Transcript Relationship with industry: the dark side of the force

Objectives
 How does this relationship impact on doctors
 The effects on our decision making
 Bounded ethicality
 Some strategies to prevent dualities of interest drifting
into conflicts of interest
 Lastly, does it matter?
Dualities of interest
 Common interests with industry
 Research and innovation
 Safe, efficacious and responsible use of drugs and medical
technologies
 Monitoring of their use, safety and efficacy
 The health professionals principal interest is patient care
and advancement of scientific knowledge
 Industry’s principal interest are commercial outcomes
How do doctors see their
interaction with industry?
How do doctors see their
interaction with industry?
 Avoiders (10%)
 Confident engagers (50%)
 Ambivalent engagers (40%)
Doran, et al., Social Science & Medicine
Volume 62, Issue 6, March 2006, Pages 1510-1519
For the Avoiders
 Risk of interacting with the pharmaceutical industry
greater than any benefit
 Receiving information and accepting largesse may
inappropriately influence treatment preferences
through persuasion and obligation
 Interaction may tacitly endorse promotional practices
 Tangible harms greatly outweighing the ‘benefit’ of
information devalued by commercial bias
Doran, et al., Social Science & Medicine
Volume 62, Issue 6, March 2006, Pages 1510-1519
For the Confident Engagers

Relationship seen as essentially sound and mutually beneficial

Opportunity to engage in a variety of roles

Improving of professional practice

Support thought to be a ‘reasonable’ exchange for specialist’s time, experience and
advocacy

Aware of potential conflicts of interest which could be managed

Potency of promotion largely overstated

Regard industry influence as arising from the interaction per se, rather than from
obligation or persuasion

Express concern that those who believe relationship as ethically suspect as overzealous
Doran, et al., Social Science & Medicine
Volume 62, Issue 6, March 2006, Pages 1510-1519
For the Ambivalent Engagers
 Structure and manage interaction with industry to minimize potential
to be compromised
 Seeing all reps to maintain a balanced view (often jointly with
colleagues)
 Declining all offers that do not clearly reflect some educational
benefit
 Critically appraise all claims made by industry
 Benefits seen to outweigh the risks
 Concern that interaction may negatively effect prescribing practices
Doran, et al., Social Science & Medicine
Volume 62, Issue 6, March 2006, Pages 1510-1519
Ethical issues
 Association may serve commercial objectives of
industry
 Inappropriately influence doctor’s decisions
 Danger of distortions of integrity of scientific research
 Erosion of public trust
How much is spent on drug promotion
 In Australia in 2001, it was estimated the pharmaceutical
industry spends about AUD21,000 per doctor per year.1
 Compare this with government expenditure on training medical
students of AUD25,000/yr
 In the US, the estimates in 2008 were US$30 billion annually on
drug promotion2
 In 2002, the US industry expended 33% of its revenues on
“selling and administration”3
1. Juriedini and Mansfield Australasian Psychiatry, 2001, v9(2) pp95-99
2. Brooks, CMAJ, July 1, 2008 Vol 179(2) pp28-29
3. Reinhardt UE. An information infrastructure for the pharmaceutical market.
Health Aff (Millwood) 2004;23(1):107-12
Does drug promotion work?
 Reduced generic prescribing
 Increase overall prescription rates
 Quick uptake of the newest, most expensive drugs
including those of only marginal benefit over existing
options with real-world safety records
 Formulary request for drugs with few if any
advantages over existing drug.
Wazana A., JAMA, January 19, 2000—Vol 283, No. 3373-3380
Lexchin J et al. BMJ 2003;326:1167-1170
©2003 by British Medical Journal Publishing Group
Failed Heuristics, Biases, and Cognitive
Dispositions to Respond
Aggregate bias
Gender bias
Representative restraint
Anchoring
Hindsight bias
Search satisficing
Ascertainment bias
Multiple alternatives
bias
Sutton’s slip
Availability error
Omission bias
Sunk costs
Base-rate neglect
Order effects
Triage cueing
Commission bias
Outcome bias
Underconfidence
Confirmation bias
Overconfidence
Unpacking principle
Diagnosis momentum
Playing the odds
Vertical line failure
Feedback sanction
Posterior probability
error
Visceral bias
Framing effect
Premature closure
Yin-Yang out
Fundamental attribution Psych-out error
error
Zebra retreat
Pat Croskerry. The Importance of Cognitive Errors in Diagnosis and Strategies to Minimize Them.
Gambler’s
fallacy
Academic Medicine
2003, Vol 78, No.8 pp775-780
2005 Canadian Survey
 150 Anaesthetists
 66% made ‘anchoring’ error
 60% made ‘conjunction fallacy’ error
 60% made an error on a probability estimate of cancer
 90% mis-estimated a simple probability
 92% believed themselves above average drivers
 91% exhibited confirmation bias in problem solving
http://www.scottishintensivecare.org.uk/Assets/Presentations/CrosKerry1.p
ps
What’s going on in our heads?
 Illusion of objectivity
 Perception of self as moral, competent and deserving
 A sense of entitlement to largesse as industry makes
them feel special
 A belief that it is acceptable and proper because
everyone does it
Chugh et al, in Conflicts of interest: challenges and solutions in business, law, medicine, and
public policy. By Don A. Moore et al 2005 pp74-95
Bounded ethicality
Bounded ethicality refers to the systematic and predictable
ways in which humans act unethically beyond their
own awareness.
Chugh, Bazerman & Banaji, in Conflicts of interest: challenges and solutions in business, law,
medicine, and public policy. By Don A. Moore et al 2005 pp 74-95
Preventing “ethical fading”
 “The key to preventing such behavior is understanding
and recognizing when and how ethical fading occurs”
 “Well-meaning people with good values can go astray,
and the challenge is to help people understand and
prepare them for the pressures they may face when
ethical questions occur.”
Tenbrunsel, A, in Conflicts of interest: challenges and solutions in business, law, medicine,
and public policy. By Don A. Moore et al 2005 pp96-103
Self image
 Autonomous professionals:




Acting in the best interest of patients
Able to assess the scientific evidence objectively
Act in an ethical manner
Have no conflicts of interest
Gifting behaviour
 “Friendship, food and flattery are all powerful tools of
persuasion”
 Acceptance of gifts induces a sense of reciprocity
 Size of gift is irrelevant
 Induces real or perceived biases
Katz et al, Am J Bioethics, Summer 2003 Vol 3, No. 3 pp 39-46
Debiasing strategies to reduce
ethical conflicts?
Strategy
Mechanism/Action
Develop insight/awareness
Provide detailed descriptions and
thorough characterizations of known
cognitive biases
Consider alternatives
Whose interests are being served?
Metacognition
Train for a reflective approach to ethical
problems eg The Four Topics Chart1
Cognitive forcing strategies
Develop generic and specific strategies
to avoid predictable bias in particular
ethically challenging situations
1. Clinical ethics : a practical approach to ethical decisions in clinical medicine. Albert R. Jonsen, Mark Siegler, William
J. Winslade. —7th ed. p8
Debiasing strategies to reduce
ethical conflicts?
Strategy
Accountability
Mechanism/Action
Establish clear
accountability/transparency for
involvement with industry
Feedback
Provide as rapid and reliable feedback
as possible on unethical behavior
Specific training
Training to identify specific flaws and
biases in thinking and provide directed
training to overcome them
Simulation
Construct ethical training videos
contrasting incorrect (biased)
approaches with the correct
(debiased) approach.
After Croskerry P. Academic Medicine Vol. 78 No 8 2003, p5
Future directions
 What should be the boundary between industry and
the profession?
 Traditionally valued societal function of medicine and
medical science of serving as arbiter of safe and
effective treatment.
 What is the societal value of an independent
profession?
 The more the profession’s identity incorporates industry
interests as part of it’s internal interests, the less
independent it becomes.
AMSA's PharmFree Pledge
 I am committed to the practice of medicine in the
best interests of patients and to the pursuit of an
education that is based on the best available
evidence, rather than on advertising or promotion.
 I, therefore, pledge to accept no money, gifts, or
hospitality from the pharmaceutical industry; to
seek unbiased sources of information and not rely
on information disseminated by drug companies;
and to avoid conflicts of interest in my medical
education and practice.