Sponsorships for medical specialists
Ratna
Magotra
"While returning from my morning walk, I saw a bird in a cage. It
reminded me of people imprisoned in prejudices. Prejudices are also cages, very
subtle and self created. First we create them, then becoming imprisoned in them,
we lose all capacity to fly in the open sky of truth. And just now I see a kite
flying in the sky. What freedom, what a liberation in its flights! One is a bird
in a cage, the other a bird in flight in the open sky, symbolic of two different
states of mind. Those who are liberated, fly in the sky of truth, but neither
are any footprints left behind, nor is any path created... there is path towards
truth, everybody has to create his own path to truth." --Osho
Introduction
When the editor asked me to
write an essay on the subject of company sponsorships for medical specialists, I
realised that I had to pay a price to bell the cat. My immediate provocation for
a debate on this subject had come from a news item inThe Times of India
of 7 May, 1997, about a government order banning doctors sponsored by
medical companies from attending conferences abroad. It is one matter to hold an
opinion about a certain subject and a totally different proposition to write a
comprehensive essay on it.
I propose to deal with the subject by highlighting the basic duties and
privileges of physicians to the professional organisations to which they belong
and then take their relationships with commercial establishments.
What are the goals and objectives of professional bodies?
The objectives of any scientific society or association are commonly based
on the following principles:
to improve the quality and practice of the discipline or the speciality;
to promote and support basic standards in the training programmes of the
speciality;
to encourage basic and clinical research in the field;
to promote the professional and educational development of its members
who have entered that field of specialty;
to provide a forum and publication for scientific presentations and
discussions.
There are minor variations between the objectives of different associations
and societies of different disciplines depending upon the special needs of the
specific speciality.
What are the ethical and moral obligations of the members of
professional organisations?
In order to remain in good
standing, all members must abide by the rules and regulations of the society.
Most societies have rigorous rules for enrolment of its members. Amongst the
rights and duties of its members, it shall be the duty of each active member to
attend regularly the meetings of the Society, to participate in the scientific
programmes, to uphold the ideals and objectives of the society, and to pay the
dues and assessments of the society.
Similarly every association or society has a number of committees to ensure
that the goals and objectives set by the founding members are achieved and the
standards maintained. In professionally mature associations and societies,
amongst many such committees are also the committee on Continuing Education and
the Committee on Standards and Ethics. These committees as well as the Medical
Councils are suitably empowered to take disciplinary action against erring
members.
What is the need for medical professionals to attend national
and international conferences, seminars and updates etc.?
Practising physicians need to keep abreast of the rapid and
continuous advances being made in their respective specialities. Medical
technology is changing at a very fast pace and is contributing to major changes
in the management of various ailments. In fact, Continuing Medical Education
(CME) is an important requirement for doctors in order to keep up with changes
in diagnostic and therapeutic medicine. A certain number of hours of CME are
mandatory for most physicians practising in the USA and several updates,
symposia and conferences have the accreditation for certain hours for CME.
As is evident from the foregoing discussion, attending these meetings,
updates, seminars and conferences is not only the primary duty of the physicians
laid down by their association or society but also a mandatory requirement and a
legal obligation as per the prevalent laws of the particular state for license
to practice.
Apart from such programmes and conferences, other avenues to keep up with
the latest knowledge are journals and other publications related to the subject.
Many of these publications are significantly supported by medical and
pharmaceutical companies. The current revolution in information technology (most
advanced societies are on the Internet), including satellite conferences, have
enabled physicians to access the latest happenings in their fields from the
comfort of their offices or homes. And yet, the charm and bonhomie of personal
interactions is possible only by attending conferences and updates. These are
also occasions for mixing pleasure with work for many physicians, otherwise busy
and overworked, as they attend these meetings with the spouse and
family.
Who should fund these conferences, updates and
seminars?
Organising a conference or an update has become a
highly professional job. The big meetings and conferences are held in five- star
hotels or convention centres with excellent facilities for lectures, audio-
visuals and banquets. These conferences, therefore, need big money to pay for
all the facilities. Medical and pharmaceutical companies give significant
financial support in organising these meetings and in turn have the privilege of
participating in a trade exhibition to promote their products to professionals
in the field. Besides, all such meetings have a registration fee paid by
physician and non- physician members attending these conferences. The
registration fees have risen over the years keeping up with the increased costs
and inflation. Surely it should be possible for the organisers to meet the
expenses through money collected by the registration fees. The actual scene is
different as most lunches, dinners and social events, becoming increasingly
extravagant by the day, are fully sponsored by various commercial organisations
flush with money and eager to influence the doctors.
While the commercial aspects of holding the conferences are beyond the
scope of this essay, I cannot but refer to huge profits made by the organisers
of the conferences. This achievement of the organising committee is enviously
applauded by the main professional body who accept the share of the profits
gratefully while the organisers keep a handsome share, albeit for educational
and research activities. This in turn sets a standard for the organisers of the
subsequent conferences who once again depend heavily upon bigger support from
commercial organisations. And thus a vicious cycle has been set in motion with
no one in particular to blame. One may argue that it is not possible to hold
such big meetings without commercial support and yet some time back, a meeting
of the Indian Academy of Pediatrics was organised without accepting any
commercial support and was by all accounts a successful one!
While one may argue in favour or otherwise of commercial support for
organising conferences, the issue under discussion relates to individual doctors
getting sponsored by these companies. It should be difficult to defend such
sponsorships for doing something which should be their normal duty. As mentioned
by Dean Ornish in his best selling book, "Drug companies make millions of
dollars educating physicians. Drug companies are the major advertisers in all
medical journals. They fund clinical trials and pay the researchers to speak at
hospitals and medical schools... Drug companies provide sandwiches and doughnuts
at hospital conferences... They provide free samples.. . also sponsor scientific
meetings . . . sometimes held in resorts, and doctors who attend may even be
given free transportation and expenses. There is nothing wrong with any of this,
and it is all very comfortable and familiar. But a subtle and sometimes overt
message to doctors gets through that drug companies are friends."
It is common for doctors to get influenced thus.
Why do medical and pharmaceutical companies support these
meetings and/ or physicians attending these meetings?
Medical
and pharmaceutical companies are basically business enterprises making huge
profits. They have a substantial budget for promotion of their products which
they achieve by advertising in medical and non- medical media as well as by
sponsoring medical events as stated earlier. Some of the big companies have a
separate budget for educational and research activities which they use for
sponsoring clinical trials, updates, seminars and conferences. They are also
keen to sponsor willing doctors to attend these meetings and are ready to pay
airfare, five- star lodging and other perks. Spouses may be included at times!
The argument that they do so because of their genuine commitment to
education and dedication to research for the benefit of mankind should be taken
with a generous pinch of salt. After all, Enron is on record as having paid for
the ‘education of politicians’ though one may never know the nature and other
details of such education. To a common person it should mean, in plain words, an
attempt to gain favour, and that is what it is. It should also be understood
that the cost of all such education, research and other promotional activities
is passed on to the consumers -- in the present context, patients.
From the foregoing, several points become clear. First, doctors belong
to a noble profession and their professional organisations have lofty goals and
objectives. Second, attending conferences and updates is absolutely essential
for doctors to keep up with the desired professional standards. Third, modern
medicine is controlled by high- tech sophistication, which is expensive and
therefore, generates fierce competition between companies and consequently,
generates marketing pulls and pressures. Fourth, doctors become unwitting
collaborators of these companies and are at a significant risk of getting
influenced while making treatment choices for their patients. Finally, the
increased costs are directly passed on to patients. In government and public
hospitals, this would mean that the administration has to spend large amounts in
getting high-tech equipment. It is not surprising that several such purchases
involve middle- men and fraudulent practices. It is not uncommon even in public
sector hospitals with limited resources to charge patients for expensive
investigations and procedures and in spite of that, find it difficult to
maintain such equipment. In private sector hospitals, once the technology is
procured at an exorbitant cost, there is increasing pressure on attending
doctors to refer patients in order to recover the cost of the equipment. This is
one explanation for the unnecessary investigations, procedures and even
operations.
Doctors - a part of society
The medical
profession is a part of society and suffers from the same maladies of erosion of
values as do the other segments of society. Is it fair to expect medical
professionals alone to hold moral and ethical values when many others have
forgotten even the definitions of these terms?
I find it extremely difficult to refute such arguments from my friends. At
the same time there are conflicts and blurring of views regarding legal, moral,
social and ethical values in any society. What may be socially sanctioned in one
society or culture may be taboo in another society. Similarly, a legal sanction
may not be moral or ethically correct and what is ethical may not have legal
sanction. Also there are likely to be as many individual variations about what
should be considered moral and ethical. However it is in order to say that
general ethical principles should have general acceptance and should determine
what ought to be done.
The present erosion of values seems to stem from the materialistic growth
of society. Upwardly mobile trends brought in by economic liberalisation have
focused sharply on the haves and have- nots. I find it paradoxical that reforms
in the economic sector, long perceived to be necessary and overdue, should be
accompanied by such mayhem and chaos in moral and ethical values. It is a
reflection on the times that each subsequent scam is bigger than the preceding
one; so much so that the scandal involving purchase of the Bofors guns appears
to be woefully small and boring in contrast to scams worth thousands of crores
unearthed in recent times. Desensitisation is complete. What is then wrong in
doctors doing something totally legitimate and innocent like enjoying the
hospitality of rich companies who after all cannot force them to use their
products? In any case, the companies are going to sponsor so many others
attending the same conference and an individual not accepting the generous
.hospitality cannot make any difference, or can s/ he?
Depriving doctors working in the public sector
The reason that a government order was necessary to ban such
practice itself means that something was more than just wrong. I, however, have
several problems in understanding this order though I must admit that my
impressions are based only on the newspaper report and I have not been able to
get a copy of the said order. Was it legal, before the above order was brought
in, for government doctors to attend conferences sponsored by medical companies?
Is it all right for doctors to attend such conferences within the country as the
order refers to conferences organised abroad? If the government order is
applicable only to doctors working in government hospitals, would it imply that
the law makers thought it to be legal and moral for doctors in private hospitals
to accept such sponsorships? If at all one has to justify commercial support, it
should be for doctors working in government and other public sector institutions
rather than for super rich doctors in private practice charging illogically high
fees from their patients and who, in any case, can not only afford these
expensive conferences but also get attractive tax benefits!
Several big private and corporate hospitals usually sponsor their staff
periodically to attend national and international conferences. Conference funds
at government and public hospitals, on the other hand, have remained limited and
unrealistically low. There is no doubt in my mind that research funding and
funds for continuing medical education in teaching institutes must increase
substantially to promote the professional skills and standing of their staff.
Measures to prevent corruption
Since there
are real risks in doctors accepting direct sponsorships from commercial
companies, several options need to be experimented with. These options should
aim at increasing the available funds of public institutions and at the same
time maintaining a healthy relationship between doctors and commercial
organisations. These arrangements should be such as to allay the present fears
ofquid pro quoand also have legal, moral and ethical
sanctions.
I have a few suggestions to make in this regard:
- Public institutions and hospitals, perennially starved of funds, should
encourage generous support from industrial houses, not necessarily those
related to medical and pharmaceutical interests. This support - specially when
offered by the latter - should have no strings attached, should be transparent
and open to public scrutiny. Doctors involved in research supported by medical
and pharmaceutical companies should be permitted to present/ publish their
findings at national and international meetings and conferences with the
support of the sponsoring companies. There is no need for the institution to
sponsor such candidates. Instead, the sums saved can be used for other
deserving candidates. Most professional societies abroad demand a declaration
of any commercial interests and on the nature of relationship between the
physician presenting the work and the sponsoring commercial company. Similar
norms should be practised in Indian societies and associations and members of
these professional organisations should work towards necessary amendments in
their respective professional bodies.
- Medical and pharmaceutical companies, normally so eager to sponsor
individual doctors, should contribute to the conference funds in public
hospitals. These institutions, in turn, should have a Conference Committee
suitably constituted to disburse the funds to different departments and
individual staff members, including nurses and technical staff members. The
Conference Committee should have unambiguous guidelines in order to ensure
fairness and transparency in its working. It will be desirable to have the
funding commitment from commercial companies for a block period (five years or
more), starting well in advance in the first financial year. Selection of the
staff as per guidelines must also be made well in advance.
- Commercial companies may continue to support conferences, seminars and
updates and allowed to promote their products ethically. The organisers of
these conferences, in turn, could reduce or waive registration fees, a benefit
passed on to all members without any favour or the risk of influencing
individual members.
- Commercial organisations should be encouraged to support activities
directly related to patient care and welfare specially in public sector
hospitals. Contributions to patient care and working conditions in public
hospitals will not only give satisfaction to the doctors and the poor patients
they treat but will also appeal to the conscience of donor
companies.
- In the same vein as above, doctors using expensive drugs, medical devices
like heart valves, pacemakers, catheters and expensive investigative tools
should use their influence with these companies to reduce their promotional
budgets and pass on the benefits to the end consumers, in this case, the
patients.
Summing up
I have made a sincere attempt to
initiate discussion on what is currently wrong in the relationship between
physicians and commercial companies. I am aware of the limitations of
generalisations on a topic like this. I hope that this essay will be followed by
other useful and valuable contributions on this subject, both from the readers
of this journal as well as from others including commercial organisations. It
will be eminently rewarding for me if suitable guidelines emerge after a
thorough discussion on the subject. This, in turn, will encourage a healthy and
ethical relationship of mutual respect and dignity between the medical
profession and commercial organisations which are dependent upon each other for
meeting their commitment to the patients.
References
1. Jain Kalpana: Doctors banned from
attending sponsored foreign conferences. The Times of India 7 May, 1997
2.
Constitution : The Society of Thoracic Surgeons (est. 1964). Chicago: Elsevier,
1997 : 1-8.
3. Mamdani MB, Mamdani B: Commercial support for continuing
medical education. Issues in Medical Ethics 1997; 5: 43- 45.
4. Vox Populi:
Conferences sponsored by drug companies. Issues in Medical Ethics 1997; 5: 93-
94.
5. Ornish Dean: Reversing heart disease. New York : Ballantine Books,
1996 : p 53.
6. Chandiramani Radhika: Rent a womb. The Times of India 22
June, 1997.
Ratna Magotra,Professor
and Head, Department of Cardiovascular and Thoracic Surgery, Seth G. S..Medical
College and K. E. M. Hospital, Parel, Mumbai 4000 12
