by Shaili Jain, M.D. New York, Cambridge University Press, 2007, 160 pp., $66.00.
The author of this book, psychiatrist Shaili Jain, aims to “heighten the reader’s awareness about physician-pharmaceutical industry interactions, the nature of these interactions and their advantages and disadvantages in a variety of medical settings” (p. xvii). The text is in some ways successful and in other ways incomplete.
Overall, Dr. Jain has organized her book logically and engagingly, with an eye toward providing practical information. For example, one chapter (Chapter 9) is entitled “To Sample or Not to Sample? The Use of Pharmaceutical Industry-Supplied Medications in Medical Practice.” Another chapter (Chapter 6) is entitled “Continuing Medical Education: How to Separate CME From Pharmaceutical Industry Promotion.” The latter includes a comparison table labeled “Promotional Programs Versus CME: What’s the Difference?” The author is critical of accepting drug company gifts, but she attempts to convey both sides of the issue.
Dr. Jain has gathered a wealth of references (up to 2006). She even includes an appendix that reprints guidelines of the American Medical Association, Pharmaceutical Research and Manufacturers of America, as well as other bodies, making the book a valuable resource.
On the other hand, despite its wealth of information, the text fails to treat the subject (physician-pharmaceutical industry interactions) with adequate depth. The chapters are studded with vignettes about doctors and pharmaceutical reps, most of whom are caricatures engaged in struggles with their conscience and life stressors. Their pangs, registered consciously, pull them toward or away from gifts and biased advice. While the basic issue of conflict of interest is identified, the unconscious operation of conflict of interest, its power within institutions, and its dynamics in organized professional work are never really explored or explained.
This lack of analytical depth is unfortunate for two reasons. First, conflict of interest is an inherently fascinating topic with psychiatric relevance. It combines aspects of psychology (e.g., perception, unconscious motivations, and the cognitive psychology of decision making) with social and ethical aspects (e.g., concepts of fairness, network influences, professionalism, and strategies of social control, including the law) (1). Issues related to conflict of interest tend to influence many of our social interactions, and physician-pharmaceutical industry interactions comprise a special case from which we can learn a great deal. Second, some of our sharpest current political challenges, as a profession, involve conflict of interest. When the New York Times reported on Senator Charles Grassley"s scrutiny of pharmaceutical funding to psychiatrists and to the APA, the reporter quipped that Grassley had discovered in psychiatry “an orchard of low-hanging fruit.” Psychiatry is on the hot seat. Nevertheless, despite such portents of external control, it is we (psychiatrists) ourselves who possess the inside views of clinical practice and medical culture that are needed in order to shape new standards. To adequately deal with conflict of interest issues, we need as much insight into these issues as possible.
Let me give an example. “Disclosure” and “transparency” are invoked by professional entities, including APA, as the predominant remedy for conflict of interest. Yet if we peruse almost any newspaper, we will see stories about decision makers in medicine, government, and other arenas where the hot-button social issue is not just the lack of disclosure but the underlying conflict of interest itself. In addition, some social science research suggests that disclosure may even paradoxically worsen decisional bias.
Thus, whether to use disclosure as a response to concerns about conflict of interest and then how to implement it both depend upon several variables. Decisions regarding the use of disclosure require an understanding of how the context and method of disclosure might matter, how disclosure might affect the behavior of the discloser, how disclosure might affect the cognitive psychology of decision making by its recipients, and whether disclosure will suffice to address basic notions of social fairness. Such decisions also require an understanding of the institutional setting. These include the constraints upon alternative methods, the stage in an organization’s development of a conflict of interest program, and the likely practicality and group acceptance of the proposed procedures.
In order to deal with such complexities, we need the benefit of both self-scrutiny and in-depth understanding of conflict of interest. Dr. Jain’s book is a good start, yet more is needed.
Challenges and Solutions in Business, Law, Medicine, and Public Policy. Edited by Moore DA, Cain DM, Loewenstein G, Bazerman MH. Cambridge, Cambridge University Press, 2005
Book review accepted for publication August 2008 (doi: 10.1176/appi.ajp.2008.08060937).