Updated guidelines setting out boundaries for relationships between hospital doctors and healthcare firms are contained in a new paper from the Royal College of Physicians.
First produced in 1986, the advice defines the current position of the college on hospitality for meetings, gifts, grants, research, declarations of interest, and doctors acting as consultants to industry. It extends the coverage of guidance beyond pharmaceutical companies to include all biomedical firms.
The report, in the July-August edition of the college's journal Clinical Medicine (2002;2: 320-2), sees a danger that money from biomedical firms might be used to interfere with a physician's independent professional judgment.
Dr John Collins, medical director at the Chelsea and Westminster Hospital NHS Trust, is joint author of the paper with treasurer of the Royal College of Physicians, Dr John Bennett.
Dr Collins said, “We are widening the guidelines to other organisations and probably being more prescriptive in terms of third party handling of funds. Always have your financial arrangements done through a third party.”
He believes that inappropriate relationships with business are much less likely than in the 1980s but adds: “I suspect that the vast majority of practising clinicians do not prescribe medicines because a company has funded them to go to a conference. However, if you were a non-medically qualified individual looking at a doctor you might wonder whether they might be influenced in any way.”
The rules in other countries differ considerably, as BMJ correspondents report below.
France: The French medical association has tightened its rulings on the receipt of gifts from pharmaceutical companies, writes Alexander Dorozynski. A doctor should not accept gifts in cash or otherwise, except small gifts not exceeding €30 (£19; $29) in value.
Contributions to a doctor's attendance at scientific meetings or congresses and “hospitality” are authorised if they are reasonable and if the selection of a remote (and therefore costly) site is justified.
Spain: Earlier this year the body representing all Spanish drug companies issued a code of practice stating that drug companies' representatives can offer medical related gifts to doctors worth up to only €19, writes Xavier Bosch. Expenses for meetings cannot include those of social or cultural events or expenses to accommodate the spouses of doctors attending the meeting. These guidelines come into effect this month.
Netherlands: The marketing code for prescription only drugs has already resulted in legal cases against pharmaceutical companies and individual doctors, writes Tony Sheldon.
In 2001 Merck Sharp and Dohme was fined £27000 ($41000; €43000) for events promoting its antimigraine drug rizatriptan (Maxalt) that included dry ski slope and go-kart contests.
Next month up to 15 doctors are due to appear in court for refusing to pay fines for accepting excess hospitality. The doctors went on a car anti- skid course, offered by German pharmaceutical company Boehringer-Ingelsheim as entertainment after an event promoting its drugs against blood pressure and rheumatism. Another 50 doctors have already paid fines of up to €250.
Australia: Drug companies have just agreed to end the lavish wooing of doctors with free lunches and resort seminars, writes Christopher Zinn. Under reforms to the pharmaceutical industry's code of conduct, all non-essential hospitality will be axed. The Australian Medical Association has welcomed the code but says the perks for prescriptions were vastly exaggerated and that more politicians than doctors enjoyed the largesse.
Nigeria: The Nigeria Medical Association frowns at physicians accepting gifts with conditions from drug companies, writes Abiodun Raufu. According to the association's vice president, Dr Kayode Obembe, “the commonest gift from drug companies to physicians is sponsoring doctors to conferences abroad, but such trips are often linked to research issues which affect the products of the drug companies.”
A senior pharmacist with Pfizer Nigeria said the most unusual request by a doctor was for a television set for the waiting room of his private clinic.
United States: In 1990 the American Medical Association and the American College of Physicians each issued guidelines on gifts from pharmaceutical companies, writes Charles Marwick. Last year the American Medical Association mounted an educational campaign to alert its members to its guidelines—evidence that nobody had been paying them much attention. Companies are reported to spend up to $5bn a year on “health promotion services.”
Among the rules set out by the association, presenting scientific information is permitted, but entertainment is not. Gifts, if less than $100 in value and intended for patients' benefit, are allowed. The Food and Drug Administration monitors promotional activities. It says action would be taken if any activities were false or misleading. But gifts do not violate the law.
India: “The practice of giving gifts, offering foreign trips, and even direct cash incentives to doctors by drug companies is rampant in India,” says Dr Puneet Bedi, gynaecologist and an independent health activist, writes Sanjay Kumar. It is much more so in areas such as cardiology where the big money is involved, he says.
The Medical Council of India, in its new Code of Ethics Regulation, March 2002, does not prohibit doctors from accepting gifts or cash incentives from drug companies (see www.mciindia.org/know/rules/ethics.htm).
New recommendations on receiving gifts
No conditions should be attached to gifts, items of equipment, or aid
Under no circumstances should cash or objects in kind be accepted by individual physicians, and gifts, honorariums, or hospitality received must be declared
Speakers at company funded meetings should not be chosen solely by the firms, and the hospitality they provide at meetings with an educational purpose should be modest
The payment of reasonable expenses and honorariums is acceptable for larger and overseas meetings but should be handled through the independent scientific body and not paid directly to individual physicians
Healthcare firms should not pay for a physician's spouse or partner to attend
Healthcare companies can fund scholarships and grants if the selection of recipients and spending rests in the hands of the academic or training institution involved
All research must be cleared by the doctor's research ethics committee, and all financial matters “should normally be handled by the finance department of the health authority, university or institution and supervised by their financial officers”
Physicians must not advertise patients' availability for use as research subjects and must obtain written agreement from the sponsoring company for the freedom to publish results in journals chosen by the physician
Doctors should be paid as consultants to the health industry only for services provided outside working hours. All arrangements must be clarified in advance in a business contract and permission to enter into such a contract obtained from the physician's employer.