Two-way collaboration may be the new paradigm for interactions between clinicians and commercial interests.
Dr Lee is a maternal-fetal medicine specialist at Northwest Perinatal Center/Women’s Healthcare Associates, LLC, Portland, Oregon.
The National Academy of Medicine (formerly the Institute of Medicine [IOM]) 2001 landmark publication, Crossing the Quality Chasm: A New Health System for the 21st Century, boldly proclaimed that “between the health care we have and the care we could have lies not just a gap, but a chasm.” This report identified 6 characteristics of a better healthcare system: safe, effective, patient-centered, timely, efficient, and equitable. As physicians, we have all witnessed first-hand vast strides toward more standardized, evidence-based and patient-centric care. However, much of this progress has focused on the interactions between patients and their providers (eg, physicians, hospital systems) and less so on the global systems in which these interactions take place. For example, we have made little progress in industry’s approach to development and integration of their products into healthcare delivery. If our healthcare system is going to continue to bridge the IOM’s quality chasm, we need to take a different approach to how healthcare providers interact with our partners in industry and use advances in evidence-based therapies and technology in a way that is consistent with the 6 characteristics outlined by the IOM.
The paradigm of the industry-physician relationship has historically been one in which industry supplies healthcare providers with innovations such as pharmaceuticals, devices, laboratory tests, and information systems. We then employ these in the everyday care of our patients. The driver for clinicians in using these novel products is the prospect of improving care, while industry seeks to gain market share and profit. Traditionally that has been where the role of industry has stopped. As a result, industry understandably has focused on one-way efforts such as funding research, sponsoring educational programs, and providing gifts to stimulate the purchase and/or use of their products, often based on small differences in performance over their competitors-whether clinically relevant or not. This approach is consistent with traditional methods in other business sectors.
However, these traditional relationships between industry and physicians have become more tenuous as they have come under greater scrutiny thanks to an increasing volume of data highlighting the potential negative influences of financial relationships between the 2 groups. The primary concerns are the introduction of bias and conflict of interest into physician decision-making, prescribing habits, and clinical research. These financial relationships are remarkably more common than one would expect. A nationwide survey by Campbell et al. from 2010 found that 84% of physician respondents reported some type of financial relationship with industry during the prior year, with the majority of these interactions involving either food and beverages (70%) or drug samples (64%). Only 14% reported receiving payments for professional services.1
The growing concern about and awareness of potential influence have led to a call for greater transparency and regulation of these relationships. In response, the literature is now replete with guidelines and recommendations from organizations such as the IOM,2 professional medical associations such as the American College of Obstetricians and Gynecologists (ACOG),3 and industry itself.4,5 Most academic medical centers have instituted formal policies regarding interactions with industry. In addition, formal legislation on reporting physician-industry financial relationships exists in several states and was also included as part of the Patient Protection and Affordable Care Act-known as the Physicians Payments Sunshine Act.6
Unfortunately, this increasing scrutiny, while warranted, has also led to greater suspicion of conflict of interest and almost a general sense of impropriety within the healthcare community toward any interactions between physicians and industry. This has led to the formation of a new gap in our healthcare system-one that may stifle progress. The collaborative exchange of ideas and knowledge between care providers and industry is vital to healthcare innovation. This is not limited to the development of new pharmaceuticals and devices, but also needs to include the ways by which we deliver innovations to our patients at the point of service. We need to develop a new way to bring industry and physicians together in a more ethically transparent manner and break free from one-way interactions.
We physicians should be defining our needs on patients’ behalf and demanding more from industry beyond small differences in products’ clinical performance. Physicians must take a greater role in helping industry understand the needs of our medical practices. This relationship needs to become a more collaborative interaction, rather than a one-way sales pitch. The following is an example using fictitious lab test Q.
Several companies sell the Q test. Each of these companies touts superior clinical performance in its marketing presentations. Perhaps you meet their representatives in your office over a small lunch that they provide or during a sponsored dinner with a compensated speaker who tells you why they should use their version of the Q test.
Now let’s further the conversation. You have heard the presentations from each of the vendors of the Q test and ask: What is your differentiating value proposition for my patients and me? Will using your specific test rather than your competitor’s really help us take better care of our patients? How will you help support a patient’s needs beyond just providing another testing option? Silence fills the room.
We need to demand more from our industry partners. Fostering this relationship is not a conflict of interest. However, as part of this advocacy role we must own the responsibility of providing our industry partners with the medical insight to understand the needs of providers, medical practices, and patients. This way they can develop systems to allow us to effectively deploy products in an efficient, patient-centered, and evidence-based manner.
Let’s push industry to think more comprehensively about how their products are used in real-life scenarios, as most products do not stand alone or cannot be incorporated seamlessly into clinical care straight out of the box. In the above example, this could include industry-based support such as 1) unbiased educational support, 2) financial support for low resource patients, and 3) optimizing technical support and interface development for more efficient and accurate information exchange. Back-and-forth developmental collaboration between physicians and industry will allow us to provide better clinical care and customer service to our patients by improving the “operational deployment package” that accompanies a product.
From the industry perspective, this developmental relationship can also be beneficial with substantial return on investment. By developing products and services using greater collaboration with the end user, the value of the product itself is augmented and becomes a more robust tool for healthcare providers. Rather than investing in traditional marketing and funding efforts that have characterized the industry-physician relationship of the past, industry resources can be diverted toward product optimization rather than sales pitch optimization. As business guru Peter Drucker so eloquently put it, “The aim of marketing is to know and understand the customer so well the product or service fits him and sells itself.” Industry needs to more actively reach out and understand the needs of its healthcare customers and develop such substantive differentiating value that products will sell themselves.
This process can be expanded beyond our lab test example. Imagine the conversation if this approach were applied to other everyday physician-industry interactions involving the vendors of oral contraceptives, intrauterine devices, ultrasound equipment, and electronic health records. The key to this is a willingness for both physicians and industry to imagine the possibilities of a collaborative relationship-one that is focused on providing the best evidence-based services to patients by bringing together healthcare providers’ knowledge and industry’s developmental capabilities.
The practice of medicine is transforming as national societies and provider members have shifted toward evidence-based protocols and standardized medicine. However, a gap still exists between our knowledge of what we should do and our ability to actually deliver this care in a way that fulfills the vision outlined by the IOM. Bridging the quality chasm cannot be done alone. It will require a fundamental shift in the physician-industry relationship that breaks out of the traditional one-way mode that is riddled with potential for bias and conflicts of interest.
We need to engage in a new paradigm of interaction based on a 2-way collaboration between physicians as the curators of clinical and operational knowledge and industry as the engine of technologic development. This shift will be essential in advancing how we deliver care in the future if we hope to live up to our fiduciary responsibilities to patients and if our industry partners hope to create products with differentiated value for their customers.
1. Campbell EG, Rao SR, DesRoches CM, Iezzoni LI, Vogeli C, Bolcic-Jankovic D, Miralles PD. Physician professionalism and changes in physician-industry relationships from 2004 to 2009. Arch Intern Med. 2010;170(20); 1820-1826. Doi 10.1001/archinternmed.2010.383.
2. Institute of Medicine. Conflict of interest in medical research, education, and practice. Washington, DC: National Academies Press; 2009. doi:10.17226/12598.
3. American College of Obstetricians and Gynecologists. Professional relationships with industry. Committee Opinion No. 541. Obstet Gynecol. 2012;120:1243-1249.
4. Pharmaceutical Research and Manufacturers of America. Code on interactions with health care professionals. Washington, DC: PhRMA;2008. Retrieved from
on August 28, 2016.
5. Advanced Medical Technology Association. Code of ethics on interactions with health care professionals. Washington, DC: AdvaMed; 2009. Retrieved from http://advamed.org/res.download/112 on August 28, 2016.
6. Health policy brief: The Physicians Payments Sunshine Act. Health Affairs. October 2, 2014.