Perception of Doctors towards Relationship with Pharmaceutical Industry

Introduction: Doctors and pharmaceutical companies are the major components of the health care system. Their interdependency on such a large scale calls for a better relationship between two stakeholders of the health care system. Most of the time this relationship has a bad impact on the reputation of the prestigious medical profession, as well as, affects the health of the poor patient causing the malafied relationship. Materials & Methods: In order to see how the relationship works in the hospitals of Azad Kashmir, the study was conducted on the doctors of Abbas Institute of Medical Sciences, Muzaffarabad. A mixed type of study was conducted from January through June 2017. In this study, 100 doctors were selected for data collection in the questionnaire method. While three different focus groups involving doctors from different specialties were made. Results: Out of 100 doctors, 36 doctors agreed that the doctors in AIMS are aware of such guidelines, 92 doctors agreed that there is a need for national guidelines to monitor the doctor and pharmaceutical company’s relationship, and 67 responded that doctor's prescription is influenced by the gifts given by pharmaceutical companies, 52 doctors agreed that pharmaceutical companies should be banned from giving gifts to physicians, 88 responded that the information provided by those representatives is only superficial and they don’t know the core information like side effects and mode of action of the drugs, 15 thought that yes it is ethical to accept the gifts from the pharmaceutical companies but only to the extent of samples of medicines. Out of 100, 89 doctors responded in favour of the incorporation of bioethics in the curriculum of the medical education Conclusion: Pharmaceutical companies have hijacked our whole health system to some extent and are polluted because of these Pharmaceutical Company’s representatives. There is a need to ascertain the fact that if this phenomenon is not controlled, in near future we will have to face very severe consequences and our patients will be at the mercy of pharmaceutical companies rather than the doctor.


Introduction
Doctors and the pharmaceutical industry are the two main components of the healthcare system which have been contributing valuable services to the medical profession. Medical sciences and pharmaceuticals are interdependent on each other. Many ethical issues may erupt during interactions between physicians and the pharmaceutical industry, mainly due to conflict of interest. These moral issues might be the suitability of doctors taking gifts and other advantages from the medicine industry that can definitely affect the decision of physicians about the treatment. This state is so astonishing that Arnold Relman a professor from Harvard, and ex-editor of the New England Journal of Medicine said, "the field of physicians is being bought by the medicine industry, not only in terms of usage of medicine but also in times of research and teaching". 1 Unethical drug practices are a common phenomenon around the world, but it is more severe in developing countries. Most physicians don't consider it an unethical practice to accept drug samples and other gifts from Medical Representatives (MRs). 2 Medical representatives visit a doctor's clinic to promote their companies products. They offer drug samples, gifts, and sponsorships for conferences. These are the various ways that drug companies try to influence the doctor's prescription in various ways. 3 Different studies showed that 80-95% of doctors are regularly visited by drug company representatives. 4 Majority of doctors receive gifts from drug companies. Most doctors deny their influence in writing prescriptions by these gifts. 5 According to another study, 6 some doctors admit that drug samples and entertainments offered by pharmaceutical companies influence the prescribing behavior of medications. Pharmaceutical companies interact with doctors to take gifts frequently and it is quite common practice. 7 Therefore, it is the most important moral issue in the medical profession so many researchers give their analytical views about it. 5,8 Even though the behavior of the doctor must not be influenced by the PRD (Physician-Drug Representative) proved by many researchers. 9 These changes result in the development of mistrust between the physician and patient giving little importance to the prescribed prescription. 10 Main advantages of humanizing this type of ethical relationship will not only serve the patients but will also bring positive change in the behavior of doctors as well as in the health care institutions. Mal-practicing in this type of relationship goes on increasing day by day. 11,12 One more important factor was given due consideration to doctors' behavior and their interaction with the medicine industries, therefore, this factor is also a source of information for the doctors. 13 In the light of the above facts there is a dire need of making policies, rules, and regulations that will monitor the relationship between doctors and the medicine industry. Various measures should be taken to undermine the various aspects of moral issues to correct the unconstructive attitude that arises from a change in the perception and knowledge of doctors who are not able to manage the relationship. 15 But the changes that take place are absurd, changes influence the practice of the doctor that including the changes in the prescription writing and knowledge. 13,14 A Physician might act as an advisor for the pharmaceutical industry. This might be in a relationship with a specific product. All the process undergoes like a business deal. If a physician works as an advisor to the pharmaceutical industry, this type of agreement shall be publicly announced. It should be recognized and reported to the concerned authorities who handle the marketing of specific drugs. 15 Some physicians insist on a different type of reward from pharmaceutical industries for prescribing medicine. They never recommend drugs to companies that do not agree to give a handsome amount of money to the physicians as a reward. Immoral drug prescription is in vogue around the globe but it is more prevalent in developing nations. Despite all those guidelines, some doctors are prescribing medicines just for the promotion of drug companies. The condition is worst in Pakistan. Pharmaceutical companies usually spend huge money on sales promotions through medical representatives. However, studies examining the attitude of physicians towards the pharmaceutical industry are lacking in Pakistan. So, more studies are required to highlight the ethical issues and explore explanations for the influence of the practice setting on the physician-industry relationship. This study will assess the opinions of doctors on accepting items of various values from pharmaceutical representatives, whether accepting such items is ethical, and whether they thought accepting such items would influence their prescribing practices. This study will also analyze how the relationships between physicians and drug companies are likely to change in the future. Objective: To assess the Perception of doctors towards the relationship with the Pharmaceutical industry.

Materials and Methods
A mixed study (qualitative and quantitative) was carried out from January through June 2017 at Abbas Institute of Medical Sciences. All ranks of doctors employed in Abbas Institute of Medical Sciences were enrolled in the study after informed consent. Data were collected using the questionnaire method and focus group discussion method. For the questionnaire method, a self-designed and self-administered questionnaire was distributed among the doctors, and a questionnaire was mailed to the participants who were not available for live sessions, and data was collected accordingly. For focus group discussions, three focus groups were constituted and there were 24 doctors from the hospital who took part in the 3 focus groups, each having 8 members. One group comprised of consultants/professors, the second was of postgraduate (PG) Trainees and house job officers, and the third of medical officers. Every group was having doctors from different specialties. Data analysis of the data from the questionnaire was carried out through SPSS and the results were shown in the form of charts and graphs for easy interpretation while in the case of focus group discussions, all the discussions were audio-tapped, and then verbatim transcription was done. After that, each transcript was read carefully and then content analysis of the data was done. Data were coded and themes were extracted and finally, three themes were finalized.

Results
In our study questionnaire was distributed among 100 doctors at Abbas Institute of Medical sciences. For some doctors who were out of reach, questionnaires were mailed to them while for others data was obtained in live sessions. Before evaluating the questions pertaining to the pharmaceutical companies, different demographic characteristics like gender, experience, and specialty of the doctors were assessed. In our study 56 doctors were male while 44 were female, eight doctors were having experience with less than one year, 33 were having experience from one to five years, 31 were having experience from 6-10 years and 28 were having experience with more than ten years. Our study included doctors from different specialties like 16 doctors were from medicine, 15 were from surgery, 13 from obstetrics, 7 from cardiology, 15 from emergency, 4 from the eye, 6 from ENT, and 24 from different other specialties. A summary of the demographic characteristics of the doctors is depicted in the tables below.  In response to the question that whether pharmaceutical companies should be banned from giving any sort of gifts to doctors, 52 doctors agreed with the question while 48 had the view that they shouldn't be banned from giving gifts to doctors. Another very important question was about the information provided by the pharmaceutical company's representatives and out of 100, only 12 were of the view that the information provided by those representatives is most of the time accurate while 88 responded that the information provided by those representatives is only superficial and they don't know the core information like side effects and mode of action of the drugs. Next question was that is it ethical to accept gifts from pharmaceutical companies and out of 100, 15 thought that yes, it is ethical to accept gifts from pharmaceutical companies but only to the extent of samples of medicines while 85 responded against the acceptance of any sort of gifts from the pharmaceutical companies. The last question was about the incorporation of bioethics in the curriculum and out of 100, 89 doctors responded in favor of the incorporation of bioethics in the curriculum of medical education while 11 thought that doctors had enough information and they can decide on their own whether something is ethical or not. After these results, each question was analyzed and depicted in the form of different graphs. Focus Group Discussions: There are 24 doctors from the hospital who took part in the 3 focus groups, each having 8 members. One group comprised of consultants/professors, the second was of PG Trainees and house job officers, and the third consisted of medical officers. Every group was having doctors from different specialties. Doctors clarified that the sole objective of the work was to know about the perceptions of the doctors in relation to interactions with the pharmaceutical industry for the purpose of research. The consent of doctors was also taken for audio-taping of the event.
After the audio-tapping, verbatim transcription of the whole discussion was done. Each transcript was read carefully and then open codes were assigned to them manually. Overlapped data was analyzed to facilitate the modification of emergent findings. After that final themes were selected based on their significance and comprehensiveness. Three themes that were finalized after detailed deliberation were; 1. Doctor-Pharma Regulations 2. Accepting the gifts from Pharmaceutical Companies and the influence of these Interactions on Physicians' drug prescribing Behaviors 3. Changing the prescribing behaviors of doctors Theme 1: Doctor-Pharma Regulations Almost all doctors of the three FG talked about the rudimentary or non-existing regulations on the Doctors-Pharma relationship in the country. Due to this reason, Pharmaceutical Companies and doctors freely make contracts as there is not legally binding. One doctor said that regulation and accountability in Pakistan are only found in papers and not in practice. Most doctors supported his statement. Several doctors highlighted that a few organizations, such as PMDC, Drug Regulatory Authority of Pakistan, and the Karachi Bioethics Group have made some guidelines, but most of the doctors are not aware of these guidelines, therefore are not in the practice. Doctors generally agreed that the regulatory authority has "failed to regulate" and is "not controlling the situation" (FG 1). One reason mentioned for weak regulatory processes may be the devolution of powers from the federal government to the provinces as a result of the 18 th constitutional amendment, 2010), which led to the decentralization of powers (FG3). It was realized that in the absence of government regulation, poor patients are left at the mercy of Pharmaceutical Companies and unethical practices, costing patients unnecessary and wasteful expenditure as well as posing a great threat to the well-being and life of patients. Many physicians expressed that in Pakistan, their interactions with Pharmaceutical Companies were mostly self-regulated by a physician of choice (FG 2). The physicians from almost all levels were interviewed and the results that were observed the interaction of physicians with the pharmaceutical industry is led by their own choice and is largely governed by their own moral sense as well as their principles. In fact, among the whole community one PG trainee confessed that "The policies and codes of conduct are always on the general level but on a personal level the thing that affects the most is your own interest, choices and your own likings and disliking" (FG3). The majority of doctors suggested that "the first step is to make and implement the regulations and control the quackery across the country.
Theme 2: Accepting the gifts from Pharmaceutical Companies and the influence of these Interactions on Physicians' drug prescribing Behaviors The majority of doctors defended that the medical reps could not change the prescribing behaviors of doctors. One doctor said that physicians' prescriptions cannot be influenced by small gifts from pharmaceutical representatives because, as doctors, they are the ones who make their own decisions about the medicines required for treating the patients. Another physician explained that pharmaceutical representatives just present their products, they could not compel for writing their products. Commenting on funding received from Pharmaceutical Companies, one senior consultant told the group that pharmaceutical companies spare almost 20% of the price for doctors. We take the gifts or funds for CME within this percentage. If we will not take the benefit of this, it will benefit the company, not the patients. He also added that doctors all over the world accept gifts and honorariums, not just in Pakistan. Some doctors said they "would never prescribe those drugs which were substandard" (FG 2). Prescribing behaviors of doctors might be influenced by the costeffectiveness of gifts. As one Medical officer explained, "I am not ought to be influenced by the minor gifts that Pharmaceutical Companies offer, however, big deals are more likely to be considerable" (FG 2). Senior consultants admitted that although the Pharmaceutical Companies sponsor conferences and symposia, this does not influence their drug prescribing behaviors, as the "being senior, the more you realize this as a professional relationship" (FG 3). Very few doctors realized that the concept of "give and take" between the doctors and Pharmaceutical Companies is not ethical and it affects patients badly (FG 1). Some doctors agreed that there are "physicians who are involved in this blame game don't even realize what they are doing wrong" and will have negative publicity in the future. (FG1).

Theme 3: How the prescribing behaviors of doctors can be changed?
Different groups suggested different views to change the prescribing behavior of doctors. Most doctors urged the Importance of Bioethics Education in medical college. One physician said that "20 years ago medical students didn't even know the word bioethics" in Pakistan, now people are talking about the incorporation of this field into the curriculum (FG3). They were of the view that current medical professionals are involved in unethical practice because they were not taught medical ethics in their courses. The doctors suggested that bioethics should be mandatory at the grassroots level when students "get interaction with the Pharmaceutical Companies from 3rd year onward" (FG1). One consultant said that ethical teachings should be reinforced throughout the career in the medical profession and there should be refresher courses on "moral and cultural values" (FG2). A few doctors suggested that enforcement of Law, regulation and accountability could be helpful to change the prescribing behavior of doctors, but most of the doctors were not in favor.

Discussion
Doctors and the pharmaceutical industry are the two main components of the healthcare system which have been contributing valuable services to the medical profession. Medical sciences and pharmaceuticals are interdependent on each other. Many ethical issues may erupt during interactions between physicians and the pharmaceutical industry, mainly due to conflict of interest. Unethical drug practices are a common phenomenon around the world, but it is more severe in developing countries. Most physicians don't consider it unethical to accept drug samples and other gifts from Medical Representatives. An immature attitude toward working among various sectors of health care units may be the root cause of disagreement between doctors, and it will in turn distress the main principle of these institutions. The medical institutions and clinics are highly saturated by the effect of the drug industries this impact are highly influential in all other health-related areas and the doctors are the main concern. This business is observed to have aptitude in developing focused associations with doctors by giving them the required things for the sake of clinical consideration related to CPD exercises in the form of advantages and privileges for persuasive doctors. Furthermore, the shortfall of administrative guidelines in the medical care area, and the weak implementations of the policies exist highly entertaining. These policies gap make space for industries to direct their terms with doctors and the doctors feel no difficulty or hurdle to accept their proposals without the fear of any action against them. In addition to this, the educational institutions have likewise surrendered their space to the business, since it is a willing wellspring of financing with enormous assets. The additional efforts needed to assemble support from these institutions are considered excessively impressive, so the industry has many more options to avail. However, during the research study, the most alarming situation is observed that some people in the medical profession have the guts to discourage the influence of the pharmaceutical industry in the healthcare sector. The situation that is prevailing in Pakistan is now considered a part of the norm and culture so the people who discourage these behaviors feel difficulty in challenging this so-called culture. Our current study was a mixed study (qualitative and quantitative) which was carried out at Abbas Institute of Medical Sciences, an affiliated hospital of AJK Medical College Muzaffarabad. Data were collected using the questionnaire method and focus group discussion method. In our study questionnaire was distributed among 100 doctors at Abbas Institute of Medical sciences. For some doctors who were out of reach, questionnaires were mailed to them while for others data was obtained in live sessions. First of all, the demographic attributes of the doctors were studied. In our study 56 doctors were male while 44 were female, eight doctors were having experience with less than one year, 33 were having experience from one to five years, 31 were having experience from 6-10 years and 28 were having experience with more than ten years. Our study included doctors from different specialties like 16 doctors were from medicine, 15 were from surgery, 13 from obstetrics, 7 from cardiology, 15 from emergency, 4 from the eye, 6 from ENT, and 24 from different other specialties. After the demographic characteristics of the doctors, responses given by the doctors to different questions from the questionnaire were analyzed. Every question from the questionnaire was analyzed on two different grounds i.e. gender of the doctors and experience of the doctors as these two factors can have an effect on the questions asked in the questionnaire. When asked about the awareness of the doctors regarding guidelines for accepting gifts from pharmaceutical companies, 36 doctors (Gender: Male = 21 and Female = 15) (Experience: less than one year = 2, 1-5 years = 9, 6-10 years = 12 and more than 10 years = 13) agreed that the doctors in AIMS are aware of such guidelines while 64 doctors (Gender: Male = 35 and Female = 29) (Experience: less than one year = 6, 1-5 years = 24, 6-10 years = 19 and more than 10 years = 15) thought that the doctors are unaware of those guidelines. These results stated that doctors are aware of the fact that there are certain guidelines regarding the acceptance of gifts from pharma companies but these regulations are very frail that most of the doctors are not willing to follow those guidelines. In our study also 36% of the doctors knew that there are certain guidelines for acceptance of gifts from pharmaceutical companies but they were unwilling to follow those guidelines as these guidelines were not strictly adhered to in our country. 16 Out of 100 doctors, 92 doctors (Gender: Male = 53 and Female = 39) (Experience: less than one year = 4, 1-5 years = 31, 6-10 years = 30, and more than 10 years = 27) agreed that there is need of national guidelines to monitor the doctor and pharmaceutical company's relationship while 8 (Gender: Male = 3 and Female = 5) (Experience: less than one year = 4, 1-5 years = 2, 6-10 years = 1 and more than 10 years = 1) responded that the prevalent guidelines should be strengthened and implemented in their true sense so that the relation of doctor and different pharmaceutical companies can be monitored. These results showed concurrence with the study whose results were that in developing countries health authorities don't have dependable rules and they don't have their own research models and depend on the research models of the western countries, so Pakistan being a developing country showed similar problem as identified in our study. So there is a need to have our own research model based on which we should have our own guidelines that are implementable in our country. 17 For the question that whether the prescription of doctors is influenced by getting different gifts from the pharmaceutical companies, 67 (Gender: Male = 36 and Female = 31) (Experience: less than one year = 5, 1-5 years = 19, 6-10 years = 22 and more than 10 years = 21) responded that yes this might be the case while 33 (Gender: Male = 19 and Female = 14) (Experience: less than one year = 3, 1-5 years = 14, 6-10 years = 9 and more than 10 years = 7) were of the view that doctors have their own prescription and is not influenced by the gifts of pharmaceutical companies. Our results were exactly in correspondence with the study that carried out the meta-analysis of 19 studies and found out that 15 out of 19 studies showed the relationship between accepting gifts from pharmaceutical companies and the rate of prescription of drugs by that company. 18 In response to the question that whether pharmaceutical companies should be banned from giving any sort of gifts to doctors, 52 (Gender: Male = 27 and Female = 25) (Experience: less than one year = 4, 1-5 years = 14, 6-10 years = 15 and more than 10 years = 19) doctors agreed to the question while 48 (Gender: Male = 29 and Female = 19) (Experience: less than one year = 4, 1-5 years = 19, 6-10 years = 16 and more than 10 years = 9) had the view that they shouldn't be banned from giving gifts to the doctors. Another very important question was about the information provided by the pharmaceutical company's representatives and out of 100, only 12 (Gender: Male = 7 and Female = 5) (Experience: less than one year = 3, 1-5 years = 4, 6-10 years = 2 and more than 10 years = 3) were of the view that the information provided by those representatives is most of the time accurate while 88 (Gender: Male = 49 and Female = 39) (Experience: less than one year = 5, 1-5 years = 29, 6-10 years = 29 and more than 10 years = 25) responded that the information provided by those representatives is only superficial and they don't know the core information like side effects and mode of action of the drugs. Our results showed an almost similar percentage of respondents who responded that the pharma representatives don't have accurate information about the medicines. So, these representatives don't have the exact information about the probable side effects of the drugs and the mode of action of the drug and it is inappropriate to rely on their information while prescribing a certain drug. 19 Next question was that is it ethical to accept gifts from pharmaceutical companies and out of 100, 15 (Gender: Male = 8 and Female = 7) (Experience: less than one year = 5, 1-5 years = 4, 6-10 years = 4 and more than 10 years = 2) thought that yes it is ethical to accept the gifts from the pharmaceutical companies but only to the extent of samples of medicines while 85 (Gender: Male = 48 and Female = 37) (Experience: less than one year = 3, 1-5 years = 29, 6-10 years = 27 and more than 10 years = 26) responded against the acceptance of any sort of gifts from the pharmaceutical companies. Results of our study were 15% who considered it ethical to accept gifts which shows in their study that out of total doctors participated in the study 25 % thought that it is suitable to accept gifts from pharmaceutical companies. 20 The last question was about the incorporation of bioethics in the curriculum and out of 100, 89 (Gender: Male = 49 and Female = 40) (Experience: less than one year = 4, 1-5 years = 30, 6-10 years = 29 and more than 10 years = 26) doctors responded in favor of incorporation of bioethics in the curriculum of the medical education while 11 (Gender: Male = 7 and Female = 4) (Experience: less than one year = 4, 1-5 years = 3, 6-10 years = 2 and more than 10 years = 2) thought that doctors had enough information and they can decide on their own whether something is ethical or not. A study on the inclusion of bioethics in the curriculum involved students from both private and public medical colleges and as per the results of that study, 57% of students from private medical colleges had some information about bioethics, and 43% of students from public medical colleges had information about bioethics and these results strongly recommend the addition of bioethics in the curriculum and our study 89% doctors did support the incorporation of bioethics in the curriculum of medical colleges. 21 In the case of focus group discussion, 24 doctors from the hospital took part in the 3 focus groups, each having 8 members. One group comprised of consultants/professors, the second was of PG Trainees and house job officers, and the third consisted of Medical officers. Every group was having doctors from different specialties. Doctors clarified that the sole objective of the work was to know about the perceptions of the doctors in relation to interactions with the pharmaceutical industry for the purpose of research. The consent of doctors was also taken for audio-taping of the event. After the audio-tapping, verbatim transcription of the whole discussion was done. Each transcript was read carefully and then open codes were assigned to them manually. Overlapped data was analyzed to facilitate the modification of emergent findings. After that final themes were extracted from the data. Three themes were; Doctor-Pharma Regulations, Accepting the gifts from Pharmaceutical Companies and the influence of this interaction on Physicians' drug prescribing Behaviors, and changing the prescribing behaviors of doctors. As far as theme-1 is concerned, FG-I inferred that although there PMC, Drug regulatory authority of Pakistan, and Karachi Bioethics group but these organizations have failed to make the doctors adherent to the guidelines or regulations set for their relationship with pharmaceutical companies. FG-II stated that every physician had some interaction with the pharmaceutical companies and that is totally selfregulated and is not governed by any regulation or guideline. FG-III was of the view that every doctor builds some relationship with the pharmaceutical companies keeping in view his/her own interest or benefit. After listening to the discussion of all the FGs, it can be concluded that in order to make a transparent and privileged relationship of doctors with pharma companies there is a dire need that the regulations and guidelines for these types of relationships must be reconsidered and should be made strict to the level that every doctor is bound to abide by the rules and regulations set by a certain regulatory body. The second theme was "accepting gifts from pharmaceutical companies and the influence of this interaction on physician's drug prescribing behavior". In this theme, there were different responses from the doctors of all the focus groups. From FG-I very few doctors realized the fact that it is not ethical to have such a relationship with pharmaceutical companies and they also don't think in doing so and prescribing the wrong medicine will have a worse impact on the patient. FG-II doctors were happier with the bigger gifts and said that smaller incentives will not affect their prescription of medicine, however, they can consider only if the gift is of higher or better value. And the FG-III doctors were of the view that the relationship with pharmaceutical companies is just a professional relationship and they will not even think to harm their reputation which they have earned after so many years of hard work just to please pharmaceutical companies in return for gifts. So this theme had different answers from all the focus groups and there should be a stringent policy of monitoring health professionals who have malafide relationships with pharmaceutical companies. Third and the final theme was changing the prescribing behavior of doctors. The crux of the discussion of all the focus groups was to incorporate bioethics in the curriculum of MBBS so that when in practice they have to face these pharmaceutical companies, they should be equipped with enough knowledge of ethics and regulations regarding these types of relationships with the pharmaceutical companies. This will enable them to value their patients and their own hard work of lots years rather than depending on the pharmaceutical company's representatives.

Conclusion
Pharmaceutical companies have hijacked our whole health system to some extent. They have representatives who are trained in a way to convince the doctors to give benefits to the companies and they also give huge remunerations to the doctors in the form of gifts like drug samples, lunches, foreign visits, clinic or home decorations, and accessories, etc. Recommendations: There are no boundaries marked for the doctors in acceptance of gifts from pharmaceutical companies. The regulations to monitor the relationship of doctors with the pharmaceutical companies are so frail that they are unable to stop this catastrophic situation. Similarly, it was also found that the understandings of ethical codes and considerations are so meager. There is a dire need to incorporate certain bioethics and the regulations regarding these types of relationships with pharmaceutical companies in the curriculum of medical education so that our future doctors will be able to tackle the inappropriate policies of these pharmaceutical companies. Monitoring of mal-practioner is important and need of the day.