The BBC reports that 11 doctors and a GlaxoSmithKline regional manager in Poland have been charged with alleged corruption. The apparent scheme was simple — GSK sales reps are given targets for new prescriptions for whatever drugs they are promoting. In order to meet those targets, it is alleged that one sales rep agreed to pay doctors £100 to give educational lectures to patients. The lectures never took place, and it was understood that in exchange for the payment the doctors would prescribe more of the rep’s drug.
The case is still under investigation but one doctor has already admitted guilt, stating that the £100 was simply too tempting.
Assuming the charges are upheld, such cases are very damaging to public confidence in the system. This is similar to cases of researchers faking their published research — I cringe every time I read about such cases.
There are some important questions, however: how common are such occurrences? And is this the isolated corruption of these individuals, or is it endemic in the system? The first question is difficult to answer. We can only know about exposed cases. Given the number of physicians and drug reps in the world, however, and the fact that the number of such cases that come to light are relatively few it would seem that such cases are the exception rather than the rule.
The second question is a bit easier to answer, but of course there can always be hidden corruption. GSK, for their part, states that such behavior is against their policy. I certainly hope this is true. GSK has been caught in scandals before. As the BBC reports:
In 2012, GSK paid $3bn (£1.9bn) in the largest healthcare fraud settlement in US history after pleading guilty to promoting two drugs for unapproved uses and failing to report safety data about a diabetes drug to the Food and Drug Administration.
These cases involved illegal activity at the corporate level. The current case most likely represents corruption at the level of the individuals directly involved.
While drug reps are certainly in sales, I have only personally seen a drug rep step over the line on one occasion. A new rep, who was clearly green, actually said to me and my colleague, “What would it take to get you to prescribe more of this drug?” I don’t think he was suggesting anything like bribery, but the statement was clearly inappropriate.
Our response was to end the encounter, and then call his company to report the incident and instruct them never to send that rep to Yale ever again.
There is no way to completely prevent isolated corruption. But we should ask about which policies would best minimize the incentives and opportunities for corruption. One approach, which is gaining favor, is to simply limit access of drug reps to doctors. This has already happened quite a bit. Drug company-sponsored lunches and talks have essentially vanished. Now my interaction is limited to signing for samples.
An even more draconian approach would be to eliminate the sales divisions of pharmaceutical companies. I am not suggesting this, but this would certainly eliminate any problems resulting from sales.
There is a potential downside to this also. There is benefit to be had from the flow of information between professionals and the private sector. Sometimes the goals of sales and good medicine align, when a new drug will improve health outcomes but is underprescribed because word has not penetrated the field yet. Companies can help get the word out and improve health outcomes.
The trick is to provide objective information, not information that is skewed in favor of the drug company. This can be accomplished by simply supporting education and outreach on the part of academics, who themselves will control the content. In my experience this is what happens most often, but obviously there are opportunities for drug companies to put their thumb on the scale, for example by their choice of academics — choosing those whose views happen to align with the company’s goals.
There are also advantages to academics advising private industry, to help them spend their research dollars in a way that is most likely to bear fruit and to meet unmet needs.
There are plenty of other measures that can be taken to minimize corruption short of a total ban on interactions between industry and practitioners and researchers. Perhaps the biggest measure is to manage the culture of the sales division. This flows from the top down — if companies want to keep their names out of the scandal pages and avoid big fines, they need to systematically train their sales reps to follow appropriate behavior, and swiftly and definitively discipline those who stray.
However, no matter what a company tells their employees during retreats and seminars, if the company sets up incentives that encourage corruption, it will still happen. GSK has already stated in response to the current episode that they will end direct payments to doctors for promotional talks, and also that they will eliminate sales goals for their reps.
No matter how a system is configured there is the potential for corruption. Even if the entire pharmaceutical industry were nationalized, there would still be a great deal of money exchanging hands, and this creates the incentive and potential for corruption.
It is critical, therefore, to identify and eliminate systemic corruption or any elements in the system that encourage or make it easy to hide corruption. This is especially important in vital industries, such as pharmaceuticals.
I do think we have been moving in the right direction in the last two decades. The tendrils of drug companies’ sales divisions have been slowly removed from academia and doctors’ offices. Gone are the previously ubiquitous drug lunches, branded gifts, and sponsored trips. There are further steps to be taken, such as those above, to maximize transparency and minimize both actual corruption and the appearance of corruption.
Exposing cases as they come to light, and shaming drug companies into taking corrective action, is an important part of this progress.