Despite heightened awareness about the undue influence that gifts from pharmaceutical companies can have on doctors' prescribing practices, and despite expanding institutional conflict-of-interest policies and state laws targeted at preventing such practices, companies continue to reward doctors for prescribing their drugs with gifts ranging from pens and paper, to free dinners and trips.
A new study by two researchers at Carnegie Mellon University, published in the Journal of the American Medical Association, helps to explain how doctors rationalize acceptance of such gifts, which author George Loewenstein, the Herbert A. Simon Professor of Economics and Psychology, describes as "barely described bribes." The study found that physicians rationalize acceptance of these gifts as a form of reward for the sacrifices they made obtaining their education.
Three hundred and one pediatric and family medicine residents answered a series of questions that asked about the acceptability of receiving different types of gifts from pharmaceutical companies. Before completing the survey, however, one group of doctors were first asked about the sacrifices they had made in getting their medical education. A second group were also first asked these sacrifice questions and then were asked whether such sacrifices could potentially justify acceptance of gifts (a rationalization that explicitly introduces the idea that this might be the case) before filling out the gift acceptability questions. A control group was asked about the acceptability of receiving gifts without being first asked about personal sacrifices or being cued with a potential rationalization.
Reminding physicians first of their medical training burdens more than doubled their willingness to accept gifts -- from 21.7 percent to 47.5 percent, and suggesting the potential rationalization further increased their willingness to accept the gifts -- to 60.3 percent. The impact of the suggested rationalization was surprising because, when asked whether their hardships justified taking gifts, most respondents said it did not. Sunita Sah, the study's lead author and a physician herself who is completing her PhD at Carnegie Mellon's Tepper School of Business, commented that "this finding suggests that even justifications that people don't accept at a conscious level can nonetheless help them to rationalize behavior that they otherwise might find unacceptable."
Both authors agree that the implications of the study are straightforward. "Given how easy it is for doctors to rationalize accepting gifts, which, from other research, we know influences their prescribing behavior, the inescapable conclusion is that gifts should simply be prohibited," said Loewenstein, who has done extensive research and writing on the role of human psychology in exacerbating conflicts of interest.
"Given the powerful human capacity to rationalize what benefits us," Sah added, "it is unlikely that we will be able to make a dent in the problem by, for example, educating physicians about the risks posed by conflicts."
This study was funded by Carnegie Mellon's internal departmental research funds.
- Sunita Sah; George Loewenstein. Effect of Reminders of Personal Sacrifice and Suggested Rationalizations on Residents' Self-Reported Willingness to Accept Gifts: A Randomized Trial. JAMA, 2010; 304 (11): 1204-1211 [link]
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