Short post this week. In response to this article, please consider the following:
Where should we draw the line - at the point at which we recognize a potential conflict of interest or at the point where our patients may consider our judgment compromised?
Should this be an individual choice or a company/institution policy?
In what situations should we as pharmacists be required to declare any real or perceived conflicts of interest and to whom should we declare these?
24 comments:
I completely agree with the tenets of the article. The idea of "raising the bar" and submitting institutions to voluntary compliance is a good idea assuming that medical centers will feel the obligation to do so. The ultimate goal, which is standardization of more moral practices focusing on the well fare of the patient would be even more of an accomplishment if institutions refused to participate in any of these behaviors voluntary, rather than pushing for legislation to force them. However, I believe that it is immoral enough and widespread enough that if we must "clean up" this behavior by laws rather than voluntary compliance, then so be it.
Industry now is the leading funder of medical research. It contributes to conducting researches, however, it also influences in failures of funding in pharmaceutical and medical devices, insurances, etc.
Health care professional have commitment to care about the interests of patients. It is not decision of any individual, it should be decided by community, companies.
Ngan Tran _ P1
I feel it would be hard to declare whether a physician's decision was a conflict of interest unless they only used one medication for a wide variety of patients, which then as a pharmacist you might want to contact them about their reasoning. I do think the pharmacist should assess new medication choices with the patient to determine whether it is right for them financially etc. especially if a generic is available that works the same way. I think the Academic Medical Centers could be beneficial to reduce the "conflicts" but only to an extent. I do think it should be individual choice, because sometimes physicians may not be open to new medications without incentives unfortunately. Some medications may be better for the patient and the physician should be well trained to assess whether the medication will be right for them.
~Leanne Wentz p1
When there is a conflict of interest between a pharmacist and a patient, the situation can become very “sticky” very quickly. Patients do not understand that pharmacists have the right to refuse to fill a prescription if they feel it could potentially be the wrong medication or harm the patient. The pharmacist is really looking out for the patient, even though the patient is not seeing eye-to-eye with the pharmacist. The pharmacist needs to make sure they explain to the patient why they are concerned and provide specific details. If the pharmacist does this, hopefully the patient will be less likely to view the pharmacist’s judgment as being compromised. I believe ultimately that this issue needs to revolve around personal choice. A pharmacist may see an issue not outlined in company policy that needs to be addressed. Any problems with conflict of interest should be reported to the prescribing physician. This way, the doctor can give some third party advice as to why or why not the pharmacist’s choice is a good one. This will help the pharmacist positively grow in making quality judgment and decisions in the profession.
-Sarah Helms (P1)
I don't believe that "gift-giving" to physicians is really that harmful to patients. In the end, the pharmacist can call the physician and have the script changed. From what I understand, only rarely does the physician refuse to change it. As long as pharmacists are trained to know the extent of what a drug is able to accomplish versus what drug reps may claim, the issue isn't as pressing as it may seem.
- Andrew Herrin, P1
I agree with Andrews comment in that I do not see the harm in pharmaceutical reps giving out sample medications, pens or bringing lunch for physicians staffs in the interest of marketting their product. Physicians have the knowledge to determine if the drugs that are being marketted are truly in their patients best interest and will act in accordance with that guiding principle. These sample meds can be especially helpful for physicians dealing with patients that are not financially well off enough to afford a Lipitor prescription for example and giving that patient some samples of Crestor to get them through the month I think can be helpful. I also think the pharm reps presentation certainly helps the physician get intellectually challenged about new medications that they may not otherwise be informed about. It also helps with staff moral as free food is always a nice perk and builds staff cohesion. Is their a potential for abuse, certainly, but I do not think the negatives outweigh the good. These are harmless acts, however, giving physicians money, club seats to ball games, elaborate dinners then I think your entering a grey area that should not be crossed. So long as the gifts are limited to staff lunches, sample medications, a presentation and some harmless pens I do not see the harm in it.
Jim Zacharias
P1
I agree with this article. Giving physicians gifts or incentives to try out new drugs doesn't help the patients. If the pharmaceutical companies are so confidant in their products then bribing the physician shouldn't have to happen. The companies should be able to use clinically based evidence to prove that their products work. I also fell that Academic Medical Centers should not be swayed by this type of business. The AMCs must be non-biased to ensure that their residence and interns learn on an evidence based approach to medicine.
Evan MacDonald P1
The article shows that there should be more stringent regulation on the health industry practice. This proposal was published in 1/2006, but the
budget of the pharmaceutical industry, which is directed to physicians, has been increased. Thus, the voluntary compliance of the academic medical centers and individual physicians do not work. In order to prevent the influence of the pharmaceutical companies on the physicians, the Federal and the state must make some laws to change the current health industry practice.
Tai Tran - P1
The influence that pharmaceutical companies have on physicians puts many patients health at risk. The number one priority of pharmaceutical companies is not to better help the patient; it is to sell their product to make money. With these motives, obviously the data and information they present to physicians in misconstrued. This in turn harms the patients well being, because the physicians will prescribe medications that might not be the absolute best for every individual patient.
A way to combat these negative influences, would be to have pharmacists take the role of drug reps in educating physicians. Another combating force could be pharmacists present in the clinics and physicians offices filtering the information from the drug reps.
Based on what the article said, it's so hard for physicians who have to make a decision all the time between patients' interest and industrial interest. In my opinion, it doesn't matter if industrial interest involves to medical professionalism as long as it is not harm for patients.
Everything has positive and negative sides; therefore we should know how to reduce the negative effects. IN that article, it is said that there are academic center education, gifts, scholarships, etc. for physicians when attending to educational conference. This is a very good idea to encourage physicians learn more about new products. Both Companies and patients can make benefit from that.
The bottom line is that industrial drug companies don't overdo their marketing without concerning to patients.
Ngan Tran - P1
"Gift-Giving" can have a potential negative effect on healthcare. Physicians may feel obligated or pressured to write certain scripts without taking the patient into consideration. Medication needs to be individualized according to the patient because we all know that there isn't one magical cure for a given disease state. People react different and instead of reaching for the drug attached to the biggest gift, physicians need to keep the best interest of the patient at heart. Having multiple drug companies involve is promoting competition, but unfortunately it is the wrong kind of competition. Instead of battling in the lab for the next break through they are battling it over at the steak houses for the next memorable gift.
Nick Conley (p1)
Last week’s posts focused on the one of the tangible aspects of COI: gifts from drug reps to prescribers. The opposition believes that “gifts” taint the prescriber’s judgment due to what is perceived as an unprofessional arrangement between a drug company and their target prescribers. Surprisingly, there was little discussion on pharmacists being influenced by drug reps (do you order their product because they say it’s the next big thing? Do you believe every word that comes out of their mouth because they hand you a brochure with fancy graphs and charts?). Keeping that in mind…
A quick survey of the student pharmacists on the blog: Were free backpacks given out again this year? How many of you are sporting a drug distributor’s logo on your back every day? How many of you took the free jump drives Target provided during orientation week? How many of you work for another pharmacy and took the Target jump drive and ate the Target pizza?
I don’t point this out to criticize the gift takers… I was once one of you. I loaded up on free swag at NCAP and APhA meetings, took all the free highlighters/jump drives/laser pointers/Sanford guides/hand sanitizer I could get my hands on, and walked away feeling pretty good about it… but I didn’t realize the overwhelming conflict of interest that I had completely ignored. I point this out because after graduation, when you’re a pharmacist and you likely work for a corporation of some sort, you’ll be considered a leader. Your business dealings with vendors, investors, and competitors will be scrutinized because of your role within the corporation. My employer provides conflict of interest training to all executives – every year, we have to recertify our understanding of the company’s policies and declare any conflicts of interest that may be perceived. It’s important to start to recognize possible COIs as a student, so that when you take on a leadership role as a pharmacist, you more readily recognize and avoid professional COIs. As a pharmacist, you’ll owe the professional courtesy of avoiding conflicts of interest both to yourself and to your employer.
___________________________________
Erica Harms, Pharm.D., R.Ph.
Executive Pharmacist
Target Pharmacy | Charlotte, NC
eharms@carolina.rr.com
I do agree that there needs to be some compliance on the part of physicians. However in a capitalistic society pharmaceutical companies need to market their products which they spent lots of money researching. Its the physicians responsibility to safeguard the interest of the patient and know where to draw the line when it comes to receiving favors from companies. These companies fund important researches that advance and improve healthcare and they need to make the money. Its upto individual physicans to decide whats to take without compromising patient care.
Jonathan Mwathi
I agree with Jim and Andrew’s argument. Physicians and pharmacists are obviously well-educated and should have the ability to determine the best treatment option for the individual patient, despite the encouragement from biased drug reps. Free pens and lunches for the staff should not have a great influence on the physician or pharmacist. As long as the gifts that the drug reps present stay modest, there should be no problems.
Allison Hoyle- P1
I found Dr. Harms’ post very helpful in accessing an issue we never touched on. We read in the article how even though the idea that small gifts do not significantly influence physician behavior is widely accepted among physicians that psychologists, sociologists and economists have all researched this and found that “the impulse to reciprocate for even small gifts is a powerful influence on people’s behavior. Individuals receiving gifts are often unable to remain objective; they reweigh information and choices in light of the gift”. We largely agreed that doctors are influenced by these small gifts, whether they are conscious of it or not. I also think though that most of us would deny being influenced at all by the small gifts we received during orientation week. I know that I don’t think I was influenced at all, but if doctors can fail to recognize influence after years in practice I’m sure we, as first year pharmacy students, could fail to recognize the influence as well so I agree with Dr. Harms that it’s important we start recognizing possible conflicts of interests as students.
Danielle Nichols- P1
I have a friend who is a physician assistant that removed everything in his office that was related to drugs and drug reps. He also stopped having appointments with drug reps. He did all of this so that his patients would not think that there was a conflict of interest. He did this so that there would be little or no question that the treatment he chose was in the best interest of the patient.
Matthew Jones P1
As much as we hate to admit it, our society is driven by industry and that includes even the medical professions. Most of the time, I don't think that patients understand the relationship between drug reps and their physicians and I think that if they did, they would be concerned that their physician was giving them the best medication. I think that it is important to recognize that the role of the drug reps and the pharmaceutical industry is necessary in furthering the medicine field. I believe that physicians need to keep the best interests of the patients in mind (which they have sworn to do) even though drug reps are offering these gifts. It's a matter of separating care from business.
--Hollee Kitts, P1
Physicians as the hierarchy of the health care profession should be able to make their clinical decisions based evidence based studies when prescribing medications. The mission of physicians should be to provide treatments that satisfy the best interest of their patients. This can’t take place when the moral requirements of the physicians’ are being compromised by the relationship they have with pharmaceutical companies. The academic medical centers have proposed solid points on how to defeat the conflict of interest that is seen in the health care system. I think some of the proposals are too extreme. The only way these drug companies can promote their drugs is by marketing their products to prescribers. Therefore eliminating marketing their products may not be the best solution. However, I agree with switching drug samples to vouchers for low-income patients. Pharmacists would have the opportunity to directly communicate with patients about their new drug and make sure if it’s worth using vouchers or switch to another affordable medication.
“Gift giving” or lunches, pens, note pads, does the patient benefit or get harmed? To me I do not believe the act of gift giving is harmful to the patient. As long as the individual drug rep is doing the right thing for the patient; not trying to sell a harmful drug to a physician, but a drug that may be the upcoming big hit in medication. Also, in the healthcare field today there is physicians who are stuck on one type of medication, it works and they stick to it for years. But without an incentive to change they are going to stick to the old medication whether or not it has more side effects than other leading drug brands. So, with this stated I see incentives as a good thing in this scenario because it will more than likely benefit the patient in the long run.
Josh Waters P1
I agree with what Ferealem has written. I strongly believe that bias should not be a factor when determining what is right and wrong for patients. Evidence based approach is the ultimate route to take. I also believe it is through these conflicts of interest that we have gotten into the mess we are currently in and only by regulating these issues will we get ourselves out of this mess. Sam Weatherspoon
It seems like the point at which we should recognize a potential conflict of interest can vary widely depending on who is defining the issue. And because of this, I think it would be hard to set a point at which either the pharmacists/doctors judgement is impaired. Because of this, I think these guidelines should be an individual choice rather than forcing an unfavorable opinion upon everyone. I'm sure some bigger corporate companies will have some kind of guidelines when it comes to these conflict of interests, but when it comes to specific details and issues, I think the pharmacist or the physician should have the right to choose.
Conflict of interest as a pharmacist and as a student does occur with some regularity. As a technician I was involved in a lunch sponsored by a Bayer. Bayer was promoting their newest glucose monitors and had been providing the pharmacy with patient savings cards for their test strips. Our pharmacy gladly accepted the free lunch as well as the coupons for our patients. As pharmacists, it is our duty to provide the best care for our patients, and that often involves finding ways to save the patient money. Diabetics have a monthly expense of purchasing test strips that cost about $1 per test strip. For the patient that tests 3 to 4 times per day, the expense being passed on to the insurance company is high. So what is the harm in recommending a specific glucose monitor for a patient that is struggling to pay their monthly copays?? I have no regrets about accepting this drug rep’s complimentary lunch, nor do I feel bad offering my patients a coupon for this company’s test strips.
~~Chrissi Tyrrell, P1
I believe we can not legislate morality or intelligence and this is one of those cases. There will always be those that have their interests in mind only; financially, socially, politically, those individuals see only themselves. I believe however that the majority do the best they can with the information available to them regardless of outside influence.
The marketing 'law' however is that a person must see things 5 times at least before they chose or consider it. We will be influenced by what we see, what we hear.
Dineane Williams
I think Chrissi makes a good point. For many of our patients, cost is a concern. If accepting patient savings cards from a company helps our patients afford their medication or test strips, is that a bad thing? A patient who doesn't have to struggle so much to cover their copay is also likely to be more compliant with their therapy, rather than trying to "stretch" their medications due to cost issues. I understand the negative aspects of accepting gifts from companies, but if the patient is truly our focus, we should also be able to see the benefits that are involved.
-Brittany Samples, P1
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