a fellow hospitalist who is abusing substances was asked, my response was unequivocally yes.

In my opinion, this discussion can be limited to two overarching principles: First, we are compelled to put our patients first. As hospitalists, we are blessed to be caring for some of the most frail and vulnerable in our society. Fortunately, an overwhelming number of us do so with pride, skill, and integrity.

The task of providing high-quality care to an empowered patient population is difficult enough with us being physically, emotionally, and mentally exhausted. But to add substance abuse to this is just a complete and utter violation of our patients’ trust. We must agree that putting our patients’ well-being beyond reproach requires us to report any colleague who is compromised.

Second, delayed help for a colleague in trouble with substance-abuse issues could be fatal—and for more than just that single colleague. At some point, we are compelled to do more than just raise an eyebrow and shake our head. Usually at the time of discovery, months if not years of substance abuse already have gone by undetected. Deferring to the next person is just not an option. There is too much at stake. It is our moral duty to help our colleagues who are unable to realize the danger they are posing to themselves, the team, and, most importantly, the patients.

Certainly, physicians do not need another lecture about the perils of substance abuse. Whether discussing prescription drugs, alcohol, marijuana, cocaine, or the like, we all have witnessed the devastating effects of abuse. The fact is, any substance that alters our ability to perform our trusted duty must be avoided.

Colleagues, the algorithm is simple: Be vigilant, observe, confirm, and report. It is our moral and ethical imperative.

Dr. Pyke is chief medical officer of Medicus Consulting, LLC.

Dr. Guerrasio

CON

Responsible, helpful action doesn’t always mean official involvement

Recognizing impairment in our colleagues is both difficult and ethically challenging. Despite national trends, medicine remains a largely self-regulated profession, and we have an ethical obligation to report impaired, incompetent, or unethical colleagues. Rarely are the indications for reporting or identifying a colleague clear.

As trained clinicians, we know the signs of substance abuse:⁶

• Frequent tardiness and absences;
• Unexplained disappearances during working hours;
• Inappropriate behavior;
• Affective lability or irritability;
• Interpersonal conflict;
• Avoidance of peers or supervisors;
• Keeping odd hours;
• Disorganized and forgetful;
• Incomplete charts and work performance;
• Heavy drinking at social functions;
• Unexplained changes in weight or energy level;
• Diminished personal hygiene;
• Slurred or rapid speech;
• Frequently dilated pupils or red, watery eyes and a runny nose;
• Defensiveness, anxiety, apathy, and manipulative behaviors; and
• Withdrawal from long-standing relationships.

Yet when it is a colleague, we are often in denial about their substance abuse. Certainly, simple seasonal allergies and allergy medications can cause a number of the above symptoms. We also are aware of and fear the potential impact of licensing board notification on a physician’s career. In fact, in a national survey of physicians, 45% of respondents who had encountered impaired or incompetent physicians had not reported them, even though 96% of those surveyed agreed that physicians should report impaired or incompetent colleagues.⁷

Similar to reporting child or elder abuse, you don’t want to be wrong.

At the same time, impaired physicians are disruptive. They negatively impact the lives of their patients, colleagues, and hospital staff.

It is possible to do both the responsible thing and not go directly to the licensing board. You are not responsible for diagnosing your colleagues, but rather recognizing possible impairment.

Check out the Federation of State Physician Health Programs’ website (www.fsphp.org) to identify a local physician health program. Call them and place a report of concern identifying your impaired colleague. While it’s possibly new to you, they have years of experience working with this situation. Trust these organizations, many of which are independent from licensing, to intervene responsibly and confidentially. They can evaluate your colleague and provide a treatment plan and monitoring, as needed. Their approach is rehabilitative rather than punitive, and they resist reporting to the medical board unless the physician-patient is noncompliant.

Physicians have better outcomes than the general population, with reported abstinence rates of 70% to 90% for those who complete treatment.^8,9 Between 75% and 85% of physicians who complete rehabilitation and comply with close monitoring and follow-up care are able to return to work.^9,10

There is hope for your impaired colleague. Contact your local physician health program.

Dr. Guerrasio is a hospitalist and director of resident and medical student remediation at the University of Colorado Denver.

References

1. Hughes PH, Brandenburg N, Baldwin DC Jr., et al. Prevalence of substance use among US physicians. JAMA. 1992;267:2333-2339.
2. Gold KB, Teitelbaum SA. Physicians impaired by substance abuse disorders. The Journal of Global Drug Policy and Practice website. Available at: http://www.globaldrugpolicy.org/2/2/3.php. Accessed June 27, 2011.
3. Wolfgang AP. Substance abuse potential and job stress: a study of pharmacists, physicians, and nurses. J Pharm Mark Manage. 1989;3(4):97-110.
4. Cicala RS. Substance abuse among physicians: What you need to know. Hosp Phys. 2003:39-46.
5. Berge KH, Seppala MD, Schipper AM. Chemical dependency and the physician. Mayo Clin Proc. 2009;84(7):625-631.
6. Bright RP, Krahn L. Impaired physicians: How to recognize, when to report, and where to refer. Curr Psy. 2010;9(6):11-20.
7. Campbell EG, Regan S, Gruen RL, et al. Professionalism in medicine: results of a national survey of physicians. Ann Intern Med. 2007;147:795-802.
8. Femino J, Nirenberg TD. Treatment outcome studies on physician impairment: a review of the literature. R I Med. 1994;77:345-350.
9. Alpern F, Correnti CE, Dolan TE, Llufrio MC, Sill A. A survey of recovering Maryland physicians. Md Med J. 1992;41:301-303.
10. Gallegos KV, Lubin BH, Bowers C, Blevins JW, Talbott GD, Wilson PO. Relapse and recovery: five to ten year follow-up study of chemically dependent physicians—the Georgia experience. Md Med J. 1992;41:315-319.

Dr. Pyke

PRO

Hospitalists’ moral obligation is to protect the patient

In this era of historic budget deficits, wars, and political strife surrounding healthcare reform, one might ask if we can afford to spend valuable time and energy on the issue of reporting physicians who abuse substances.

At first glance, I certainly had skepticism about the subject, but then I dug deeper. To my surprise (and likely yours), studies indicate that physicians develop substance-abuse problems as often or more than the general population does.¹ Recent reports detail horrific patient outcomes at the hands of health providers whose actions are compromised by drug use. With data showing the prevalence of substance abuse among physicians hovering around 10% to 12%, we must accept the reality that hospitalists are not exempt.^2,3,4,5

As medical doctors, our promise to our patients is to provide care in an ethical manner. Even if we try to live in denial, most of us would agree that with great blessing (or power) comes great responsibility. So when the question of reporting a fellow hospitalist who is abusing substances was asked, my response was unequivocally yes.

In my opinion, this discussion can be limited to two overarching principles: First, we are compelled to put our patients first. As hospitalists, we are blessed to be caring for some of the most frail and vulnerable in our society. Fortunately, an overwhelming number of us do so with pride, skill, and integrity.

The task of providing high-quality care to an empowered patient population is difficult enough with us being physically, emotionally, and mentally exhausted. But to add substance abuse to this is just a complete and utter violation of our patients’ trust. We must agree that putting our patients’ well-being beyond reproach requires us to report any colleague who is compromised.

Second, delayed help for a colleague in trouble with substance-abuse issues could be fatal—and for more than just that single colleague. At some point, we are compelled to do more than just raise an eyebrow and shake our head. Usually at the time of discovery, months if not years of substance abuse already have gone by undetected. Deferring to the next person is just not an option. There is too much at stake. It is our moral duty to help our colleagues who are unable to realize the danger they are posing to themselves, the team, and, most importantly, the patients.

Certainly, physicians do not need another lecture about the perils of substance abuse. Whether discussing prescription drugs, alcohol, marijuana, cocaine, or the like, we all have witnessed the devastating effects of abuse. The fact is, any substance that alters our ability to perform our trusted duty must be avoided.

Colleagues, the algorithm is simple: Be vigilant, observe, confirm, and report. It is our moral and ethical imperative.

Dr. Pyke is chief medical officer of Medicus Consulting, LLC.

Dr. Guerrasio

CON

Responsible, helpful action doesn’t always mean official involvement

Recognizing impairment in our colleagues is both difficult and ethically challenging. Despite national trends, medicine remains a largely self-regulated profession, and we have an ethical obligation to report impaired, incompetent, or unethical colleagues. Rarely are the indications for reporting or identifying a colleague clear.

As trained clinicians, we know the signs of substance abuse:⁶

• Frequent tardiness and absences;
• Unexplained disappearances during working hours;
• Inappropriate behavior;
• Affective lability or irritability;
• Interpersonal conflict;
• Avoidance of peers or supervisors;
• Keeping odd hours;
• Disorganized and forgetful;
• Incomplete charts and work performance;
• Heavy drinking at social functions;
• Unexplained changes in weight or energy level;
• Diminished personal hygiene;
• Slurred or rapid speech;
• Frequently dilated pupils or red, watery eyes and a runny nose;
• Defensiveness, anxiety, apathy, and manipulative behaviors; and
• Withdrawal from long-standing relationships.

Yet when it is a colleague, we are often in denial about their substance abuse. Certainly, simple seasonal allergies and allergy medications can cause a number of the above symptoms. We also are aware of and fear the potential impact of licensing board notification on a physician’s career. In fact, in a national survey of physicians, 45% of respondents who had encountered impaired or incompetent physicians had not reported them, even though 96% of those surveyed agreed that physicians should report impaired or incompetent colleagues.⁷

Similar to reporting child or elder abuse, you don’t want to be wrong.

At the same time, impaired physicians are disruptive. They negatively impact the lives of their patients, colleagues, and hospital staff.

It is possible to do both the responsible thing and not go directly to the licensing board. You are not responsible for diagnosing your colleagues, but rather recognizing possible impairment.

Check out the Federation of State Physician Health Programs’ website (www.fsphp.org) to identify a local physician health program. Call them and place a report of concern identifying your impaired colleague. While it’s possibly new to you, they have years of experience working with this situation. Trust these organizations, many of which are independent from licensing, to intervene responsibly and confidentially. They can evaluate your colleague and provide a treatment plan and monitoring, as needed. Their approach is rehabilitative rather than punitive, and they resist reporting to the medical board unless the physician-patient is noncompliant.

Physicians have better outcomes than the general population, with reported abstinence rates of 70% to 90% for those who complete treatment.^8,9 Between 75% and 85% of physicians who complete rehabilitation and comply with close monitoring and follow-up care are able to return to work.^9,10

There is hope for your impaired colleague. Contact your local physician health program.

Dr. Guerrasio is a hospitalist and director of resident and medical student remediation at the University of Colorado Denver.

References

1. Hughes PH, Brandenburg N, Baldwin DC Jr., et al. Prevalence of substance use among US physicians. JAMA. 1992;267:2333-2339.
2. Gold KB, Teitelbaum SA. Physicians impaired by substance abuse disorders. The Journal of Global Drug Policy and Practice website. Available at: http://www.globaldrugpolicy.org/2/2/3.php. Accessed June 27, 2011.
3. Wolfgang AP. Substance abuse potential and job stress: a study of pharmacists, physicians, and nurses. J Pharm Mark Manage. 1989;3(4):97-110.
4. Cicala RS. Substance abuse among physicians: What you need to know. Hosp Phys. 2003:39-46.
5. Berge KH, Seppala MD, Schipper AM. Chemical dependency and the physician. Mayo Clin Proc. 2009;84(7):625-631.
6. Bright RP, Krahn L. Impaired physicians: How to recognize, when to report, and where to refer. Curr Psy. 2010;9(6):11-20.
7. Campbell EG, Regan S, Gruen RL, et al. Professionalism in medicine: results of a national survey of physicians. Ann Intern Med. 2007;147:795-802.
8. Femino J, Nirenberg TD. Treatment outcome studies on physician impairment: a review of the literature. R I Med. 1994;77:345-350.
9. Alpern F, Correnti CE, Dolan TE, Llufrio MC, Sill A. A survey of recovering Maryland physicians. Md Med J. 1992;41:301-303.
10. Gallegos KV, Lubin BH, Bowers C, Blevins JW, Talbott GD, Wilson PO. Relapse and recovery: five to ten year follow-up study of chemically dependent physicians—the Georgia experience. Md Med J. 1992;41:315-319.

Dr. Pyke

Recent discussions on conflicts of interest in medical publications underscore the significance of the important yet fragile relationship between the pharmaceutical industry and healthcare professionals. Among these is an examination of how academic departments can maintain a relationship with the industry.¹ This study suggests that if appropriate boundaries are established between industry and academia, it is possible to collaborate. However, part of the policy in this investigation included “elimination of industry-supplied meals, gifts, and favors.”²

The Institute of Medicine’s “Conflict of Interest in Medical Research, Education, and Practice” included groundbreaking recommendations.3 Among them was a call for professionals to adopt a policy that prohibits “the acceptance of items of material value from pharmaceutical, medical device, and biotechnology companies, except in specified situations.”³

Our nation has been embroiled in a healthcare debate. Questions of right versus privilege, access versus affordability, and, of course, the perpetual political overlay have monopolized most of the discourse. Some contend that healthcare reform will redefine the current relationship between pharma and physicians . . . and not a moment too soon.

Lest there be ambiguity, though, the medical profession remains a noble vocation. This notwithstanding, until 2002, physicians freely participated in golf outings, received athletic tickets, and dined at five-star restaurants. But after the pharmaceutical industry smartly adopted voluntary guidelines that restrict gifting to doctors, we are left with drug samples and, of course, the “free lunch.” Certainly, pharma can claim it has made significant contributions to furthering medical education and research. Many could argue the tangible negative effects that would follow if the funding suddenly were absent.

But let’s not kid ourselves: There is a good reason the pharmaceutical industry spends more than $12 billion per year on marketing to doctors.⁴ In 2006, Rep. Henry Waxman (D-Calif.) said, “It is obvious that drug companies provide these free lunches so their sales reps can get the doctor’s ear and influence the prescribing practices.”² Most doctors would never admit any such influence. It would be, however, disingenuous for any practicing physician to say there is none.

A randomized trial conducted by Adair et al concluded the “access to drug samples in clinic influences resident prescribing decisions. This could affect resident education and increase drug costs for patients.”⁵ An earlier study by Chew et al concluded “the availability of drug samples led physicians to dispense and subsequently prescribe drugs that differ from their preferred drug choice. Physicians most often report using drug samples to avoid cost to the patient.”⁶

Sure, local culture drives some prescribing practice, but one must be mindful of the reality that the pharmaceutical industry has significant influence. Plus, free drug samples help patients in the short term. Once the samples are gone, an expensive prescription for that new drug will follow. It’s another win for the industry and another loss for the patient and the healthcare system.

Many studies have shown that gifting exerts influence, even if doctors are unwilling to admit it. But patients and doctors alike would like to state with clarity of conscience that the medication prescribed is only based on clinical evidence, not influence. TH

Dr. Pyke is a hospitalist at Geisinger Wyoming Valley Medical Systems in Mountain Top, Pa.

References

1. Dubovsky SL, Kaye DL, Pristach CA, DelRegno P, Pessar L, Stiles K. Can academic departments maintain industry relationships while promoting physician professionalism? Acad Med. 2010;85(1):68-73.
2. Salganik MW, Hopkins JS, Rockoff JD. Medical salesmen prescribe lunches. Catering trade feeds on rep-doctor meals. The Baltimore Sun. July 29, 2006.
3. Institute of Medicine Conflict of Interest in Medical Research, Education and Practice Full Recommendations. 4-28-09.
4. Wolfe SM. Why do American drug companies spend more than $12 billion a year pushing drugs? Is it education or promotion? J Gen Intern Med. 2007;11(10):637-639.
5. Adair RF, Holmgren LR. Do drug samples influence resident prescribing behavior? A randomized trial. Am J Med. 2005;118(8):881-884.
6. Chew LD, O’Young TS, Hazlet TK, Bradley KA, Maynard C, Lessler DS. A physician survey of the effect of drug sample availability on physicians’ behavior. J Gen Intern Med. 2000;15(7):478-483.

Dr. Pyke

Recent discussions on conflicts of interest in medical publications underscore the significance of the important yet fragile relationship between the pharmaceutical industry and healthcare professionals. Among these is an examination of how academic departments can maintain a relationship with the industry.¹ This study suggests that if appropriate boundaries are established between industry and academia, it is possible to collaborate. However, part of the policy in this investigation included “elimination of industry-supplied meals, gifts, and favors.”²

The Institute of Medicine’s “Conflict of Interest in Medical Research, Education, and Practice” included groundbreaking recommendations.3 Among them was a call for professionals to adopt a policy that prohibits “the acceptance of items of material value from pharmaceutical, medical device, and biotechnology companies, except in specified situations.”³

Our nation has been embroiled in a healthcare debate. Questions of right versus privilege, access versus affordability, and, of course, the perpetual political overlay have monopolized most of the discourse. Some contend that healthcare reform will redefine the current relationship between pharma and physicians . . . and not a moment too soon.

Lest there be ambiguity, though, the medical profession remains a noble vocation. This notwithstanding, until 2002, physicians freely participated in golf outings, received athletic tickets, and dined at five-star restaurants. But after the pharmaceutical industry smartly adopted voluntary guidelines that restrict gifting to doctors, we are left with drug samples and, of course, the “free lunch.” Certainly, pharma can claim it has made significant contributions to furthering medical education and research. Many could argue the tangible negative effects that would follow if the funding suddenly were absent.

But let’s not kid ourselves: There is a good reason the pharmaceutical industry spends more than $12 billion per year on marketing to doctors.⁴ In 2006, Rep. Henry Waxman (D-Calif.) said, “It is obvious that drug companies provide these free lunches so their sales reps can get the doctor’s ear and influence the prescribing practices.”² Most doctors would never admit any such influence. It would be, however, disingenuous for any practicing physician to say there is none.

A randomized trial conducted by Adair et al concluded the “access to drug samples in clinic influences resident prescribing decisions. This could affect resident education and increase drug costs for patients.”⁵ An earlier study by Chew et al concluded “the availability of drug samples led physicians to dispense and subsequently prescribe drugs that differ from their preferred drug choice. Physicians most often report using drug samples to avoid cost to the patient.”⁶

Sure, local culture drives some prescribing practice, but one must be mindful of the reality that the pharmaceutical industry has significant influence. Plus, free drug samples help patients in the short term. Once the samples are gone, an expensive prescription for that new drug will follow. It’s another win for the industry and another loss for the patient and the healthcare system.

Many studies have shown that gifting exerts influence, even if doctors are unwilling to admit it. But patients and doctors alike would like to state with clarity of conscience that the medication prescribed is only based on clinical evidence, not influence. TH

Dr. Pyke is a hospitalist at Geisinger Wyoming Valley Medical Systems in Mountain Top, Pa.

References

1. Dubovsky SL, Kaye DL, Pristach CA, DelRegno P, Pessar L, Stiles K. Can academic departments maintain industry relationships while promoting physician professionalism? Acad Med. 2010;85(1):68-73.
2. Salganik MW, Hopkins JS, Rockoff JD. Medical salesmen prescribe lunches. Catering trade feeds on rep-doctor meals. The Baltimore Sun. July 29, 2006.
3. Institute of Medicine Conflict of Interest in Medical Research, Education and Practice Full Recommendations. 4-28-09.
4. Wolfe SM. Why do American drug companies spend more than $12 billion a year pushing drugs? Is it education or promotion? J Gen Intern Med. 2007;11(10):637-639.
5. Adair RF, Holmgren LR. Do drug samples influence resident prescribing behavior? A randomized trial. Am J Med. 2005;118(8):881-884.
6. Chew LD, O’Young TS, Hazlet TK, Bradley KA, Maynard C, Lessler DS. A physician survey of the effect of drug sample availability on physicians’ behavior. J Gen Intern Med. 2000;15(7):478-483.

Dr. Pyke

Recent discussions on conflicts of interest in medical publications underscore the significance of the important yet fragile relationship between the pharmaceutical industry and healthcare professionals. Among these is an examination of how academic departments can maintain a relationship with the industry.¹ This study suggests that if appropriate boundaries are established between industry and academia, it is possible to collaborate. However, part of the policy in this investigation included “elimination of industry-supplied meals, gifts, and favors.”²

The Institute of Medicine’s “Conflict of Interest in Medical Research, Education, and Practice” included groundbreaking recommendations.3 Among them was a call for professionals to adopt a policy that prohibits “the acceptance of items of material value from pharmaceutical, medical device, and biotechnology companies, except in specified situations.”³

Our nation has been embroiled in a healthcare debate. Questions of right versus privilege, access versus affordability, and, of course, the perpetual political overlay have monopolized most of the discourse. Some contend that healthcare reform will redefine the current relationship between pharma and physicians . . . and not a moment too soon.

Lest there be ambiguity, though, the medical profession remains a noble vocation. This notwithstanding, until 2002, physicians freely participated in golf outings, received athletic tickets, and dined at five-star restaurants. But after the pharmaceutical industry smartly adopted voluntary guidelines that restrict gifting to doctors, we are left with drug samples and, of course, the “free lunch.” Certainly, pharma can claim it has made significant contributions to furthering medical education and research. Many could argue the tangible negative effects that would follow if the funding suddenly were absent.

But let’s not kid ourselves: There is a good reason the pharmaceutical industry spends more than $12 billion per year on marketing to doctors.⁴ In 2006, Rep. Henry Waxman (D-Calif.) said, “It is obvious that drug companies provide these free lunches so their sales reps can get the doctor’s ear and influence the prescribing practices.”² Most doctors would never admit any such influence. It would be, however, disingenuous for any practicing physician to say there is none.

A randomized trial conducted by Adair et al concluded the “access to drug samples in clinic influences resident prescribing decisions. This could affect resident education and increase drug costs for patients.”⁵ An earlier study by Chew et al concluded “the availability of drug samples led physicians to dispense and subsequently prescribe drugs that differ from their preferred drug choice. Physicians most often report using drug samples to avoid cost to the patient.”⁶

Sure, local culture drives some prescribing practice, but one must be mindful of the reality that the pharmaceutical industry has significant influence. Plus, free drug samples help patients in the short term. Once the samples are gone, an expensive prescription for that new drug will follow. It’s another win for the industry and another loss for the patient and the healthcare system.

Many studies have shown that gifting exerts influence, even if doctors are unwilling to admit it. But patients and doctors alike would like to state with clarity of conscience that the medication prescribed is only based on clinical evidence, not influence. TH

Dr. Pyke is a hospitalist at Geisinger Wyoming Valley Medical Systems in Mountain Top, Pa.

References

1. Dubovsky SL, Kaye DL, Pristach CA, DelRegno P, Pessar L, Stiles K. Can academic departments maintain industry relationships while promoting physician professionalism? Acad Med. 2010;85(1):68-73.
2. Salganik MW, Hopkins JS, Rockoff JD. Medical salesmen prescribe lunches. Catering trade feeds on rep-doctor meals. The Baltimore Sun. July 29, 2006.
3. Institute of Medicine Conflict of Interest in Medical Research, Education and Practice Full Recommendations. 4-28-09.
4. Wolfe SM. Why do American drug companies spend more than $12 billion a year pushing drugs? Is it education or promotion? J Gen Intern Med. 2007;11(10):637-639.
5. Adair RF, Holmgren LR. Do drug samples influence resident prescribing behavior? A randomized trial. Am J Med. 2005;118(8):881-884.
6. Chew LD, O’Young TS, Hazlet TK, Bradley KA, Maynard C, Lessler DS. A physician survey of the effect of drug sample availability on physicians’ behavior. J Gen Intern Med. 2000;15(7):478-483.