The Problem
In medical school, many students learn that the price of lunch is free. We often meet pharmaceutical representatives in the kitchen or at a restaurant where a nice meal is served while the doctor, resident or student is detailed on the benefits of the product that the agent is recommending. Over many years, this has become part of our culture, and to many physicians, this is an “innocent” practice that does not affect our medical decision-making. The continued use of revenues by the pharmaceutical industry to promote physician meals and giveaways, such as pens, pads and other gifts, suggests that there are benefits for these individuals in continuing this practice. Current proposed legislation in many states and at the federal level has called on these companies and doctors to disclose the amounts and number of gifts that exchange hands. There is a danger to throwing all physician and industry relationships into the same melting pot. It is important that we, as a medical community, correct this issue in a way that allows proper exchange of information with drug manufacturers and continues to promote helpful collaboration in education, research and development.

The Pledge
In the United States, the pressure on medical professionals continues to rise with increasing costs of providing care, reduced reimbursement, higher malpractice fees and the fear of poorly informed politicians creating universal socialized health care. In some cases, we are undervalued both in the operating room and in the pain center and do not receive proper reimbursement for our efforts compared to other specialties. Despite these issues, it is not conceivable that members of our society, or any medical specialty, are in need of free pens, meals, trips, golf balls, reflex hammers, sporting event tickets, stethoscopes or other trinkets. At this time, we must take a pledge as physicians:

We will not accept any gift from an entity that has a product that we have the power to use in the care of our patients.

We will not use marketing products in the presence of our patients that bear the name of a company unless that product is of educational value to the patient or is directly involved in the care of the sick individual.

We will not accept any meal, trip or social activity reimbursement unless the item is directly related to an educational event that will improve our knowledge or skills.

Physician and Staff Education
In many circumstances, pharmaceutical companies can be very helpful in educating both physicians in a practice and the staff who helps care for our patients. Education should be based on the best available evidence and on peer-reviewed materials that have direct relationships to the product in question. When possible, these activities should occur in an environment that does not include the exchange of any items of value. If the educational event does occur in a setting where a meal is served, the value should be reasonable, and both the educational content and costs should be documented by both parties. Physicians and pharmaceutical company representatives can give each other valuable educational information, and the desire to be unbiased should not interfere with the exchange of knowledge regarding new products or new indications for existing drugs.

Physician Consulting and Research
The value of a physician in an area of specific patient treatment can be very high. In some cases, the advancement of patient care cannot occur without the insight, research and advice of key opinion leaders in the field of interest. These collaborative relationships are very valuable and are often important in moving the field forward and in saving lives and improving the quality of live for millions. The federal government has given guidelines for relationships between physicians and companies. Other voluntary guidelines have been reached by companies in many areas of pain treatment that both set rules and give codes of behavior. The criteria for these relationships should include:

• The amount paid for research and consulting should be at fair market value for the physician’s skills.

• The time or activity performed should be documented by the parties to justify payment.

• The work of the physician should have intrinsic value to advancing patient care and safety. The consulting or research should have value that contributes to the proper care of current and future patients.

• The details of the relationship should be set forth in a written agreement for a set period of time to ensure that the value and timelines stay current.

• The agreement of the company and physician should not include any requirement to use the product that is manufactured or distributed by the company requesting the doctor’s services. Meals, travel and educational materials required in the work produced by the agreement are reasonable expenses and do not constitute gifts.

On a Diet: No Free Lunches
In 2005, as part of our compliance plan and goals, our company created a policy of accepting no gifts, meals or other items of value in relation to a product. In order to discuss a new drug or product, the company representative must make an appointment with the physician and must bring a peer-reviewed article to support his or her points of discussion. Since initiating this program, we have found that the information we have received is of much higher quality and has more significance to our patient care. We have realized that the opportunity to “influence” our decision making is much more scientific when the free lunch is eliminated. The end result of taking this pledge is to improve patient care and to choose products based on scientific merit, not fancy marketing or free coconut cream pie. I urge each member of ASA to join me in making this pledge. It is a pledge that will purify your practice and improve your image. For those who feel that we are being too conservative and who argue that there is no harm from accepting gifts, I urge you to go to your local Walmart and buy generic pens. They write just as clearly and are not blurred by a cloud of misinformation.

Bibliography:

• AdvaMed’s Code of Ethics. (2007) Available from Advanced Medical Technology Association. www.advamed.org/MemberPortal/About/code/codeofethics.htm.
• Deer T, Krames E. Physicians, industry, and science: Moving forward as neuromodulation matures. Neuromodulation. 2007; 10(3):203-205.

Timothy R. Deer, M.D., is President and CEO, The Center for Pain Relief, Inc., and Clinical Professor, West Virginia University, Charleston, West Virginia.