Many of us remember our first stethoscope or perhaps that first pad and pen we used to sign and order a prescription for a first patient who saw us as “their doctor.” Some of us are even old enough to remember getting that first doctor’s black bag.

Most of us probably also remember the company name emblazoned on those first gifts, just as we remember the gifts large and small that probably have continued through the years. In all likelihood our patients also remember, at least subliminally, that their trusted doctor is somehow associated with one company or another.

The pharmaceutical and medical device industry spends tens of billions of dollars annually to market to physicians. (One study by our Stanford Center for Research in Disease Prevention found that companies in 1998 spent $12.8 billion to market drug products alone to doctors).

Much of this gifting - donuts for residents after a long night on call, trips to conferences, or free “sample” medications for our families - is couched in altruism, and yes, much of it is clearly useful for caregivers at all levels of experience. This is the holiday season and gifts are very much on our minds. But the issue of industry gifts is a part of our lives throughout the year.

For the past six months or more the Ethics and Graduate Medical Education committees have been working to formulate a policy to ensure that physicians and industry - specifically pharmaceutical and instrument company representatives - can interact most productively, appropriately and beneficially at Stanford University Medical Center.

As we formulate an industry vendor interaction policy, we must be careful not to throw out the baby with the bathwater. Many gifts from our industry partners make important social and educational efforts possible. Companies have provided funds for the support of educational seminars and conferences, for research, and for textbooks for residents and interns. So where do we draw the line?

Our two committees, along with many of their colleagues throughout the nation, believe that the line is overstepped when the gift seems to influence the physician’s decision making. While “seems” is ambiguous, the public is helping to provide a litmus test. Published reports and perhaps conversations with your patients and nonphysician friends reflect that there is growing concern about the influence of pharmaceutical company gifts on physician decision making. National organizations, including the American Medical Association, have already formulated policies that our committees have reviewed.

The AMA, to cite an important example, states that gifts to physicians should entail a benefit to patients and should not be of substantial value. Gifts of minimal value relating to the physician’s work, such as pens, notepads and textbooks, are okay.

The AMA approves industry funding of conferences or meetings primarily dedicated to promoting objective scientific and educational activities. Financial support and potential conflict of interests must be disclosed.

Subsidies to underwrite the cost of continuing medical education conferences or professional meetings are permissible because they contribute to improvement in patient care. However, the AMA guidelines state that the subsidy should be used to reduce conference fees and should be channeled through the conference sponsor, not handed to the participant.

The AMA believes it is appropriate for faculty at conferences or meetings to receive reasonable compensation or honoraria and to accept reimbursement for expenses. However, the guidelines are violated when the company pads these payments with consulting or advisory fees.

Scholarships or other special funds to permit medical students, residents, and fellows to attend carefully selected educational conferences are appropriate under the guidelines if the selection of the students, residents and fellows is done by the educational institution and not the company.

The bottom line is that no gift should be accepted if there are strings attached.
Here at SHC, based on the deliberations of the AMA and others, the Ethics Committee has proposed a policy it hopes to bring to the Medical Board for adoption.

A key feature of our draft proposal is to disallow pharmaceutical and device industry sales representatives from interacting in hospital or clinic areas with medical students, residents, and physicians. This policy is not meant to restrict in-service training (e.g. for new equipment) provided by the representative under contract to SHC, nor would it apply to sales personnel invited to SHC as part of a formal procurement process.

All educational funding from industry, again in line with the AMA policies, must be unrestricted. The funds can be directed to particular departments, but the donor cannot specify content, speaker or topic. Funding for events should be open whenever feasible to more than one company to avoid corporate branding of the event. All corporate contributors to events, speaker series, grand rounds, etc. must be disclosed.

Taking the AMA guidelines one step further is a proposal to do away with gifts of any kind, including food. Gifts with identifiable drug or industry company names would not be allowed in the hospital or clinics, according to this proposed policy.

Fortunately, the policy would be more than a list of restrictions. The Ethics Committee has recommended that new residents and staff receive some education about conflicts of interest and the role of industry gift giving and prescribing practices. The Graduate Medical Education Committee agrees that education on physician–industry relationships is probably the best way to provide an institutional culture where conflicts of interest are minimized and largely self-policed. The GME committee wishes to provide our physicians in training with the attitudes and skills needed to manage these valuable relationships for life and not just while they are here at Stanford.

I do not wish to be seen as the Grinch who stole all the industry freebies, especially at this holiday time. I really do believe that a culture that fosters ethics in the context of gifts will actually highlight the true values of sharing and altruism in a spirit consistent with the season - and the practice of quality, ethical medicine.

Please forward your comments regarding this topic to either biomedical ethicist David Magnus, chair of the Ethics Committee, at dmagnus@stanford.edu; faculty psychiatrist Shashank Joshi of the Graduate Medical Education Committee, at svjoshi@stanford.edu; or me at lshuer@stanford.edu.

I wish all of you a very Happy Holiday Season and a Healthy New Year!