Perspective
An Intellectual Virtue “Vaccination” for Physician–Pharmaceutical Industry Interactions Shahram Ahmadi Nasab Emran, MD, MA
Abstract The pharmaceutical industry’s wide range of interactions with physicians, trainees, and other medical professionals— interactions that include information transfer and financial incentives—has been the source of undue influences, especially on physicians’ prescription behavior. Current literature has mainly been focused on the financial element of these influences, and the problems in medical professional–pharmaceutical industry interactions are mainly viewed in terms of conflicts of interest. There is often the assumption that physicians are intellectually competent but biased because of financial incentives.
It is widely acknowledged that the
pharmaceutical industry’s wide-ranging interactions with physicians, trainees, and other medical professionals—which, besides clinical trials, consist mainly of information transfer (e.g., CME courses, providing drug information and samples) and financial incentives (e.g., gifts, lunches, free trips, various kinds of money transfer)—have created undue influences on medical professionals’ behavior, especially physicians’ prescription behavior. Most of the current literature on the issue of medical professional–pharmaceutical industry interactions is focused on defining the ethical boundaries of these interactions1,2 by establishing ethical codes of professional conduct such as those formulated by medical professions’
Dr. Ahmadi Nasab Emran is a teaching assistant, Albert Gnaegi Center for Health Care Ethics, Saint Louis University (SLU), St. Louis, Missouri. He is also a candidate for a PhD in health care ethics at SLU. Correspondence should be addressed to Dr. Ahmadi Nasab Emran, Salus Center, 3545 Lafayette, 5th Floor, St. Louis, MO 63104-1314; telephone: (314) 606-0751; fax: (314) 977-5150; e-mail: sahmadin@ slu.edu. Acad Med. 2015;90:30–32. First published online October 14, 2014 doi: 10.1097/ACM.0000000000000525
30
The author rejects that assumption and proposes an alternative explanation for the observed influence of the pharmaceutical industry on physicians’ behavior by emphasizing the importance of the informationtransfer side of the interactions and maintaining that physicians and other medical professionals need certain intellectual virtues (i.e., competencies) to properly assess the information, which is often unreliable and biased. These virtues are necessary for the practice of modern medicine and include mindfulness, the ability to understand practical implications of
newly found evidence, to consider alternative explanations of data, to recognize and correct errors, to decide on the best available evidence, and to tailor that to the needs and values of individual patients. On the basis of this view, the author recommends that the best solution for the observed problems in physician–pharmaceutical industry interactions is to “vaccinate” physicians and other medical professionals by increasing efforts to inculcate the necessary intellectual virtues early in medical education and fostering them throughout those individuals’ professional lives.
associations, developing ethical rules of behavior for drug company representatives, and formulating regulations that demarcate the boundaries of appropriate conduct for physicians.* The main theme in all these rules, codes, and regulations has been the notion of reducing the influence of conflicts of interest3 that, because of financial and other incentives, can affect physicians’ decision making. As a result, the rules, codes, and regulations have been focused mainly on limiting the level of permissible gifts and incentives.2
sometimes necessary but misses the more fundamental importance of fostering physicians’ intellectual competence so they can fully understand drug company information. I explain these views in more detail in the section entitled “An Intellectual Virtue ‘Vaccination.’”
The approach described above assumes that physicians are intellectually competent to assess drug companies’ information but that there must be constraints to protect them from being seduced by various incentives offered by the companies. I disagree with the first part of that assumption, since, as I will explain, I do not think that physicians are intellectually competent to assess drug company information. As for the second part, making rules and regulations is * To facilitate easier reading, in the rest of this article, the term “physicians” is often used as a shorthand way of saying “physicians, trainees, and other medical professionals.” However, the longer term is used when necessary for emphasis or to avoid any misinterpretation.
Background
Pharmaceutical information transfer to physicians Physicians constantly receive information from drug company representatives about new drugs and technologies. This kind of information transfer is pervasive, convenient, and inexpensive for the physicians.4 As a result, they rely on drug representatives as one of the main sources of information about new drugs and therapeutic methods.5,6 In addition to the information provided by the representatives, drug companies directly influence the content of information communicated in CME programs by means of their selection of topics and speakers.6 A related type of information transfer is the provision of drug samples to physicians. Most physicians receive drug samples from drug companies.7 In this way, physicians become informed about the new drugs and technologies and their applications. All in all, the pharmaceutical
Academic Medicine, Vol. 90, No. 1 / January 2015
Perspective
industry heavily influences the nature of information that physicians receive about new drugs and therapeutic methods. The question that arises, however, is whether the quality of the transferred information can be trusted. The quality of transferred information Drug company representatives are often assumed to be a reliable source of information and are expected to provide the most up-to-date information. In this sense, the role of pharmaceutical representatives seems to be in line with the best interest of patients, doctors, and the public.8 However, many studies have made such an assumption highly questionable. On the basis of a MEDLINE search of the literature from 1966 to 1996, Lexchin9 found four surveys on the quality of information that was provided to physicians by drug company representatives in three industrialized countries. The results of the surveys indicated that they failed to give out safety information and, when safety information was mentioned, it was often done to cast the drug being detailed in a favorable light. There were frequently inaccuracies in the information representatives transmitted.9
Pharmaceutical representatives communicate only positive data about a drug and conceal adverse effects in order for the drug to appear to be better than the currently used alternatives. As Lexchin summarizes, the studies have consistently demonstrated that detailers selectively transmit only positive information about their company’s products. Side effects and contraindications are rarely mentioned, and the information that detailers give to physicians is frequently inaccurate.9
More recent studies10,11 indicate that matters have not changed much since Lexchin’s survey of the literature. The quality of information that physicians receive from pharmaceutical representatives is poor, or at least suspect, because it is biased in favor of the drugs that are being promoted. How is this kind of biased information received by physicians? The impact of the transferred information on physicians’ practice Are physicians and trainees able to recognize the inaccuracies and biases in the information they receive from
Academic Medicine, Vol. 90, No. 1 / January 2015
the pharmaceutical representatives? According to Wazana,12 who performed a MEDLINE search from 1994 to 2000, studies indicate that physicians are unable to identify wrong claims about drugs made by pharmaceutical representatives. Other influences on physicians resulting from the interaction with pharmaceutical representatives included awareness, preference, and rapid prescription of a new drug and … making formulary requests for medications that rarely held important advantages over existing ones; increasing prescription rate; [and] prescribing fewer generic but more expensive, newer medications at no demonstrated advantage.12
Why are physicians often unable to recognize poor-quality, inaccurate, and biased information received from pharmaceutical representatives? On the basis of an intellectual virtue approach, which I will now explain, the main reason for this phenomenon should be sought at the person-level characteristics of physicians. An Intellectual Virtue “Vaccination”
The concept of intellectual virtues in medicine For physicians and other medical practitioners to fulfill their roles— including being able to interpret drug companies’ information—they need to have certain competencies, which in this article I call virtues, in the wide Aristotelian sense of that term.13 What are these intellectual virtues? First, with the tremendous amount of new data in medicine, physicians need to keep their knowledge constantly updated. But in addition, they should be able to critically analyze and interpret the data they receive and extrapolate the practical relevance of the data. They also need welldeveloped professional character traits, habits of mind, and attitudes. Related examples of intellectual virtues include mindfulness,14 using evidence in making arguments, considering counterarguments, considering alternative explanations of data,15 having habits of inquiry,16 and being willing to recognize and correct errors.17 Finally, physicians should be able to recognize the best evidence and tailor that to the needs and values of individual patients.
There seems to be a similarity between what I describe as the intellectual virtues and the skills of evidence-based medicine (EBM), especially critical thinking. Both critical thinking and EBM include a set of cognitive excellence such as creativity, open-mindedness, flexibility, and persistence.18–20 However, there is something more than knowledge and skills operating here: “To be effective, critical thinkers must also have the necessary dispositions (attributes, habits of mind, attitudes) to use knowledge and complement the skills.”20 Hence, what physicians need is a combination of certain intellectual skills and the appropriate attitude and motivation—the two defining components of intellectual virtues.21 In fact, however, these components seem to be missing in many EBM teaching programs22; taking the virtue approach seriously could add something important to physicians’ professional performance. In addition, whereas an intellectual virtue is by definition function-specific, critical thinking seems to be a more general entity, which itself consists of a set of specific intellectual virtues. The need for intellectual virtues in medicine Changing roles of practitioners of medicine in various social and historical contexts necessitate different virtues for the practice of medicine. For example, one of the distinguishing features of contemporary medicine is its vast reliance on the evidence obtained from research.23 Consequently, being a good practitioner requires the intellectual excellence of being able to understand the results of research and having the ability to continually acquire and incorporate new knowledge.24 With the increasing importance of statistics and EBM in new knowledge and medical practice, the need to teach trainees statistical skills becomes more pressing.25 However, the fact is that “clinicians across levels of training have low perceived knowledge of biostatistics concepts.”26 Most residency programs failed to develop what has been called “physician numeracy” skills in the trainees.27 In other words, if physicians do not develop these and the other necessary intellectual virtues during their medical education, there is no chance that they will do better in their interactions with pharmaceutical representatives. As Matthews and McPherson28 rightly said so well decades ago:
31
Perspective They are doomed to have to accept without reservation the statements made in summaries, discussions, or conclusions [of journal articles], and their clinical practice may thus be altered on the basis of flimsy or inconclusive evidence.
In addition, physicians need to constantly update their knowledge of other fields. The modern practice of medicine “demands that physicians integrate into their practices not only the results of clinical and pathophysiologic studies but also the results of epidemiologic studies.”29 A large part of published medical research is primarily epidemiologic in nature, uses statistical language, and expresses the results in terms of probabilities. The abilities to appropriately interpret research data, find their weaknesses and biases, and identify and integrate the relevant information into their daily practice of medicine are indispensable virtues for contemporary medical practitioners. I maintain that the practice of medicine today requires a set of intellectual virtues, as described above, that many physicians and other medical professionals lack. The problem they have in interpreting drug companies’ information—as well as in interpreting research findings in general—can be explained as a consequence of that lack. Regarding the interpretation of drug companies’ information, a possible objection to my emphasis on the importance of intellectual virtues might be that the real problem is somewhere else, not in physicians’ lack of intellectual virtues. It might be argued that financial incentives create an unconscious bias in physicians that operates in a self-serving manner and leads them to changes in prescription behavior that favor drug companies.30 According to this view, the primary problem is in the motivation component of the act, not in its intellectual virtue component. I disagree; I believe the primary problem is in the intellectual virtue component. As long as physicians and others lack the necessary intellectual virtues, the first-line remedy is to solve the intellectual-deficit problem, because under current conditions even a wellintended and rightly motivated physician who is not intellectually prepared could easily act inappropriately in his or her interactions with the pharmaceutical industry, including interpreting that
32
industry’s information. Whatever the effect of unconscious self-serving biases may be, to investigate that effect we first need to make sure that physicians are equipped with the necessary intellectual virtues to do their jobs. Equipping medical professionals in this way must start early. The intellectual habits of a physician develop simultaneously with learning clinical skills early in medical education.31 Hence, I maintain that the best solution for the observed problems in physician–pharmaceutical industry interactions is to “vaccinate” physicians and other medical professionals by increasing efforts to inculcate the necessary virtues early in medical education and fostering them throughout those individuals’ professional lives. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable.
References 1 Chimonas S, Rothman DJ. New federal guidelines for physician–pharmaceutical industry relations: The politics of policy formation. Health Aff (Millwood). 2005;24:949–960. 2 Wager E. How to dance with porcupines: Rules and guidelines on doctors’ relations with drug companies. BMJ. 2003;326:1196–1198. 3 Studdert DM, Mello MM, Brennan TA. Financial conflicts of interest in physicians’ relationship with pharmaceutical industry: Selfregulation in the shadow of federal persecution. N Engl J Med. 2004;351:1891–1900. 4 Manchanda P, Honka E. The effects and role of direct-to-physician marketing in the pharmaceutical industry: An integrative review. Yale J Health Policy Law Ethics. 2005;5:785–822. 5 Lurie N, Rich EC, Simpson DE, et al. Pharmaceutical representatives in academic medical centers: Interaction with faculty and housestaff. J Gen Intern Med. 1990;5:240–243. 6 Komesaroff PA, Kerridge IH. Ethical issues concerning the relationship between medical practitioners and the pharmaceutical industry. 2002;176:118–121. 7 Campbell EG, Gruen RL, Mountford J, Miller LG, Cleary PD, Blumenthal D. A national survey of physician–industry relationships. N Engl J Med. 2007;356:1742–1750. 8 Blumenthal D. Doctors and drug companies. N Engl J Med. 2004;351:1885–1890. 9 Lexchin J. What information do physicians receive from pharmaceutical representatives? Can Fam Physician. 1997;43:941–945. 10 Mintzes B, Lexchin J, Sutherland JM, et al. Pharmaceutical sales representatives and patient safety: A comparative prospective study of information quality in Canada, France and the United States. J Gen Intern Med. 2013;28:1368–1375.
11 Spurling GK, Mansfield PR, Montgomery BD, et al. Information from pharmaceutical companies and the quality, quantity, and cost of physicians’ prescribing: A systematic review. PLoS Med. 2010;7:1–22. 12 Wazana A. Physicians and the pharmaceutical industry: Is a gift ever just a gift? JAMA. 2000;283:373–380. 13 Irwin T. Aristotle: Nicomachean Ethics. Indianapolis, Ind: Hackett Publishing Co.; 1999. 14 Epstein RM. Mindful practice. JAMA. 1999;282:833–839. 15 Steinkuehler C, Duncan S. Scientific habits of mind in virtual worlds. J Sci Educ Technol. 2008;17:530–543. 16 Irby DM, Cooke M, O’Brien BC. Calls for reform of medical education by the Carnegie Foundation for the Advancement of Teaching: 1910 and 2010. Acad Med. 2010;85:220–227. 17 Epstein RM, Hundert EM. Defining and assessing professional competence. JAMA. 2002;287:226–235. 18 Staib S. Teaching and measuring critical thinking. J Nurs Educ. 2003;42:498–508. 19 Maudsley G, Strivens J. “Science”, “critical thinking”, and “competence” for Tomorrow’s Doctors: A review of terms and concepts. Med Educ. 2000;34:53–60. 20 Profetto-McGrath J. Critical thinking and evidence-based practice. J Prof Nurs. 2005;21:364–371. 21 Zagzebski LT. Virtues of the Mind: An Inquiry Into the Nature of Virtue and the Ethical Foundations of Knowledge. Cambridge, England: Cambridge University Press; 1996. 22 Coomarasamy A, Khan KS. What is the evidence that postgraduate teaching in evidence based medicine changes anything? A systematic review. BMJ. 2004;329:1–5. 23 Sackett DL, Rosenberg WMC, Muir Gray JA, Haynes RB, Richardson WS. Evidence-based medicine: What it is and what it isn’t. Br Med J. 1996;312:71. 24 Schwarz MR, Wojtczak A. Global minimum essential requirements: A road towards competence-oriented medical education. Med Teach. 2002;24:125–129. 25 Miles S, Price GM, Swift L, Shepstone L, Leinster SJ. Statistics teaching in medical school: Opinions of practicing doctors. BMC Med Educ. 2010;10:1–8. 26 West CP, Ficalora RD. Clinician attitudes toward biostatistics. Mayo Clin Proc. 2007;82:939–943. 27 Goutham R. Physician numeracy: Essential skills for practicing evidence-based medicine. Fam Med. 2008;40:354–358. 28 Matthews DR, McPherson K. Doctors’ ignorance of statistics. Br Med J (Clin Res Ed). 1987;294:856–857. 29 Weiss ST, Samet JM. An assessment of physician knowledge of epidemiology and biostatistics. J Med Educ. 1980;55:692–697. 30 Cain DM, Detsky AS. Everyone’s a little bit biased (even physicians). JAMA. 2008;299:2893–2895. 31 Novack DH, Epstein RM, Paulsen RH. Toward creating physician–healers: Fostering medical students’ self-awareness, personal growth, and well-being. Acad Med. 1999;74:516–520.
Academic Medicine, Vol. 90, No. 1 / January 2015
An Intellectual Virtue “Vaccination” for Physician–Pharmaceutical Industry Interactions Shahram Ahmadi Nasab Emran, MD, MA
Abstract The pharmaceutical industry’s wide range of interactions with physicians, trainees, and other medical professionals— interactions that include information transfer and financial incentives—has been the source of undue influences, especially on physicians’ prescription behavior. Current literature has mainly been focused on the financial element of these influences, and the problems in medical professional–pharmaceutical industry interactions are mainly viewed in terms of conflicts of interest. There is often the assumption that physicians are intellectually competent but biased because of financial incentives.
It is widely acknowledged that the
pharmaceutical industry’s wide-ranging interactions with physicians, trainees, and other medical professionals—which, besides clinical trials, consist mainly of information transfer (e.g., CME courses, providing drug information and samples) and financial incentives (e.g., gifts, lunches, free trips, various kinds of money transfer)—have created undue influences on medical professionals’ behavior, especially physicians’ prescription behavior. Most of the current literature on the issue of medical professional–pharmaceutical industry interactions is focused on defining the ethical boundaries of these interactions1,2 by establishing ethical codes of professional conduct such as those formulated by medical professions’
Dr. Ahmadi Nasab Emran is a teaching assistant, Albert Gnaegi Center for Health Care Ethics, Saint Louis University (SLU), St. Louis, Missouri. He is also a candidate for a PhD in health care ethics at SLU. Correspondence should be addressed to Dr. Ahmadi Nasab Emran, Salus Center, 3545 Lafayette, 5th Floor, St. Louis, MO 63104-1314; telephone: (314) 606-0751; fax: (314) 977-5150; e-mail: sahmadin@ slu.edu. Acad Med. 2015;90:30–32. First published online October 14, 2014 doi: 10.1097/ACM.0000000000000525
30
The author rejects that assumption and proposes an alternative explanation for the observed influence of the pharmaceutical industry on physicians’ behavior by emphasizing the importance of the informationtransfer side of the interactions and maintaining that physicians and other medical professionals need certain intellectual virtues (i.e., competencies) to properly assess the information, which is often unreliable and biased. These virtues are necessary for the practice of modern medicine and include mindfulness, the ability to understand practical implications of
newly found evidence, to consider alternative explanations of data, to recognize and correct errors, to decide on the best available evidence, and to tailor that to the needs and values of individual patients. On the basis of this view, the author recommends that the best solution for the observed problems in physician–pharmaceutical industry interactions is to “vaccinate” physicians and other medical professionals by increasing efforts to inculcate the necessary intellectual virtues early in medical education and fostering them throughout those individuals’ professional lives.
associations, developing ethical rules of behavior for drug company representatives, and formulating regulations that demarcate the boundaries of appropriate conduct for physicians.* The main theme in all these rules, codes, and regulations has been the notion of reducing the influence of conflicts of interest3 that, because of financial and other incentives, can affect physicians’ decision making. As a result, the rules, codes, and regulations have been focused mainly on limiting the level of permissible gifts and incentives.2
sometimes necessary but misses the more fundamental importance of fostering physicians’ intellectual competence so they can fully understand drug company information. I explain these views in more detail in the section entitled “An Intellectual Virtue ‘Vaccination.’”
The approach described above assumes that physicians are intellectually competent to assess drug companies’ information but that there must be constraints to protect them from being seduced by various incentives offered by the companies. I disagree with the first part of that assumption, since, as I will explain, I do not think that physicians are intellectually competent to assess drug company information. As for the second part, making rules and regulations is * To facilitate easier reading, in the rest of this article, the term “physicians” is often used as a shorthand way of saying “physicians, trainees, and other medical professionals.” However, the longer term is used when necessary for emphasis or to avoid any misinterpretation.
Background
Pharmaceutical information transfer to physicians Physicians constantly receive information from drug company representatives about new drugs and technologies. This kind of information transfer is pervasive, convenient, and inexpensive for the physicians.4 As a result, they rely on drug representatives as one of the main sources of information about new drugs and therapeutic methods.5,6 In addition to the information provided by the representatives, drug companies directly influence the content of information communicated in CME programs by means of their selection of topics and speakers.6 A related type of information transfer is the provision of drug samples to physicians. Most physicians receive drug samples from drug companies.7 In this way, physicians become informed about the new drugs and technologies and their applications. All in all, the pharmaceutical
Academic Medicine, Vol. 90, No. 1 / January 2015
Perspective
industry heavily influences the nature of information that physicians receive about new drugs and therapeutic methods. The question that arises, however, is whether the quality of the transferred information can be trusted. The quality of transferred information Drug company representatives are often assumed to be a reliable source of information and are expected to provide the most up-to-date information. In this sense, the role of pharmaceutical representatives seems to be in line with the best interest of patients, doctors, and the public.8 However, many studies have made such an assumption highly questionable. On the basis of a MEDLINE search of the literature from 1966 to 1996, Lexchin9 found four surveys on the quality of information that was provided to physicians by drug company representatives in three industrialized countries. The results of the surveys indicated that they failed to give out safety information and, when safety information was mentioned, it was often done to cast the drug being detailed in a favorable light. There were frequently inaccuracies in the information representatives transmitted.9
Pharmaceutical representatives communicate only positive data about a drug and conceal adverse effects in order for the drug to appear to be better than the currently used alternatives. As Lexchin summarizes, the studies have consistently demonstrated that detailers selectively transmit only positive information about their company’s products. Side effects and contraindications are rarely mentioned, and the information that detailers give to physicians is frequently inaccurate.9
More recent studies10,11 indicate that matters have not changed much since Lexchin’s survey of the literature. The quality of information that physicians receive from pharmaceutical representatives is poor, or at least suspect, because it is biased in favor of the drugs that are being promoted. How is this kind of biased information received by physicians? The impact of the transferred information on physicians’ practice Are physicians and trainees able to recognize the inaccuracies and biases in the information they receive from
Academic Medicine, Vol. 90, No. 1 / January 2015
the pharmaceutical representatives? According to Wazana,12 who performed a MEDLINE search from 1994 to 2000, studies indicate that physicians are unable to identify wrong claims about drugs made by pharmaceutical representatives. Other influences on physicians resulting from the interaction with pharmaceutical representatives included awareness, preference, and rapid prescription of a new drug and … making formulary requests for medications that rarely held important advantages over existing ones; increasing prescription rate; [and] prescribing fewer generic but more expensive, newer medications at no demonstrated advantage.12
Why are physicians often unable to recognize poor-quality, inaccurate, and biased information received from pharmaceutical representatives? On the basis of an intellectual virtue approach, which I will now explain, the main reason for this phenomenon should be sought at the person-level characteristics of physicians. An Intellectual Virtue “Vaccination”
The concept of intellectual virtues in medicine For physicians and other medical practitioners to fulfill their roles— including being able to interpret drug companies’ information—they need to have certain competencies, which in this article I call virtues, in the wide Aristotelian sense of that term.13 What are these intellectual virtues? First, with the tremendous amount of new data in medicine, physicians need to keep their knowledge constantly updated. But in addition, they should be able to critically analyze and interpret the data they receive and extrapolate the practical relevance of the data. They also need welldeveloped professional character traits, habits of mind, and attitudes. Related examples of intellectual virtues include mindfulness,14 using evidence in making arguments, considering counterarguments, considering alternative explanations of data,15 having habits of inquiry,16 and being willing to recognize and correct errors.17 Finally, physicians should be able to recognize the best evidence and tailor that to the needs and values of individual patients.
There seems to be a similarity between what I describe as the intellectual virtues and the skills of evidence-based medicine (EBM), especially critical thinking. Both critical thinking and EBM include a set of cognitive excellence such as creativity, open-mindedness, flexibility, and persistence.18–20 However, there is something more than knowledge and skills operating here: “To be effective, critical thinkers must also have the necessary dispositions (attributes, habits of mind, attitudes) to use knowledge and complement the skills.”20 Hence, what physicians need is a combination of certain intellectual skills and the appropriate attitude and motivation—the two defining components of intellectual virtues.21 In fact, however, these components seem to be missing in many EBM teaching programs22; taking the virtue approach seriously could add something important to physicians’ professional performance. In addition, whereas an intellectual virtue is by definition function-specific, critical thinking seems to be a more general entity, which itself consists of a set of specific intellectual virtues. The need for intellectual virtues in medicine Changing roles of practitioners of medicine in various social and historical contexts necessitate different virtues for the practice of medicine. For example, one of the distinguishing features of contemporary medicine is its vast reliance on the evidence obtained from research.23 Consequently, being a good practitioner requires the intellectual excellence of being able to understand the results of research and having the ability to continually acquire and incorporate new knowledge.24 With the increasing importance of statistics and EBM in new knowledge and medical practice, the need to teach trainees statistical skills becomes more pressing.25 However, the fact is that “clinicians across levels of training have low perceived knowledge of biostatistics concepts.”26 Most residency programs failed to develop what has been called “physician numeracy” skills in the trainees.27 In other words, if physicians do not develop these and the other necessary intellectual virtues during their medical education, there is no chance that they will do better in their interactions with pharmaceutical representatives. As Matthews and McPherson28 rightly said so well decades ago:
31
Perspective They are doomed to have to accept without reservation the statements made in summaries, discussions, or conclusions [of journal articles], and their clinical practice may thus be altered on the basis of flimsy or inconclusive evidence.
In addition, physicians need to constantly update their knowledge of other fields. The modern practice of medicine “demands that physicians integrate into their practices not only the results of clinical and pathophysiologic studies but also the results of epidemiologic studies.”29 A large part of published medical research is primarily epidemiologic in nature, uses statistical language, and expresses the results in terms of probabilities. The abilities to appropriately interpret research data, find their weaknesses and biases, and identify and integrate the relevant information into their daily practice of medicine are indispensable virtues for contemporary medical practitioners. I maintain that the practice of medicine today requires a set of intellectual virtues, as described above, that many physicians and other medical professionals lack. The problem they have in interpreting drug companies’ information—as well as in interpreting research findings in general—can be explained as a consequence of that lack. Regarding the interpretation of drug companies’ information, a possible objection to my emphasis on the importance of intellectual virtues might be that the real problem is somewhere else, not in physicians’ lack of intellectual virtues. It might be argued that financial incentives create an unconscious bias in physicians that operates in a self-serving manner and leads them to changes in prescription behavior that favor drug companies.30 According to this view, the primary problem is in the motivation component of the act, not in its intellectual virtue component. I disagree; I believe the primary problem is in the intellectual virtue component. As long as physicians and others lack the necessary intellectual virtues, the first-line remedy is to solve the intellectual-deficit problem, because under current conditions even a wellintended and rightly motivated physician who is not intellectually prepared could easily act inappropriately in his or her interactions with the pharmaceutical industry, including interpreting that
32
industry’s information. Whatever the effect of unconscious self-serving biases may be, to investigate that effect we first need to make sure that physicians are equipped with the necessary intellectual virtues to do their jobs. Equipping medical professionals in this way must start early. The intellectual habits of a physician develop simultaneously with learning clinical skills early in medical education.31 Hence, I maintain that the best solution for the observed problems in physician–pharmaceutical industry interactions is to “vaccinate” physicians and other medical professionals by increasing efforts to inculcate the necessary virtues early in medical education and fostering them throughout those individuals’ professional lives. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable.
References 1 Chimonas S, Rothman DJ. New federal guidelines for physician–pharmaceutical industry relations: The politics of policy formation. Health Aff (Millwood). 2005;24:949–960. 2 Wager E. How to dance with porcupines: Rules and guidelines on doctors’ relations with drug companies. BMJ. 2003;326:1196–1198. 3 Studdert DM, Mello MM, Brennan TA. Financial conflicts of interest in physicians’ relationship with pharmaceutical industry: Selfregulation in the shadow of federal persecution. N Engl J Med. 2004;351:1891–1900. 4 Manchanda P, Honka E. The effects and role of direct-to-physician marketing in the pharmaceutical industry: An integrative review. Yale J Health Policy Law Ethics. 2005;5:785–822. 5 Lurie N, Rich EC, Simpson DE, et al. Pharmaceutical representatives in academic medical centers: Interaction with faculty and housestaff. J Gen Intern Med. 1990;5:240–243. 6 Komesaroff PA, Kerridge IH. Ethical issues concerning the relationship between medical practitioners and the pharmaceutical industry. 2002;176:118–121. 7 Campbell EG, Gruen RL, Mountford J, Miller LG, Cleary PD, Blumenthal D. A national survey of physician–industry relationships. N Engl J Med. 2007;356:1742–1750. 8 Blumenthal D. Doctors and drug companies. N Engl J Med. 2004;351:1885–1890. 9 Lexchin J. What information do physicians receive from pharmaceutical representatives? Can Fam Physician. 1997;43:941–945. 10 Mintzes B, Lexchin J, Sutherland JM, et al. Pharmaceutical sales representatives and patient safety: A comparative prospective study of information quality in Canada, France and the United States. J Gen Intern Med. 2013;28:1368–1375.
11 Spurling GK, Mansfield PR, Montgomery BD, et al. Information from pharmaceutical companies and the quality, quantity, and cost of physicians’ prescribing: A systematic review. PLoS Med. 2010;7:1–22. 12 Wazana A. Physicians and the pharmaceutical industry: Is a gift ever just a gift? JAMA. 2000;283:373–380. 13 Irwin T. Aristotle: Nicomachean Ethics. Indianapolis, Ind: Hackett Publishing Co.; 1999. 14 Epstein RM. Mindful practice. JAMA. 1999;282:833–839. 15 Steinkuehler C, Duncan S. Scientific habits of mind in virtual worlds. J Sci Educ Technol. 2008;17:530–543. 16 Irby DM, Cooke M, O’Brien BC. Calls for reform of medical education by the Carnegie Foundation for the Advancement of Teaching: 1910 and 2010. Acad Med. 2010;85:220–227. 17 Epstein RM, Hundert EM. Defining and assessing professional competence. JAMA. 2002;287:226–235. 18 Staib S. Teaching and measuring critical thinking. J Nurs Educ. 2003;42:498–508. 19 Maudsley G, Strivens J. “Science”, “critical thinking”, and “competence” for Tomorrow’s Doctors: A review of terms and concepts. Med Educ. 2000;34:53–60. 20 Profetto-McGrath J. Critical thinking and evidence-based practice. J Prof Nurs. 2005;21:364–371. 21 Zagzebski LT. Virtues of the Mind: An Inquiry Into the Nature of Virtue and the Ethical Foundations of Knowledge. Cambridge, England: Cambridge University Press; 1996. 22 Coomarasamy A, Khan KS. What is the evidence that postgraduate teaching in evidence based medicine changes anything? A systematic review. BMJ. 2004;329:1–5. 23 Sackett DL, Rosenberg WMC, Muir Gray JA, Haynes RB, Richardson WS. Evidence-based medicine: What it is and what it isn’t. Br Med J. 1996;312:71. 24 Schwarz MR, Wojtczak A. Global minimum essential requirements: A road towards competence-oriented medical education. Med Teach. 2002;24:125–129. 25 Miles S, Price GM, Swift L, Shepstone L, Leinster SJ. Statistics teaching in medical school: Opinions of practicing doctors. BMC Med Educ. 2010;10:1–8. 26 West CP, Ficalora RD. Clinician attitudes toward biostatistics. Mayo Clin Proc. 2007;82:939–943. 27 Goutham R. Physician numeracy: Essential skills for practicing evidence-based medicine. Fam Med. 2008;40:354–358. 28 Matthews DR, McPherson K. Doctors’ ignorance of statistics. Br Med J (Clin Res Ed). 1987;294:856–857. 29 Weiss ST, Samet JM. An assessment of physician knowledge of epidemiology and biostatistics. J Med Educ. 1980;55:692–697. 30 Cain DM, Detsky AS. Everyone’s a little bit biased (even physicians). JAMA. 2008;299:2893–2895. 31 Novack DH, Epstein RM, Paulsen RH. Toward creating physician–healers: Fostering medical students’ self-awareness, personal growth, and well-being. Acad Med. 1999;74:516–520.
Academic Medicine, Vol. 90, No. 1 / January 2015
