Excess entertainment or educational experience?

Medical Marketing and Media, Jul 1998 by Liebman, Milton

Drug companies are treading a fine ethical line in their CME programs for physicians. Critics complain and the AMA pays attention.

Are the all too human frailties of physicians being exploited when pharmaceutical firms use entertainment to entice attendance at often self-serving educational programs? Following an educational event, is dinner at a fine restaurant and tickets for the group to a theater, movie, or baseball game acceptable under guidelines for professional ethics?

The questions are not academic. They are being faced every day by the American Medical Association (AMA), individual physicians, and the drug industry. The question is whether ethical guidelines are being breached and how can they be reinforced.

The AMA is receiving "finger-pointing complaints" from competing drug companies, as is common in this industry, according to one source. "I have seen evidence that some companies have been in violation," said attorney Stephen Latham, secretary to Council on Ethical and Judicial Affairs for the AMA and director of its Ethics Standards Division. "I have not seen enough examples of violations, not enough for the AMA to make a blanket statement."

Also, he added, physician members receive invitations, send them to us, and ask whether they fit under the guidelines.

The AMA regards $100 as acceptable for an industry gift to physicians under the AMA Code of Ethics. The price of a textbook often exceeds that amount. It is not clear that "hospitality" involving dinner and theater, associated with educational programs, costs more.

Excesses bring ethical guidelines

Dinners and entertainment following CME programs appear modest compared to expenditures during the beginning of this decade. Pharmaceutical companies flew high prescribers half way around the world to attend part-day symposia at fashionable resort locations. The revenue that an individual physician could generate and the amount that the drug company could therefore afford to spend for entertainment and education was carefully calculated.

Those practices came to an end when the AMA Council on Ethical and Judicial Affairs in December 1990 wrote an opinion, which became part of the Code of Medical Ethics, defining acceptable gifts to physicians from industry. Two days after its release, the ethics position was adopted by the Pharmaceutical Research and Manufacturers of America (PhRMA) on behalf of its member companies, which now number about 50.

Under Opinion 8.061, the key proviso for entertainment associated with educational activities appears to be: "Subsidies for hospitality should not be accepted outside of modest meals or social events held as a part of a conference or meeting." Also, the opinion says that physicians should not accept subsidies "directly or indirectly" from industry to pay for travel, lodging, other personal expenses, or professional time for attending educational conferences.

Gifts accepted by individual physicians, as differentiated from hospitality, should not be of substantial value and should primarily "entail a benefit to patients," or be related to the physician's work.

The AMA Council followed up with a response to questions to further clarify its ethics statement. As published in the Food and Drug Law Journal in 1992, these were among the comments made.

"In a study of drug industry funding for continuing medical education, researchers found a relationship between the source of funding and physician prescribing patterns." The study cited measured physician prescribing before and after attending one of three CME courses sponsored by a single drug company. "While after each course there were increases in the prescribing of all drugs, the greatest effect occurred for the drug whose company was the major financial supporter of the course," according to the Council statement.

However, the Council "has not lost sight of the need for physicians to receive the broadest possible exposure to new and different healthcare products and their clinical applications." As a result, at company-sponsored events, "the dinner must be a modest meal," the Council said. And gifts with "a value to the physician in the general range of $100 are permissible." And that was in 1992.

Stephen Latham said, under current interpretations, "If you have a seminar, you can have a cocktail party. It allows the participants to communicate with each other, it continues the learning discussions."

Critics in the press don't see it that way. A feature story in the Washington Post questioned whether drug companies were adhering to the rules. "Drugmakers (sic) are offering doctors a variety of entertainment and emoluments to attend company-sponsored medical discussions that might help promote products." In response, drug industry personnel were quoted in the story as saying "the events allow manufacturers to reach physicians who can move market share ..."

The story reported that some physicians "say these efforts are thinly veiled attempts to curry favor, potentially violating ethical guidelines intended to prevent the industry from improperly influencing doctors." Other doctors say "the events help them keep up with developments in medical science," the newspaper said.