Last July, the University of California Davis Health System introduced new guidelines governing the relationship between pharmaceutical vendors and the faculty and students engaged in teaching and clinical care there. The policies have been called some of the strongest in place at academic medical centers to date.
Tim Albertson MD PhD and Garen Wintemute MD MPH, chair and committee member of the UCDHS Pharmacy and Therapeutics Committee, respectively, were instrumental in the process of building and implementing the Davis policies. Recently, PostScript talked with them about what that change looked like on the ground. Highlights from the interview appear below.
The full report, including UC Davis School of Health Sciences policies, can be found on the Prescription Project website. What was the impetus for change?
The impetus was the appearance of the article by Troyen Brennan MD and others in the January 2006 issue of the Journal of the American Medical Association. The article came at a time of heightened awareness of the influence of industry practices on the medical profession, and it made specific recommendations that provided a focus for our efforts. Earlier books and journal articles had documented the problem, in many cases better than Brennan et al., but had made more general recommendations. The Brennan article provided a blueprint.
Who resisted, and why?
There was relatively little resistance to proposals to eliminate gifts and samples. Some resistance was motivated by personal financial considerations. One particularly candid opponent said, “Hey. I need the money.”
Others objected to what they perceived as an infringement of their autonomy as professionals—a stance that proponents saw as ironic, given the nature of the evidence concerning gifts and prescribing behavior. Still others were concerned about the future of educational programs or other services, such as free clinics, that were dependent on industry support.
How did you overcome this resistance?
Arguments arising from shared basic values proved to be very persuasive, particularly with those who were not so much active resisters as sensing themselves to be caught in a dilemma. Many faculty were beneficiaries of the status quo, but were uneasy with that status. For them, supporting the proposals became an opportunity to reassert the beliefs that led them to medicine in the first place.
Here is an example. At a meeting of the medical staff executive committee to consider the proposals regarding gifts and samples, many members expressed concerns about the termination of benefits that they or their departments received from pharmaceutical and device vendors. How, for example, would textbooks remain available? What about expensive diagnostic equipment? Tension ran high. At a critical moment, a senior member of the committee quietly told the group, "I think we should be the leaders. We'll figure it out. Let's take a step in the right direction." The tension could almost be heard leaving the room; the discussion was essentially over. The evidence itself was a powerful tool. We made the most important articles available on the health system’s intranet site. We frequently encountered myths that had been well-documented in the evidence we had reviewed. These included beliefs in the lack of influence of small gifts and in the idea that one’s colleagues, but not oneself, might be susceptible to such influences. By referring to empirical data, we were able to counter these myths preemptively, without shaming those who believed in them.
Let’s talk about environmental factors. What attributes of Davis set up this process to work, and what factors were working against you?
The Dean of our school of medicine, Dr. Claire Pomeroy, was supportive from the beginning. She was critical in demonstrating that such reforms can be taken while maintaining the institution's openness to working with health industries in ways that benefit patients and the public.
The UC system gives faculty a large role in its governance. Faculty here feel empowered to shape the institution.
Perhaps the most important factor working against us was the determination that policy reforms regarding honoraria, speaking relationships, and grants and contracts need to be formulated across all disciplines at the university rather than just for health professionals.
How will you enforce these guidelines?
Until now, enforcement has fallen to a few key members of the vendor relations committee. The Dean is commissioning a permanent committee, chaired by our chief compliance officer and representing all stakeholders in the health system, to take over monitoring and enforcement for the future.
What piece of advice would you offer AMCs that are just beginning this process? From the UC Davis experience, what is most critical to getting such a process off the ground successfully?
First, know the evidence. It is quite compelling. A group of 10 to 20 original research papers and structured reviews forms a core set. Other examples of industry efforts to influence physician behavior, such as individually-targeted detailing based on mining of prescription data, may be helpful.
Second, identify champions; there needs to be at least one person for whom, at least temporarily, this issue comes first.
Third, be inclusive. Identify supporters in critical departments to review the issues with their colleagues. If the institution’s structure suggests it, discuss the issues at grand rounds and elsewhere. Enlist the students and residents.
Fourth, talk to everyone, as often as possible. Buy-in by the faculty avoids a top-down approach and is probably critical to long-term success.
Fifth, use values-based arguments along with the evidence. Many people profit from their relationships with health care industries, but almost all of those people, at some level, see a conflict between those relationships and the ideals of their profession. Bring those conflicts out into the open.
Finally, make specific plans for monitoring and enforcement; changing policies is only the beginning.