Doctors without conflict

The relationship between the pharmaceutical and/or medical device industry and doctors is often a topic of discussion. Paradoxically, the issue is also one that is most neglected by both our governments and our doctors. No government, federal or provincial has ever considered it necessary to regulate these relationships in a serious and effective manner.

A conflict of interest arises when an association or a relationship has the potential to influence one’s professional judgement or actions. It does not per se constitute corruption but has the potential to cloud one’s judgment in favour of the relationship that exists. This is often at the expense of the one to whom the services are being provided.

The conflicts of interest in the Pakistani healthcare system present a unique challenge and demand extra scrutiny as the industry is regulated differently (if at all) from the West. Pakistani companies are at liberty to market the same medication under different brand names as opposed to the West where a medicine may only be marketed under a single brand name; when exclusivity patents expire there, other companies can then manufacture and market but only under the generic name.

So the same antibiotic, with the same ingredients, may be available in Pakistan under different names with different prices. Doctors are at complete liberty to pen down any brand name of their choice on their prescription pads, thus opening avenues to conflict at best, and outright corruption at worst.

It is an open secret that a decent proportion of doctors in Pakistan has at least some relations with the pharmaceutical industry. Since the industry itself is not well regulated, selling their products to the maximum is considered necessary with utter disregard to ethics or legalities.

The mushroom growth of pharmaceutical companies should ideally have led to market competition and benefitted the patients but the result has been quite the opposite. Pricing is arbitrary and quality is variable and debatable. The companies promote their products through their physician representatives or ‘medical reps’.

Quite a number of pharmaceutical companies offer numerous incentives or kickbacks to doctors to use or prescribe their products. Stories go that it could be a monthly cash arrangement, paying the lease on a car, buying office furniture or supplies etc. Hajj and Umrah excursions are also put on the pharmaceutical companies’ tab.

As a quid pro quo, the doctors are usually given a minimum monthly target of prescriptions to write. These are then prescribed to patients, whether they genuinely need the drug or not. Very little consideration is given to the  affordability or efficacy of a particular medicine even if an alternative is available at a far lower cost.

The medical device industry and implanting doctors go a step further. Be it orthopaedic implants, cardiac pacemakers, coronary stents or general surgical supplies, some doctors do not consider it unethical to have a fixed cut in each device that is used. This has led to a serious situation where copycat products that have not been studied extensively in large clinical trials and whose safety is not well established are frequently being used.

The pervasive ‘bribing’ of doctors, as highlighted above, is a crime and should be dealt as such with the full force of the law. However, there are other situations that can be considered grey areas but need to be addressed as well.

Pharmaceutical companies frequently sponsor doctors for ‘educational activities’. A number of doctors in Pakistan have thus become well-travelled tourists, accumulating tons of frequent flier miles. A doctor living and working abroad likely does not travel nearly as much of the world as one practising in a remote corner of Pakistan.

Attending scientific meetings does enhance one’s professional knowledge and enables one to stay up to date in the rapidly evolving world of medicine. Grants from the industry play an important role towards achieving these goals for doctors. However, this should not be unregulated. Clear and precise boundaries have to be drawn.

Grants for tertiary care hospitals should only come to the medical education department as unrestricted grants-in-aid. The medical education department should then be responsible for disbursing expenses to the doctors to attend scientific meetings. All this should be done under a set protocol without favouritism.

For doctors who are directly sponsored by the industry for any educational activity, consultancy fees or speaker’s remuneration, strict conflict of interest disclosure laws should be formulated and implemented. The pharmaceutical industry should be mandated to make publicly available the names of doctors, the amounts paid or any sponsorship of an educational activity. This information should be published on a secure but unrestricted website.

The information provided by the industry regarding sponsorship of doctors for any activity should clearly show in its tax filings and be subject to audit. Similarly, doctors should be required to disclose to a provincial or central regulating authority any monetary receipts or ‘educational’ sponsorships. And this information should be in the public domain.

An open and accountable healthcare system will benefit all, except perhaps a few greed-driven companies and corrupt doctors. It will foster healthy competition, improve quality of care and drive prices of medicines and devices down. It is about time both state and society woke up to the task and tackled this on a priority basis.

After the devolution of powers under the 18th Amendment, the provincial governments should take the lead and regulate the healthcare industry. Doctors also need to take the initiative themselves and bring forward proposals for regulating the profession.

The writer is a former president of the Association of Pakistani Cardiologists of North America (APCNA).

He tweets @spaelaney