Narrative Matters: The Power of the Personal Essay in Health Policy

CHAPTER 6: DRUG RESISTANCE: BATTLING UNDUE INFLUENCE

CHAPTER 6 DRUG RESISTANCE BATTLING UNDUE INFLUENCE
A Matter of Influence Howard Brody As Drug Marketing Pays Off, My Mother Pays Up Janet R. Gilsdorf No Free Lunch Paul Jung
A Matter of Influence Changing times call for changing policies on the presence of drug company reps in residency programs. Howard Brody I was sitting in a room off the hospital cafeteria with a group of our family practice residents, waiting for teaching rounds to begin, when I asked them about the pledge taken by some doctors to “just say no” to drug reps by not accepting any gifts from them. Did the residents think that any of their peers would sign such a pledge? “Maybe half would,” said one. “That’s way too optimistic,” replied another. A third resident explained that she would refuse to sign the pledge, not because of a desire to get freebies, but out of a conviction that she was educating herself before embarking on her career. How would she know how or whether to interact with drug reps later on if she did not gain some experience with them now? About ten years ago I served on a committee in our department that decided that our residency site should make no effort to eliminate contact with drug reps or their gifts. We argued that part of residents’ training was learning how to deal with the reps’ blandishments in order to prepare them for their presence in later professional practices. I remain sympathetic to our resident’s educational arguments. Still, if our committee were voting today, I would advocate a policy that made our residency program—and indeed, the whole hospital—a “drugrep -free zone.” I would justify this draconian action by pointing to how much has changed in the past decade. The pharmaceutical industry has drastically, if incrementally and therefore often invisibly, upped the ante. Too much is now at stake. Volume 21, Number 2: 232–234. March/April 2002. High Stakes Evidence is steadily mounting that we physicians are, in fact, influenced by the industry’s largess. The proof does not by itself matter. What matters is how blind we are to the fact that we are being influenced. This lack of critical awareness seems to demand regulatory oversight. Today it is naïve to claim that each of us can make our own informed decisions about this matter. The likelihood is high that those among us who deny the loudest that we are influenced and who are most angered and insulted by this apparent reflection on our professional integrity are precisely the people who are most influenced and whose prescribing patterns are most deleterious to the well-being of patients. Also, we must be aware of the growing scope of the problem as it extends its tentacles into every aspect of medicine. In the past I could entertain the impression that although I might get biased reports if I spoke with drug reps, I could always find the truth by consulting my professional publications. Today I have no such confidence. Even the most prestigious journals have published numerous papers by authors with serious, undisclosed conflicts of interest ; and when a study reveals facts that are deemed unfriendly to the sales of a drug, the sponsoring company may use intimidation to prevent or delay publication of the results. Knowing how the few scientists who have dared to anger their company sponsors have been vilified, slapped with nuisance lawsuits, and had their research careers shattered, I conclude that a good many investigators whose studies revealed information unfavorable to a drug company quietly buried their data and never sought to publish at all. The disparate pieces of this puzzle are interconnected. At first glance, whether our residents get to gobble down nice lunch sandwiches provided by the drug reps seems unrelated to whether a study’s authors misrepresent their findings because of a financial conflict of interest. But why are residents so angry if a policy is proposed that will limit their free meals? Why is Harvard Medical School willing to look the other way with a policy that its faculty receive only $10,000 annually in consulting fees or $20,000 in stock? Culture of Entitlement What the residents and the Harvard faculty have in common is a culture of entitlement. Since the first day of medical school, we have been primed by...