PracticalDermatology

It’s probably a sign of the times: Working with pharma used to be very easy, but these days, there are compliance issues with what can be done and how much money can be spent on working with a physician. In terms of seeking opportunities for industry collaboration, the dynamics have changed considerably there as well because pharma’s very firewalled off now, and marketing and medical affairs don’t interact. This shifting landscape presents new ethical implications for both dealing with pharmaceutical reps in the office and for working with industry in the role of speaker, consultant, or researcher.

Ethical Relations With Sales Reps

Maintaining ethical and professional relationships with pharmaceutical sales reps starts with accepting that there’s a new pharma. As I wrote in an opinion piece on the topic, “This is not your father’s pharma.¹” Unfortunately, I think the days of the sales reps are numbered. They really can’t do anything – they can’t buy lunch, they can’t talk off script, and for anyone who wants to be involved in promotional speaking or doing trials, all the sales rep can do is introduce you to someone that they can’t be in the same room with.

There are still some old-school derms who will flirt with reps to get something out of it or extort the reps with their writing volume. They hold them hostage and say, “If I don’t get invited to be a speaker or get invited to an advisory board, then I’m going to stop writing your drug.” There’s still a lot of quid pro quo out there, and that’s bad news. It’s the small percentage of docs who do that who give us all a bad image.

Of course, sales reps can be aggressive, too. They are taught how to close a sale, but the idea that a sales rep has a right to be pushy is obviously going to be met with resistance. Some reps come into the office and say, “I have a contest” or “I have a quota” or “You’re writing too much of the competitor.” That always meets with resistance, and no one’s going to fall for that.

In the past, I’ve had reps say, “You’re not helping me. I need you to write more or I cannot make you a speaker.” My response was, “I don’t need to do anything, and the more you push like that, it’s not a good look for the company.”

On the flip side, you’ll have reps who come in and make a lot of small talk or spend so much time buttering up the staff that you don’t get to hear the core message.

Reps should be polished and polite and maintain a certain etiquette in the office: They can’t come in, call you by your first name, or talk about prescription volume in front of patients. If you have a room full of patients and they see you talking to drug reps, they may be thinking it’s taking more of their time. Or, if they see a drug rep bring in lunch, they might think, “Oh great, I’m going to get the prescriptions for the drug from that rep.”

By the same token, it’s up to us to be considerate and give reps the time necessary to discuss their product and not treat them as a caterer or an avenue to break into medical education.

I have the reps make appointments so I know when they’re coming, and we meet in a conference room out of view from patients. It’s important to keep the discussion professional and focused on a new study or patient resources, for example.

Being ethical means following standards that are set for any kind of business, but also being professional, especially when there’s an age difference or a gender difference. Plus, you never know who’s a whistleblower nowadays, and some rep could be in the office taking notes or recording things that could lead to serious consequences. There are some physicians who get themselves trapped, especially if they’re flirtatious or looking for some sort of secondary gain. It comes back to bite them.

Working With Industry and Managing “Conflicts”

Unfortunately, physicians who do clinical research or consulting are often held to different standards of ethics as well as potential conflicts of interest. The ethical dilemma boils down to: Are you really doing something wrong by working with industry? That’s the bias that a lot of people have – they automatically think if you’re a consultant for industry or doing research trials, then you’re guilty of doing something wrong, which is false.

For many docs in these roles, what they’re doing is part of their career and is based on trying to move things forward in the field. If I’m tapped to speak on my expertise, and it involves research with pharmaceutical agents, why is that a crime? But that’s the way many people view it.²

With guideline committees, for example, there’s all this discussion of “so-and-so shouldn’t be on a guidelines council” or a paper because they’re conflicted with industry. Well, what comprises conflict? If I’m doing research and I’m unbiased in who I’m doing research with, how does that make me biased? If I’m only doing research with one product and I’m promoting that product, then sure, that makes me conflicted, and I should be taken out of the equation. But if I’m doing unbiased clinical research in controlled settings, how does it make me conflicted in my ability to discuss the guidelines of care for patients?

The result of that sort of gatekeeping is inferior promotional guidelines. I’ve seen this with acne and with eczema – some friends of mine were dismissed from panels because they were consultants for industry doing research trials. Those who aren’t involved in this work might say they’re not conflicted with industry, but you’re still biased if you’re calling other people conflicted without basis.

I think the bias against physicians working with pharma is a very severe form of prejudice. There’s also hypocrisy involved. For example, say you’re attending a meeting that received a lot of industry support; should there be two sets of dues and registration fees if you’re strongly biased against industry? If you’re going around saying industry’s bad and that people who work with industry are unethical, why should you accept the discounted registration that’s been built from industry support? That’s a total double standard. People like that who are outspoken and feel strongly against working with industry shouldn’t be accepting industry support.

There are extremes on either side – there’s the extreme of going all in and wanting everything from pharma versus wanting nothing to do with pharma. Those extremes are not healthy, and part of it stems from our training programs –many of the residency programs are not allowed to have access to pharma or industry. You can imagine what that does when you lock people up and take away their ability to have judgment. They’re either going to go one way or the other.

Becoming an Ethical Thought Leader

For physicians interested in industry collaboration, it comes down to: What do you want to get out of your career? If I’m mainly working on trials and I get invited to do promotional speaking, I might think that’s going to make me look conflicted for my research trial. But at the same time, it’s a good source of revenue and can also provide a good balance to your career. Ultimately, you want to do what’s going to make sense to you, but you have to approach it in a fashion that doesn’t look like you’re trying to get something out of it.

Remember: The sales reps can’t help you get into speaking. There’s this new role of thought leader liaisons that have come up in the last decade, who are now working primarily at conferences and promotional programs. And medical affairs people with advanced degrees who are heavily involved with medical education and clinical trials.

When young dermatologists come to me and ask how to get involved with speaking, for example, the first thing I tell them is: Write your own lecture that is disease- and therapy-based and not related to brands or products, and present at a CME meeting where you can submit an abstract and prove you have something unique to offer. That way, you develop relationships and create a niche in an area you are passionate about, and then people will come to you with opportunities rather than you having to seek them out.

1. Bhatia N. Dermatology and virtual realities with industry: It’s not your father’s pharma anymore. SKIN: J Cutan Med. 2020;4(4):309-311.

2. Bhatia N. Don’t just rent your opinion… own it. J Clin Aesthet Dermatol. 2020;13(7):12–16.