To the Editor: It is encouraging to see the Journal continuing its tradition of taking on contentious issues in publishing articles about the negative influence of the pharmaceutical industry.1 With respect to the practical suggestions to address this issue, I suggest that reliance on our profession to substantially improve the situation, although laudable and appropriate, is too optimistic given the gross denial by our colleagues that there is an issue. Our professional bodies simply do not have the support to enforce codes of conduct. The Royal Australasian College of Physicians (RACP) has published guidelines on this issue,2 but I doubt most of its members have read them.

I fully support Breen’s comments relating to funding of educational activities, but I suggest that the pharmaceutical pseudo-educational dollar be bypassed by a major expansion in government funding.3 The provision of regularly updated, easily accessible treatment guidelines integrated into prescribing software (which most general practitioners use daily) would go a long way to decreasing our reliance on the drug dollar for information on appropriate treatment. This requires government investment and professional college cooperation, but would lead to recurrent savings to the Pharmaceutical Benefits Scheme and better treatment.

Currently, the federal government spends $21 million on drug information to doctors,4 while the drug industry spends $1 billion on marketing.5 To partially redress this imbalance would, however, require both political will and pressure from the profession.

To the Editor: Thank you for publishing the Viewpoint by Breen regarding pharmaceutical industry relationships with the medical profession1 — but please do not coin the word “pharmaproof”. This word unintentionally casts aspersions on fellow clinicians — pharmacists — who share the dilemma of aggressive pharmaceutical marketing influencing professional decisions.

The relationship between the industry and pharmacists is actually more complicated, as we are not only advocates for patients and advisers to doctors on the safe and evidence-based use of medicines, but also the buyers of the pharmaceutical products. This last function means that most pharmacists cannot be removed from the business side of medicine supply and must work with the manufacturers to obtain supplies in a timely fashion and at the best price.

In my work as a hospital pharmacist, the pharmaceutical industry helps in planning financial aspects of medicine supply, sponsoring various activities that the public health system and universities are unable to, and providing specific product information — be it for marketed, unregistered or trial medicines.

Most pharmacists cannot choose to not see industry representatives. The formation of such relationships can indeed insidiously affect our clinical decision-making, as outlined by Breen. Unfortunately, the issue of industry’s influence on pharmacists’ decision-making has only rarely been discussed in the pharmacy literature.2-4

Both medical and pharmacy clinicians must be aware of this influence and act accordingly. Peter Mansfield’s Healthy Skepticism (www.healthyskepticism.org) is a good starting point to increase this awareness. However, the movement must include physicians and pharmacists on the same side. I have often been told that we must have the latest new drug on the hospital’s formulary because . . . and have been given a hefty manufacturer-prepared dossier as the sole reason for the request.

I urge physicians to work with pharmacists and be “pharma(cist)friendly”, yet also “industryaware”.

To the Editor: The Journal recently published three interesting articles on the relationship between the medical profession and the pharmaceutical industry.1-3 With Medicines Australia (the pharmaceutical manufacturers’ association) setting up a strict code of conduct (tighter than for any other industry I know), a better balance seems to be on the horizon. Breen reminded us of our responsibilities to protect ourselves and our patients from slick marketing by pharmaceutical companies.1

One technique our surgery has found useful is to have a personal code of conduct. Our surgery has a guide for pharmaceutical reps (copies available from the author). It advises reps that we are not interested in seeing their promotional material, especially those useless coloured graphs. However, we are very happy to look at published trials regarding their product and associated diseases. Personally, I have found the resources available from many reps useful and time-saving.

Breen is concerned about our professional leaders being in denial about the influence of the pharmaceutical industry on doctors’ prescribing habits. If this is so, then the same leaders have complete amnesia and catatonia about another influence that potentially threatens to engulf us.

The sale of supplements and complementary medicines in Australia is a billion-dollar business now. Every month I receive more requests to use supplements for conditions varying from heart disease, cancer and fatigue to non-specific therapies such as detoxification, immune support, metabolic enhancer and anti-ageing. I can sell all these products directly to consumers (patients) at a mark-up I consider reasonable. Alternatively, I can recruit patients to become sellers in a multilevel marketing scheme (similar to pyramid selling). One doctor who practises nutritional medicine full-time has told me he buys $10 000 worth of vitamin E at the start of the year and manages to sell it over the ensuing 12 months for $100 000. I imagine most of that doctor’s patients are recommended vitamin E for their health complaints or health maintenance. This is entirely legal, although there are major ethical concerns about conflict of interest.

To date, there has been little debate among our leaders regarding proper guidelines and regulation of this behaviour. With the enormous potential of the complementary industry to be a useful partner in health management, this needs to be sorted out sooner rather than later.

Comment: I commend Masters on his personal code of conduct in dealing with the pharmaceutical industry. I also share his concerns about the ethical minefield that lurks in the interface between complementary and conventional medicine. Some of the issues involved have recently been explored in the Journal’s series on Complementary and Alternative Medicine.1

However, his scenario of a doctor selling vitamin E to patients raises specific concerns, and the Australian Medical Association’s Code of Ethics2 provides some ethical principles in this regard. Specifically, it states that a doctor should:

• “make sure that you do not exploit your patient for any reason”

• “exercise caution in publicly endorsing any particular commercial product or service not covered by the Therapeutic Goods Advertising Code”3 and

• “when referring your patient to institutions or services in which you have a direct financial interest, provide full disclosure of such interests”.

Translating these principles into daily professional conduct means the practitioner must at all times declare pecuniary interest in the sale of products and be aware of the evidence base of the commercial recommendation so as to not mislead the patient. This involves clear communication of potential benefit, adverse effects, and possible drug–drug interactions of whatever product is promoted.

But, above all, the whole thrust of the AMA Code of Ethics is to ensure that perverse incentives remain foreign to the patient–doctor relationship. Ultimately, it is an individual doctor’s choice.