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Objectives How does this relationship impact on doctors The effects on our decision making Bounded ethicality Some strategies to prevent dualities of interest drifting into conflicts of interest Lastly, does it matter? Dualities of interest Common interests with industry Research and innovation Safe, efficacious and responsible use of drugs and medical technologies Monitoring of their use, safety and efficacy The health professionals principal interest is patient care and advancement of scientific knowledge Industry’s principal interest are commercial outcomes How do doctors see their interaction with industry? How do doctors see their interaction with industry? Avoiders (10%) Confident engagers (50%) Ambivalent engagers (40%) Doran, et al., Social Science & Medicine Volume 62, Issue 6, March 2006, Pages 1510-1519 For the Avoiders Risk of interacting with the pharmaceutical industry greater than any benefit Receiving information and accepting largesse may inappropriately influence treatment preferences through persuasion and obligation Interaction may tacitly endorse promotional practices Tangible harms greatly outweighing the ‘benefit’ of information devalued by commercial bias Doran, et al., Social Science & Medicine Volume 62, Issue 6, March 2006, Pages 1510-1519 For the Confident Engagers Relationship seen as essentially sound and mutually beneficial Opportunity to engage in a variety of roles Improving of professional practice Support thought to be a ‘reasonable’ exchange for specialist’s time, experience and advocacy Aware of potential conflicts of interest which could be managed Potency of promotion largely overstated Regard industry influence as arising from the interaction per se, rather than from obligation or persuasion Express concern that those who believe relationship as ethically suspect as overzealous Doran, et al., Social Science & Medicine Volume 62, Issue 6, March 2006, Pages 1510-1519 For the Ambivalent Engagers Structure and manage interaction with industry to minimize potential to be compromised Seeing all reps to maintain a balanced view (often jointly with colleagues) Declining all offers that do not clearly reflect some educational benefit Critically appraise all claims made by industry Benefits seen to outweigh the risks Concern that interaction may negatively effect prescribing practices Doran, et al., Social Science & Medicine Volume 62, Issue 6, March 2006, Pages 1510-1519 Ethical issues Association may serve commercial objectives of industry Inappropriately influence doctor’s decisions Danger of distortions of integrity of scientific research Erosion of public trust How much is spent on drug promotion In Australia in 2001, it was estimated the pharmaceutical industry spends about AUD21,000 per doctor per year.1 Compare this with government expenditure on training medical students of AUD25,000/yr In the US, the estimates in 2008 were US$30 billion annually on drug promotion2 In 2002, the US industry expended 33% of its revenues on “selling and administration”3 1. Juriedini and Mansfield Australasian Psychiatry, 2001, v9(2) pp95-99 2. Brooks, CMAJ, July 1, 2008 Vol 179(2) pp28-29 3. Reinhardt UE. An information infrastructure for the pharmaceutical market. Health Aff (Millwood) 2004;23(1):107-12 Does drug promotion work? Reduced generic prescribing Increase overall prescription rates Quick uptake of the newest, most expensive drugs including those of only marginal benefit over existing options with real-world safety records Formulary request for drugs with few if any advantages over existing drug. Wazana A., JAMA, January 19, 2000—Vol 283, No. 3373-3380 Lexchin J et al. BMJ 2003;326:1167-1170 ©2003 by British Medical Journal Publishing Group Failed Heuristics, Biases, and Cognitive Dispositions to Respond Aggregate bias Gender bias Representative restraint Anchoring Hindsight bias Search satisficing Ascertainment bias Multiple alternatives bias Sutton’s slip Availability error Omission bias Sunk costs Base-rate neglect Order effects Triage cueing Commission bias Outcome bias Underconfidence Confirmation bias Overconfidence Unpacking principle Diagnosis momentum Playing the odds Vertical line failure Feedback sanction Posterior probability error Visceral bias Framing effect Premature closure Yin-Yang out Fundamental attribution Psych-out error error Zebra retreat Pat Croskerry. The Importance of Cognitive Errors in Diagnosis and Strategies to Minimize Them. Gambler’s fallacy Academic Medicine 2003, Vol 78, No.8 pp775-780 2005 Canadian Survey 150 Anaesthetists 66% made ‘anchoring’ error 60% made ‘conjunction fallacy’ error 60% made an error on a probability estimate of cancer 90% mis-estimated a simple probability 92% believed themselves above average drivers 91% exhibited confirmation bias in problem solving http://www.scottishintensivecare.org.uk/Assets/Presentations/CrosKerry1.p ps What’s going on in our heads? Illusion of objectivity Perception of self as moral, competent and deserving A sense of entitlement to largesse as industry makes them feel special A belief that it is acceptable and proper because everyone does it Chugh et al, in Conflicts of interest: challenges and solutions in business, law, medicine, and public policy. By Don A. Moore et al 2005 pp74-95 Bounded ethicality Bounded ethicality refers to the systematic and predictable ways in which humans act unethically beyond their own awareness. Chugh, Bazerman & Banaji, in Conflicts of interest: challenges and solutions in business, law, medicine, and public policy. By Don A. Moore et al 2005 pp 74-95 Preventing “ethical fading” “The key to preventing such behavior is understanding and recognizing when and how ethical fading occurs” “Well-meaning people with good values can go astray, and the challenge is to help people understand and prepare them for the pressures they may face when ethical questions occur.” Tenbrunsel, A, in Conflicts of interest: challenges and solutions in business, law, medicine, and public policy. By Don A. Moore et al 2005 pp96-103 Self image Autonomous professionals: Acting in the best interest of patients Able to assess the scientific evidence objectively Act in an ethical manner Have no conflicts of interest Gifting behaviour “Friendship, food and flattery are all powerful tools of persuasion” Acceptance of gifts induces a sense of reciprocity Size of gift is irrelevant Induces real or perceived biases Katz et al, Am J Bioethics, Summer 2003 Vol 3, No. 3 pp 39-46 Debiasing strategies to reduce ethical conflicts? Strategy Mechanism/Action Develop insight/awareness Provide detailed descriptions and thorough characterizations of known cognitive biases Consider alternatives Whose interests are being served? Metacognition Train for a reflective approach to ethical problems eg The Four Topics Chart1 Cognitive forcing strategies Develop generic and specific strategies to avoid predictable bias in particular ethically challenging situations 1. Clinical ethics : a practical approach to ethical decisions in clinical medicine. Albert R. Jonsen, Mark Siegler, William J. Winslade. —7th ed. p8 Debiasing strategies to reduce ethical conflicts? Strategy Accountability Mechanism/Action Establish clear accountability/transparency for involvement with industry Feedback Provide as rapid and reliable feedback as possible on unethical behavior Specific training Training to identify specific flaws and biases in thinking and provide directed training to overcome them Simulation Construct ethical training videos contrasting incorrect (biased) approaches with the correct (debiased) approach. After Croskerry P. Academic Medicine Vol. 78 No 8 2003, p5 Future directions What should be the boundary between industry and the profession? Traditionally valued societal function of medicine and medical science of serving as arbiter of safe and effective treatment. What is the societal value of an independent profession? The more the profession’s identity incorporates industry interests as part of it’s internal interests, the less independent it becomes. AMSA's PharmFree Pledge I am committed to the practice of medicine in the best interests of patients and to the pursuit of an education that is based on the best available evidence, rather than on advertising or promotion. I, therefore, pledge to accept no money, gifts, or hospitality from the pharmaceutical industry; to seek unbiased sources of information and not rely on information disseminated by drug companies; and to avoid conflicts of interest in my medical education and practice.