Ethics

In my opinion, accepting non biased educational products (i.e. books) and using unrestricted educational grants (i.e. for course travel, grand rounds) are NOT conflicts of interest. Steaks, strippers and the champagne room...now that is more of a grey area!!

I think it depends on how the gift is presented. If they flat out say "use this product and I will buy you a trip to hawaii", that is bad. If they just give money without any restrictions (i.e books for residents not based on use of the product), they are just advertising. These are companies that are in business to make money, and part of their strategy for doing that is to provide a product that does something and make sure you know about it. If you are the type of person that will feel beholden to these individuals if they give you stuff, then you shouldn't accept. However, if you are going to use the product that serves your patient best (the drug that works for them, or the implant that you can use best to achieve your desired outcome), I don't see the problem with allowing someone to assist your education in the form of books or informational seminar that comes with food. On the other hand, I may be the wrong person to ask since I have accepted an invite to the spa from one of our reps (although I have no role in purchasing or prescribing at this point, so maybe its not that bad).

there are AMA guildlines for this ....

Ethical opinions and guidelines


Opinion E-8.061: clarifying addendum


i have also place the pdf file on

Non biased texts such as Rockwood and Green, and Campbells are NOT a confilct of interest while you are a resident. Residents have very little control over what their staff uses implant wise anyway. Now that companies have more money to burn on residencts now that the ethical guridelines have changed is a great thing for education. Most residents graduate and seek jobs elsewhere, so there is no obligation to use the rep's procuct afer you graduate even if they buy you a book.. Don't look a gift horse in the mouth is what I say. Best of luck

-ED

Let's not forget about that part of us that we vaguely understand: the subconscious.

A night in the champagne room, a trip to a spa, a free meal, or yes, even a free copy of Rockwood and Greene with NO advertising are all in the same boat. You are getting something for free. Human nature invokes in you a desire to repay a favor, no matter how insignificant or "neutral". Your acceptance of a free pen can impact your future prescribing (or selection) behavior. Otherwise they wouldn't do it. They are not doing this for your education, and there are other ways to find out the necessary information to treat patients.

Saying you have no control over the implants selected now is a poor argument. Saying that you are somehow above their influence is unwise. They know that, and they also know that sending you a pretty cheerleader with a marketing degree will, on average, influence your behavior down the road.

Eathdawg and md007,

you both have great points .... truth is, taking books from a rep is probably ok as long as ther is no quid pro quo ...

i will finish this thought ... got to go watch my chief scope ...

I am more in line with md007. He is right to say the subconscience is hard to understand or control. Yes, they would not do it unless they got a benifit. They are in it for the money, as a buisness and that is fine but we need to be aware of it. It seems that programs are using this perk as a way to avoid the cost to the dept. It is hard to say as a resident that you/I will not take the book because you need it and can't afford it any other way so I do not fault the residents, but departments need to evaluate the practice, including free lunches and even pens.

md007,

I really have nothing further to say to you other than lighten up. We finished our other little spat on a good note, but it is becoming painfully obvious to me that you are the type who is high and mighty and looks down their nose at everyone around them because you feel as though you are smarter, and somehow a moral notch above them. Yes, I AM judging you now because all you really want to do is stir the pot. I wished you luck in the match, and I still mean it because I don't want to throw out any ill will, but I can assure you based on your numerous posts that I am glad I didn't match in a program with you and if I were still involved with the residency selection process, I wouldn't look favorably at a candidate on such a moral high horse, nor one nearly as cocky. I hope you hid it well during the interviews.

I received many books as a resident and I am glad I did. I don't even remember who gave me what, and despite what you think about the subconscious, Dr. Freud, my implants of choice are in no way affected by a Rockwood and Green I recieved six years ago. I agree that the days of Carribean trips for the doc and his wife are rightfully over, and consideration needs to be (and is) being given to ethical concerns regarding gifts from reps, but you seriously need to stop taking every issue and applying theoretical issues to the max and realize we live in a practical world and judgement calls can and should be made regarding every issue. If you want to refuse every book offered to you as a resident because of some strange inability to reisist your subconscious then fine, but don't judge your fellow residents who accept perfectly valid opportunities to save money and enhance their training.

Sorry to everyone else for the rather personal rant, but I just can't stand when someone is so judgemental toward the profession they have chosen to be a part of. If orthopedists and doctors are so corrupt and greedy, then maybe you would be better off joining the priesthood.

ok ... to finish the thought ...

a little note on reps ... they will do whatever it takes to get you to speak with them and use their product ... books, dinner, sporting events, etc. ... their purpose is that you become familiar with their product and eventually will use it ... on the resident end, they are putting that time in for the company because in most cases you will probably have a different rep unless you stay in the area ...

a couple of things that go against you using a product because they bought you a nice $300 dollar fracture book ...

1. if the rep does not give good service .. you will not use them ...
2. if they don't have good product you will not use them
and 3 this is the thing that is effecting most of use now, if they don't have a contract with the hospital YOU CAN NOT USE THEM ...

so, take the books and meals, beware of the quid pro quo .... use the products that you feel are the best (if the hospital allows you) ... and that's all i got to say about that ....

I participate in this forum to further my knowledge of orthopaedics/the application process, to learn about other perspectives, and to offer my own perspective to those who browse this forum. Perhaps we can all benefit from our participation somehow. I hope to be able to share my ideas and test the response to them without suffering personal attacks. Your comments can be quite hurtful, but c'est la vie.

For the record, I don't believe to be riding a high and mighty horse. I am just as human and vulnerable to influence as the next person. I am willing to admit that I don't know how everything in this world influences me. I believe that individuals with the best intentions sometimes do the wrong thing because of the situation in which they are placed. As for stirring of pots: I believe that is something to be proud of. It isn't, by any means, for everyone. I believe the status quo allows plenty of room for improvement, but perhaps I am too hard on myself and my hopeful profession. I still fail to see how challenging the current way of thinking is a bad thing. I also fail to see how discussing things theoretically makes me out of touch with reality. Damn Einstein, et al.

As for an "inability to resist my subconscious"...correct me if I am wrong, but is it actually possible to resist one's own subconscious? Isn't that the whole point of the name?

I believe it is now accepted that industry can impact what gets published, and that when a connection exists, the results of the study are significantly more likely to lead to pro-industry conclusions. I haven't found much in the orthopaedic literature discussing bias in the way we are. Most of it focuses on conflict of interest (which may lead to bias, often subconsciously). I am not saying that gifts are or are not a conflict of interest (unless your behavior leads to the gift). However, in discussing bias, many believe that interactions with industry leads to bias in the prescribing behavior of physicians. Articles I've come across on the topic focus more on medical residents. In my opinion, it is clear that similarities exist between them and orthopaedic residents. I also believe that similarities exist between conflict of interest and the bias that may or may not be present after receiving a free, unsolicited gift without an EXPLICIT method of repaying that gift. I think the majority opinion will eventually change, but only if someone "stirs the pot". I am pretty sure that we won't achieve any progress if we all think the exact same.

I will try to simplify my hypothesis/perspective/"morally superior" position (again, tongue in cheek). I have only one question I really would like to have answered:

If a well-designed study, double blind study were done that randomized orthopaedic residents to getting free stuff from industry reps with a control group that did not have this exposure, and the results of the study showed equivalent patient outcomes and equivalent knowledge as measured by OITEs and board exams, BUT those who were exposed were significantly more likely to use products from companies from which they received free gifts, then would you still believe it is a good thing?

I have my hypothesis, and that is all. I don't KNOW one way or the other.

Bravo, md007, Bravooooooo.

You have once again succeeded in diverting attention away from the issue at hand and back to yourself. I am sorry I hurt your little feeling (not feelings, but your little feeling). I really am. But I question, how are my "personal attacks" any more viscious than your assertion that I am "unwise" and unethical to throw patient care aside based on the latest rep to send a topless cheerleader to my office. I contend, and still do, that I am perfectly capable of making decisions based on what implant I think is appropriate despite what textbook I received six years ago. We simply agree to disagree, but don't come on this board and condemn countless residents, past and future, who freely accept orthopedic texts from reps as unethical. If you choose to do so, don't complain when your opinion is contradicted.

That is all. -ED

While company gifts may not be as blatant as in the past (sending you on trips for using only their total joint components) there is still a lot of money spent to "woo" doctors, and that money directly influences costs of the company and cost of components/implants. It is retarded that the implant company makes more than the surgeon when performing many types of operations. Say you have a big trauma with no insurance. Whats the hospital's compensation? Zero. The Orthopods? Zero. The IM Nail companies? Depending on the contract with the hospital, sometimes a discounted, but often the same price as for a patient with full coverage.

I dont know if any of you went to the academy last week in san diego, but there was a LOT of money spent by companies on marketing. For example, a "reception" (not even a lecture or educational event) by Depuy rented out AN ENTIRE AIRCRAFT CARRIER (USS Midway). I went simply because I wanted to see the carrier but there were THOUSANDs of people there, all getting free booze and food with live music. This had to cost WELL in to the six figures to put on. Now I dont think that this is the same as giving residents textbooks, which I have accepted and do not feel is a conflict, but it is an example of the lengths companies will go to to get your time/attention.

The question is where is the line drawn. Regardless if you agree you are effected or not, it is hard to disagree that the companies are CONSTANTLY trying to "whittle" you down with continous exposure to their name/brand. Ask any marketing CEO, they will tell you that exposure to what they are selling is the key to success.
Its up to everyone to "draw their own line". But remember, the companies and their reps are not "your buddy", or "are looking out for you", they are selling you something. Tell them there is no chance in hell you will ever use XXXX brand of implants and see how often they visit/offer you things.

all great points, even those from md007... i'm just kidding man. I have never interacted with you. small joke.

a brief, market-based argument: yes, companies obviously spend these sometimes ludicrous amounts of money in the hope that they will influence our choices. if there were conclusive proof that gifts/trips etc had no effect, i don't know of any self-respecting marketing chief who would continue to throw good money after bad.

however -- just because we MAY be being influenced doesn't necessarily entail that we're being unduly pulled in any one direction. No company, in an open market, will let another get an advantage when it can do something about it. An easy example from medicine: do you think that if the Lipitor guys come over and buy the fleas lunch, the zocor/mevacor/crestor et al fellas are just gonna sit back? no. they'll also swing by with bad chinese.

if you're being influenced in a number of directions -- by essentially all the products available to you -- are you being unduly influenced in any one direction? I don't think so. In the end, you retain your choice -- what product (implant, drug, whatever) you like the best, for your own reasons.