Push, promote or educate…musings of a pharmacologist on drug promotion

• Chanolean Shashindran^1*

1. ¹A recent NDTV programme aired on national television created a lot of angst among those in the medical profession.[1] Here was another instance of the profession being shown in a bad light, due to the dealings of a few unethical practitioners. The truth, however, is that corruption among medical practitioners is rampant. Nationwide indignation at the media reports led the Medical Council of India (MCI) to care and act and the ethics committee of the MCI met immediately and initiated enquiry. One doctor who produced fake medical degree certificates when questioned by the MCI was arrested and two others were summoned by the MCI.[1,2] The union health minister Harsh Vardhan, who is also a medical doctor, tweeted, “One more sting operation on doctors exposing greed and readiness to shed professional ethics. I again appeal to brother doctors‑‑‑show spine!” “Physician heal thyself” is the phrase that occurs to me, as we as a profession fight to maintain a modicum of dignity. Medicinal drugs are not commodities that patients can purchase at their discretion. By law, the transaction between pharmacist and patient is dictated by a prescription from the treating physician. The pharmaceutical industry spends 15% to 20% of its annual budget on medicinal drug promotion. Medical representatives are extensively used for medicinal drug promotion because one‑to‑one interaction is a powerful method of communicating. The most important purpose of this interaction is to change the prescribing behavior of the doctor in a “desirable” way. However, what is desirable from a commercial viewpoint may not be desirable from the clinical viewpoint. Medical representatives induce practitioners to change their prescribing habits by offering them bribes in the form of expensive consumer goods and all‑expenses‑paid trips to exotic tourist spots.[3] They also pay inappropriate sums of money to practitioners to wine and dine at their so‑called promotional meetings or banquets.[3] Pharmaceutical companies publish advertisements which make tall claims and do not adhere to World Health Organization’s (WHO) norms of ethical drug promotion.[4] They hire opinion leaders to write positive reviews about their products in leading medical journals. Often the reviews are written by paid ghostwriters and published in the names of luminaries in the field. Companies use underhand tactics to browbeat medical journal editors into changing journal policies to suit them. They have been known to influence learned societies to issue therapeutic guidelines favorable to their products. Perhaps what is most damaging is the manipulation of the results of research (sponsored by them) in their favor. Pharmaceutical companies hire academics to defend their products (especially the ones with dubious results/effects) in meetings held by drug regulators. The New England Journal of Medicine bans anyone who is a paid consultant to a pharma company from writing editorials in their journal. A former editor was not allowed to take over till he severed his ties with 20 pharma companies! Drugs always will be the mainstay of medical management, and as long as patients have to buy the medicines prescribed by their doctor, the element of suspicion that doctors are in league with the industry will remain. What needs to be done is to change this status quo slowly and steadily. Since 1985, the Jawaharlal Institute of Post graduate Medical Education and Research (JIPMER) in Puducherry, India, has [Downloaded free from http://www.jpharmacol.com on Wednesday, October 13, 2021, IP: 157.45.222.78] Shashindran: Push, promote or educate 226 Journal of Pharmacology and Pharmacotherapeutics | October-December 2014 | Vol 5 | Issue 4 conducted a training programme for interns at the beginning of their hospital posting.[5] One of the sessions includes a role play simulating a physician–detail man (medical representative) interaction. The aim is to familiarize interns with the promotional pressures they are likely to encounter in their professional lives. The positive feedback on the session from interns and faculty led to the conclusion that this approach could usefully be adopted by other medical schools, through the development of video and training materials. With the help of Dr. Ken. J. Harvey of La Trobe University, and support from the Action programme of the WHO, the video‑based educational module, entitled Push, Promote or Educate, was made at JIPMER in 1994.[6] The video aimed to (a) immunize medical professionals against irrational marketing focus, (b) highlight the areas where promotional pressures infringe upon professional duties and ethics, and (c) help identify overt and covert pharmaceutical messages that promote rather than educate. The video was produced in support of and based on the “Ethical criteria for Medicinal Drug Promotion”, WHO, Geneva, 1988.[4] The production of the video was technically and financially supported by the WHO. The success of the video as a training tool is mainly because it closely matches a real‑life experience which interns and the faculty can relate to. Also, videos are popular teaching–learning aids among students as they are a change from didactic lectures. However, one effort at one place in the country will have little impact on the general scene of medical practice. What is needed is for medical teachers all over India to confront these issues as “must know; must do” areas of concern which are on par with “never events” in the patient safety scenario. Medical students, postgraduates and faculty should learn from an early stage in their training that colluding with the pharmaceutical companies is akin to “dancing with porcupines”. Like all good habits learnt from an early age, good prescribing attitudes should be taught early in medical school, long before students see or prescribe for their first patient. For decades now, the medical fraternity has played down the issue of receiving gifts from drug companies. Ethics and professionalism are words that are often spoken at conferences, medical education workshops and during curricular reform meetings. However, very little is done to inculcate these values in undergraduate and postgraduate education. Perhaps we are afraid that including these topics will force us to look at ourselves critically and make the change. The Dept. of Pharmacology, JIPMER, included practical exercises in reviewing unethical drug promotional literature into the curriculum, way back in the late 1980s.[7] Many other medical colleges in various states have also included these exercises for undergraduates. However, it has not led to any visible change in attitudes. The MCI should insist on orientation of new medical graduates to its regulations on professional conduct, etiquette and ethics. These aspects should be covered in the curricula under forensic medicine and other clinical disciplines. For example, good prescribing skills can be taught in pharmacology but ought to be reinforced by every clinical department. Faculty members in medical colleges can set an example to their students by refusing to accept gifts of any magnitude from pharmaceutical companies.[8] Patients often trust physicians with their lives. Physicians, for their part, owe unwavering allegiance to their patients and should recognize that any breach of faith erodes the doctor‑patient relationship and desecrates the Hippocratic oath. It is up to us to stem the rot in medical practice by inculcating ethical behavior in students of the present generation. The curricular resources needed to implement these topics are all available at the click of a button. Why then are we not doing more? REFERENCES 1. Mehrotra S. Doctor Arrested after NDTV Expose, Two Others Summoned by Medical Watchdog. Available from: http://www.ndtv.com/article/india/ doctor‑arrested‑after‑ndtv‑expose‑two‑others‑summoned‑by‑medical ‑watchdog‑575106. [Last accessed on 2014 Aug 13]. 2. Mehrotra S. Doctor Caught in NDTV Investigation Arrested. Available from: http://www.ndtv.com/article/india/doctor‑caught‑in‑ndtv‑investigation‑ arrested‑575501. [Last accessed on 2014 Aug 13]. 3. Moynihan R. Who pays for the pizza? Redefining the relationships between doctors and drug companies. 1: Entanglement. BMJ 2003;326:1189‑92. 4. Ethical criteria for medicinal drug promotion‑World Health Organization, Geneva, 1988. 5. Shashindran CH, Sethuraman KR. Integrated Orientation Programme for Interns on Quality Care. 3rd ed. Pondicherry, India: JIPMER; 1995. 6. Shashindran CH, Sethuraman KR. Drug Promotion: Push, promote or educate. Essential Drugs Monitor No. 020. Available from: http://apps.who. int/medicinedocs/fr/d/Js16517e/2.2.html#Js16517e. 2.2. [Last accessed on 2014 Sep 01]. 7. Gitanjali B. Developing lifetime pharmacology skills in India. Essential Drugs Monitor No. 027. Available from: http://apps.who.int/medicinedocs/ en/d/Jh1467e/2.html. [Last accessed on 2014 Sep 01]. 8. Moynihan R. Who pays for the pizza? Redefining the relationships between doctors and drug companies. 2: Disentanglement. BMJ 2003;326:1193‑6. CH. Shashindran, Professor and Head, Department of Pharmacology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India, Australia.

Published in Journal of Pharmacology and Pharmacotherapeutics