It has been a long time coming: the AAMC has finally taken a strong stance against the distribution of free gifts (from pens and bags to food, travel expenses, vacations, ghost-written papers, etc.) to physicians, medical school staff members, and students by pharmaceutical and medical device companies (reference). The AAMC is not a ruling body for medical schools, but it does provide guidelines and directives that most medical schools choose to follow. Responding to the growing efforts of companies to influence the medical decisions of doctors, the AAMC has proposed an all-out ban, no strings attached.
Surprisingly, several executives from major pharmaceutical companies including Amgen, Eli Lilly, and Pfizer were on the task force, although it seems their dissenting opinions were overruled by the majority. One of the Amgen representatives expressed conditional support for the AAMC’s report “because we have a different view about the accuracy concerning representations about the motives of the participants.” This is not entirely untrue, but it illustrates the subversive nature of the tactics many companies have used to influence prescription writing, device usage, and product endorsement behavior of physicians. Various studies have consistently demonstrated that physicians who accept gifts underestimate their susceptibility to influence by the drug and device makers over their medical practice decisions. Most physicians do not perceive their acceptance of free gifts as prostituting themselves to these companies, when in reality, they are allowing these companies to take advantage of their sense of entitlement (something often developed in medical school).
Some members of my generation of physicians-in-training might complain: “Our predecessors received free gifts and tens of thousands of dollars in speaking fees; why shouldn’t we?” My response: suck it up. How hard is it to buy your own pens and lunch? The movement within the field to expose financial conflicts of interest has done a reasonable job of revealing the extent of potential influence of drug and device makers over medical practice, but it is now our job to take a stand and say “no.”
Today’s New York Times featured an article discussing the tendency for a number of states to raise tobacco taxes in order to make up for deficits in the budget, particularly with respect to financing health care reform and medical research. Interestingly, the tobacco companies, unhappy about the rising taxes, gave this argument in response:
The tobacco industry counters that smokers already bear an unfair tax burden and that increases encourage cross-border purchases and bootlegging. Cigarette manufacturers also argue that tobacco taxes make for an unstable revenue source because of declining sales. An analysis of recent tobacco tax increases conducted by Altria, the parent company of Philip Morris USA Inc., concluded that three-fourths of them had raised less money than projected.
The first argument is amusing at best. When did tobacco companies start caring about the well-being of their customers? I suppose they care about the financial well-being of their customers but not their health. As long as the tobacco companies can make a profit from tobacco sales, they will be happy; otherwise, they could simply lower tobacco product prices to compensate for the tax increases. Given their benevolence and concern for their customers, will tobacco companies do this? Not likely! The second argument is spurious. It is improbable for any analysis or study by a tobacco company to be scientifically sound and unbiased, but nonetheless, the conclusion is of interest. However, does it matter if the money raised is lower than expected? Tobacco taxes have been very successful in the past at raising some money for medical research in states such as Louisiana, but perhaps they shouldn’t be depended on as a sole method of covering deficits.
The many societal (e.g. anti-smoking laws) and financial (e.g. taxes) barriers to smoking seem to function well as preventive measures for starting the habit of smoking, and they similarly might help the medical profession set the stage for patients to quit smoking (since we now have more effective medications/patches and counseling methods). That is, people would rather quit or taper their smoking habits than pay the taxes (e.g. being “financially burdened” by the new taxes). People adjust. Tobacco companies might not. Even if the tobacco taxes do not raise as much money as expected, is there any harm done except to an industry that feeds off the anxiety and fatigue of its consumers (to the detriment of their health)? I say tax away.
Leading into my third year clinical clerkships, I predict that my posts will become increasingly shorter in length (which is probably a good thing) as I will have less free time to myself and more time to commit to my patients and team members. Nonetheless, reflecting on my experiences through writing is a personal commitment and a powerful learning tool for me as I seek to continue developing the self-awareness and self-assessment skills required of a good physician. Here is a short reflection on developing thoughts.
I believe that in the liminal spaces of sickness and healing, there are few words said that lack a deeper meaning. We, as physicians, must be careful and conscientious of the words we choose to convey our instructions, encouragement, and bad news. Our partners in this relationship, our patients, do the same, though perhaps with less premeditation. For the first time, an inpatient, encouraging me and a team member during our early stages of medical training, spoke these words to me: “God gave you the power to heal.” In those words, I find not only encouragement but also the desire to assign meaning and order to his tortuous path. With the will of God breathing a purpose into each action and interaction, it is possible to move forwards through each hardship with a peaceful mind and connect to those who would help or test you along the path.
I am not a religious person, and I am uncertain as to whether or not I ever will be. However, I do believe in a greater order connecting each person and living being and a meaning behind every occurrence. For me, believing that there is a greater order and reason serves to assure me that not all events and outcomes are in my control. On the other hand, believing that the power of healing is a gift from God reminds me that I have a responsibility to use my abilities (however nascent at this time) to serve the well-being of all people, all who are connected by this greater order and reason. The former prevents the anguish and the tendency to cast and misplace blame that arises from the failure of a patient to recover as expected. The latter marks the commitment needed to always do everything in my power (within reason) to help and understand he or she who suffers. I believe that those who enter medicine with a prior connection to God through religion have an advantage in this area: they are more likely to quickly develop the range of behavior and systems of rationalization that are appropriate and helpful in the care of patients. That is, they may be more humble than others in their perceptions of their effect on patient outcomes and more likely to recover from the trauma of poor patient outcomes, while also being more committed to using the gift of healing given to them. Religions may not always promote the values we support as practitioners of medicine (equality, compassion, tolerance), but most do. Accordingly, I hope that physicians-in-training with religious beliefs and commitments always find a place to speak with other students, and patients, about their faiths and their intersections with medicine and patient care. Not all in medicine fits within the purview of science: much revolves around how we connect to another person, and how we see that connection.