Ethical dilemma of doctors

The relationship between the medical profession and the pharmaceutical industry in the Philippines is one that sparks a lot of controversies. Especially among those who are not doctors, this relationship is constantly eyed as one of the main reasons why drugs in the country are among the most expensive in the world. Doctors are wined and dined, brought to exclusive golf courses abroad for a round or two, even provided “entertainment.” That these things actually happen is a shame to the profession and tars the majority who strive to maintain an unwavering commitment to the highest ideals of professional conduct. I believe it has become so rampant that both the Philippine Medical Association (PMA) and the Philippine College of Physicians (PCP) have provisions in their Code of Conduct about how members should behave towards the pharmaceutical industry as a whole. - Dr. Noel Pingoy.



Sunday Inquirer Magazine / Sunday Inq Mag
FIRST PERSON
First Person : Disclosures
By Noel P. Pingoy, MD
Philippine Daily Inquirer
Posted date: November 06, 2010


“SERBIS, Dok!”

This was the actual phrase that one medical representative used some time ago, and I squirmed at all its negative connotation in pop literature. In med rep jargon, “servicing” could mean anything that addresses the needs of a physician – from simple errands to food to transport. One doctor I know would ask a med rep to bring him all the way to Baguio for a caffeine fix. Another would ask a rep to run across the street for a bottle of shampoo because she was about to wash her hair. Whoever invented this term must have been clever enough to disguise its derogatory character.

Still there I was agreeing to be “serviced” to Davao for a medical event. In the past, I was more comfortable taking the bus: It’s a short trip anyway, there are snugger seats, a bigger leg room, more privacy should I fall asleep (or even snore) as I am wont to, etc. But the med rep was insistent, telling me that she faces a reprimand should I be late in getting to the venue. I reluctantly agreed. Woke up five towns later and found out, through desultory conversation, that thanks to this favor, I had deprived a two-year old of her mother’s care this weekend when I could have taken the bus. I expressed my regrets at this situation and the med rep was stunned: “Are you for real, Doc?” she asked. “May doktor pa bang ganito?”

The relationship between the medical profession and the pharmaceutical industry in the Philippines is one that sparks a lot of controversies. Especially among those who are not doctors, this relationship is constantly eyed as one of the main reasons why drugs in the country are among the most expensive in the world. Doctors are wined and dined, brought to exclusive golf courses abroad for a round or two, even provided “entertainment.” That these things actually happen is a shame to the profession and tars the majority who strive to maintain an unwavering commitment to the highest ideals of professional conduct. I believe it has become so rampant that both the Philippine Medical Association (PMA) and the Philippine College of Physicians (PCP) have provisions in their Code of Conduct about how members should behave towards the pharmaceutical industry as a whole.

My ambivalence about the medic-pharma relationship started when my youngest brother was taken in by a promising local pharmaceutical company as a sales representative. Having grown up in a family of doctors, he had a high regard for members of the profession through the conduct of his uncles, aunt and cousins. But he was not prepared for what transpired during his first day of work when he went home throwing up and racked by a severe headache – from disenchantment perhaps. Or from revulsion even. He recounted how he was asked by one doctor to fetch a daughter from school, and then ordered to buy booze for another. He resigned immediately. It probably scarred him for life.

Seeing how difficult it was for him, I vowed to myself never to personally let another person from the pharma industry go through that humiliation again. Don’t get me wrong. I have deep respect for the pharmaceutical industry which made it easier for me to obtain my subspecialties with the scholarships that they give to fellows-in-training.

At the same time, I view the pharmaceutical industry primarily as a business enterprise with social responsibility. Drug companies are for the most part business entities investing millions in the research, development, marketing and promotion of drugs that will answer the needs of patients worldwide. With each successful launching of a new drug, every company stands to earn megabucks in profits. I see no problem with that; they simply reap what they sow. Still, I would like to think that beyond mere economic remuneration, the company has a conscience that covers everything, from drug development to marketing, that the highest standards of research and ethics are complied with. I admire companies that do not only have the pulse for what the world needs (thus taking innovative, even risky, strides to address some of the world’s dreaded scourges) but also the heartbeat for what the needy world can afford and sustain. Simply put, safe, effective and affordable drugs are what every patient needs.

As a medical oncologist I am fully aware of the power of the medicines to affect the survival and quality of life of many patients. The drugs that I give may alleviate a patient’s pain and even arrest the growth of his/her cancer, but these same drugs may also cause another’s discomfort and morbidity with their inherent complications and toxicities. A remarkably effective drug for one patient may be useless for another; thus, I appreciate drug companies that highlight not only the efficacy of their products, but the side effects as well.

I value my relationship with the pharmaceutical companies principally on the premise that this interaction allows me to make informed choices for the benefit of my patients. The patient’s best interest remains the means and the end of this relationship, whatever is superfluous to it is of marginal consequence. Thus, it should be nurtured with utmost reverence and assiduousness.

With medical representatives, I keep a prudent distance that allows ample breathing space for deference and professionalism, but still close enough for unimpeded communication and openness. Throughout my journey as a doctor (from clerkship to internship to residency/fellowship to present practice), there are certain limitations, certain “codes” that I set for myself as far as my dealings with the reps are concerned. These are purely personal and have nothing to do with the rest of my colleagues in the profession.

Never sell a drug sample. A “Physician’s Sample Not For Sale” is exactly that.

Don’t ask a med rep “Bakit di mo ako kino-cover?” Part of a doctor’s commitment to the patient is to research information about the drugs being prescribed and not to depend on the pharma industry to provide peer-reviewed articles and other resources or items that can enhance their practice.

Never demand favors, even in jest. While a good dinner in a quiet restaurant is conducive to good conversation where medical breakthroughs can be discussed, asking favors, even a free lunch or dinner, can put doctors at a disadvantage as it makes them beholden to the other party. On the other hand, a med rep might not be in a position to offer the favors being requested and would thus be put in an embarrassing position.

No such thing as a free lunch. Given our culture and the Filipinos’ respect for “utang na loob,” there is always the unspoken expectation that the free lunch or dinner will somehow be reciprocated. In this case, with doctors prescribing drugs being pushed by the med rep.

Never on Sunday. Remember that med reps have families too, and that their weekends are better spent bonding with their loved ones than servicing your needs.

No junkets please. Trips are the perks in a doctor’s life especially to a medical oncologist. They can also be opportunities for professional/personal growth where doctors can pick up nuggets of wisdom and information that can save a patient’s life. But refuse trips that are primarily junkets. For example, choose a palliative care meeting over a product launching anytime.

Always prioritize a patient’s welfare. The pharmaceutical industry being a business enterprise, doctors who patronize a company’s products are often rewarded with trips abroad. I see nothing wrong with that, this being an integral element in free enterprise. Patients need the products, doctors prescribe them, company appreciates the patronage and rewards the doctor (in that exact order). What is revolting is when priorities change like: Company needs the patronage and a reward is dangled; doctors bite and patient need is created for the products.

Stay clear of conflicting interests. When I first set up practice in Gensan, I tried to help my patients with procuring chemotherapeutic drugs for them since none of the pharmacies carried the products here. Until I found out I had difficulty concentrating on my clinical practice while going through receipts, reimbursements, rebates, refunds, etc. I therefore asked my siblings to put up a pharmacy that will carry the products that my patients need. My only request to my brothers is to think beyond mere profit, that patients need these drugs and it is of great service to them if the prices could be kept reasonably fair. But I know where I stand and will often tell med reps: If it’s about clinical info, talk to me. For business matters, talk to them.

Avoid exchange deals. Never willfully and casually ask someone from the pharmaceutical industry for personal favors in exchange for the use of their products. Never abuse your stature as a doctor in dealing with the pharmaceutical industry. At the same time, never allow your professional, even personal, issues with the pharmaceutical companies to cloud your judgments and choices pertaining to patient care and accountability.

I only have respect for the pharmaceutical industry. I am sure they feel the same for my profession in general. •

For feedback, e-mail pingoynoel@yahoo. Com

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