Yom Kippur, the Jewish day of atonement, is upon us. It is Judaism’s most sacred holiday. It is a day of fasting and prayer to atone for sins of the past year. According to traditional teachings, a person’s fate is written in the Book of Life on Rosh Hashanah (the Jewish New Year) and on Yom Kippur the verdict is “sealed”.
Dermatologists make ethical decisions on a daily, if not hourly basis. Ethical choices abound with one’s relationship with industry involving multiple realms: 1) receiving gifts; 2) conduct of clinical trials; 3) appearance of advertisements in professional journals; 4) continuing medical education programs and educational grants to societies and departments; 5) drug sampling; and 6) other conflicts of interests (1).
I am a dermatologist, not a medical ethicist. I am writing this commentary with the belief that most of us are well-meaning folks, with few outliers having either the sublime ethics of Mother Theresa or the nefarious scruples of Bernie Madoff.
In a fascinating study, Feng et al performed a retrospective review using the publicly available Centers for Medicare and Medicaid Services (CMS) Sunshine Act Open Payment database. All payments to dermatologists from companies making products reimbursed by a government-run health program were reviewed. Mean, median, and range of payments made, including quantity and total sum of payments, per clinician. Total payments and number of transactions per category of payment, geographic region, and payment source were also assessed. A total of 8333 dermatologists received 208 613 payments totaling more than $34 million. The median total payment per dermatologist was $298 with an interquartile range of $99 to $844. The top 10% of dermatologists (n = 833) received more than $31.2 million, 90% of the total payments. The top 1% each (n = 83) received at least $93 622 and accounted for 44% of total payments. While 83% of payment entries were for food and beverage, they accounted for only 13% of total amount of payments. Speaker fees (31.7%), consulting fees (21.6%), and research payments (16.5%) comprised 69.8% of total payment amount. The top 15 companies were all pharmaceutical manufacturers and paid dermatologists $28.7 million, representing 81% of total disbursement. The authors concluded that dermatologists received substantial payments from the pharmaceutical industry. The nature and amount of payments varied widely. The impact of the data on patient care, physicians practice patterns, and patient perception of physicians is unclear (2).
In an accompanying editorial Resneck states that “Transparency is a laudable goal and, if done properly, may help patients make informed judgments about interactions between industry and physicians. Accurate and properly contextualized transparency can also help physicians evaluate the independence of colleagues writing or speaking about the risks and benefits of drugs or medical devices.” He acknowledges that while certain interactions, including gifts and meals, may influence prescribing behavior, ethical collaboration between physicians and industry may benefit society by fostering novel innovations. If data is to be transparent, it must be accurate. Dr. Resneck offers straightforward suggestions, such as providing physicians the opportunity to preview data before manufacturers transmit it to CMS (3).
I decided to look at my personal data from www.openpaymentsdata.cms.gov to see how accurate it is. The following were recorded: 1) Allergan $10.96; 2) Amgen $39.53; 3) Anacor $1,063.36 4) Bayer $20.24 5) Galaderma $29.75 and 6) Valeant $37.90. The largest payment was for an “advisory board” session for Anacor when they presented data on crisaborole for atopic dermatitis (I wrote a commentary about this agent on August 13th, 2016 – I invite readers to determine if I offered a fair, unbiased assessment). I assume that $1000 was for the professional function that $63.36 was for the served lunch. All of the other payments would have been for breakfasts at our grand rounds. All I usually eat is a bagel, some fruit, and coffee. The only believable number is Allergan’s $10.96. Perhaps the companies calculate the assigned cost per participant by dividing the total catering bill by the numbers of signed attendees? If you exclude the $1000 honorarium, $210.74 in pharma-sponsored food was attributed to me.
I understand the concept that even the smallest gift can imply reciprocity – I gave you a bagel, won’t you please prescribe my drug? (I won’t even begin to address the issue of not being able to prescribe it even if I wanted to – that will have to wait for another commentary). The fact, however, is that no practicing dermatologist is completely sheltered from a relationship of industry and practice. Would you be able to afford the subscription to JAMA Dermatology, where this study was published, if there were no pharmaceutical advertisements? Would you prefer to spend a several thousand dollars registration fee at the AAD meeting without pharmaceutical support, or keep the current fee with those subsidies?
I am completely comfortable with having such data made public. If anyone wants to question my relationships, that’s fine. I’m human. Perhaps I’m at risk of being influenced by a cookie-wielding smiling drug representative. I hope I have enough integrity that I would always put my patient’s interests first, though. Ultimately, we all have to set our own acceptable thresholds in our relationships with industry. None of us are immune from moral relativism. If we drive at 50 miles per hour, the person passing you at 65 miles an hour is a speed demon, and the one creeping in front of you is a slow poke. Somehow I believe there must be some difference in influence between accepting more than $90,000 from industry compared to $200 of breakfasts. In the spirit of the high holiday season, each of us must decide if we need to atone for our relationships with the pharmaceutical industry. This year, think I have other issues higher on the atonement priority list.
- Sams WM, Freedberg IM. The dermatology-industry interface: Defining the boundaries J Am Acad Dermatol 2000; 43: 550-4.
- Feng H, et al. Exploring the industry-dermatologist financial relationship: Insight from the open payment data. JAMA Dermatol 2016; Published online October 5, 2016.
- Resneck JR, Jr. Transparency associated with interactions between industry and physicians: Deficits in accuracy and consistency of public data releases. JAMA Dermatol 2016; Published online October 5, 2016.