Personal View: The danger of denial
Authors: Des Spence
Journal: BMJ (2004)

Have you ever caught a glimpse of yourself in a mirror and thought, “Oh, that's just a bad angle.” How many of us men have seen the top of our head in the monitor of a security camera and said to ourselves, “It's just a very bright light.” In psychobabble this is known as denial, one of the most popular of the “coping strategies.” I like using denial as a strategy, as it is easy, convenient, effective, and applicable to almost every life situation. My vanity about my baldness and weight is a source of amusement to my friends and family and is harmless. However, what happens when our denial affects other people, even lots of other people, such as our patients?

I used denial in my relationship with the pharmaceutical industry and how this relationship affected my practice and patients. I wanted to believe that all the “freebies” and “fees” were justifiable and that my frequent contact with the industry did not affect my practice. Yes, I tended to prescribe the latest antihistamine, proton pump inhibitor, statin, or antihypertensive drug, but what harm was I doing?


The industry uses hospitality to gain contact and influence over doctors


One night, after having yet again been paid £250 by a drug company for speaking at an evening meeting, I was basking in my importance. My wife (a Glaswegian) wasn't so impressed and told me she preferred the snivelling nobody she met 15 years earlier getting £1.80 an hour for pulling pints. It was true—I was becoming the sort of person I had always hated and was being consumed by the money and flattery. Why was I being wooed with lecturing fees, chairing fees, dinners, and trips away?

On reflection, it was obvious. My practice's budget alone was £500 000 a year, and the budget for the local healthcare cooperative area, for which I had some responsibility, was perhaps 10 times as much. A 1% change in the budget was worth £50 000 a year to the drug companies; any money spent inflating my already large ego was trifling in comparison. Many of the other “influential” doctors in the city were getting the same treatment.

Why hadn't I seen this before? As a student I had taken countless pens, eaten many sandwiches, been on “sponsored” nights, and even been given that pinnacle of 1980s chic, a Filofax. I thought that the industry was fantastic and couldn't get enough of its hospitality. As a resident I went with my colleagues to some of the most expensive restaurants in Glasgow and got drunk at the expense of the industry. In general practice my lunch was provided daily by the representatives of the drug companies, we had sponsored practice meetings, and representatives even attended and financially supported our Christmas parties. I had daily contact with the industry. I now feel ashamed of what I did. In my defence I can say only that I was doing what everybody else did and knew no better. I would like to say that this hospitality culture has changed, but I fear that it has not. We all know what is happening and, frankly, I have heard many more blatant abuses of hospitality.

The industry needs us and uses hospitality to gain contact and influence over doctors. Contact is personalised through the friendship of the representatives, and we are beholden whether we like it or not. The industry exploits this relationship and systematically and cynically targets the most important and influential doctors. More direct offers of lectureship fees, consultancy fees, and foreign travel seek to reinforce this “friendship” with medical opinion leaders.

We doctors view the hospitality and flattery as a perk of the job, and we like it. Rather like alcoholic people, however, the profession gets very angry and defensive at anyone who suggests that we might have a problem.

Why does it matter? Resources and money, for one thing. The money for the hospitality comes directly from the public purse, and drug costs in the United Kingdom alone are £9bn ($16bn; €14bn) annually and rising. The money, however, is secondary to the other problems we are facing. As a profession we are complicit in generating a health obsessed population who sit trembling waiting for the next risk factor to be identified and the next “wonder” drug to treat it. We have neutered the healthy, and we are all tumbling towards a polypharmaceutical end.

We complain bitterly about the lack of respect accorded to us as doctors. The current hospitality relationship with the pharmaceutical industry only serves to undermine us still further in the eyes of the public. Deny that you have a bald spot—but don't deny that the drug industry sets the health agenda and influences every sphere of our medical lives.