An old article I wrote

NursePrescribing, 2003, Vol 1 No 3

COMMENT

Freebies, favours and the seven deadly sins: keeping on the straight and narrow

In the editorial of the British Medical Journal, dated 31 May 2003, the writer commented on the avarice and excess that characterize the nature of our professional relationships with the pharmaceutical industry. As avarice is one of the seven deadly sins, this article considers how applicable the others may be to our relationship with the industry.

This article looks at guilt, the nature of greed and the ways in which we, as professionals, can work to make sure that we stay on the straight and narrow. In recognizing that sin is temptation and that we can overcome temptation, we can then consider a way in which we can live alongside our tempters with our eyes and attention fixed firmly to enhancing patient care.

It is, of course, interesting to note that this journal, as with so many others, has only been brought to you today because the pharmaceutical industry is prepared to support its production. We can all say that we do not rely on the pharmaceutical industry, but is that true?

Traditionally the seven deadly sins are listed as:

• Avarice (greed)
• Gluttony
• Envy
• Lust
• Wrath (anger)
• Pride
• Sloth.

Back in the 13th century, Aligheri Dante categorized these into three broad areas which, in turn, gave you an idea of just how badly you were sinning. With huge apologies to the literary creativity of Dante in his Divine Comedy, I will adopt and adapt his categorization.

Excessive self-interest

Avarice

Simply put, this is wanting to make sure that you get your fair share, or maybe just a little bit more to be on the safe side.

You know the feeling when the medical sales representative has been around and you just pop up to reception to see if he left any pens. Maybe you didn’t get one last time and you just want to make sure. Or those times when you went to conference and started going around the exhibitors to see which stand was giving away a plastic carrier bag, so that you had somewhere to put the pens and mouse pads. ‘Oh, and that mug and a couple of journals.’ ‘See the one over there that has some of those little fluffy bugs, and where did you get those mini chocolates from?’ ‘Who did you say was giving away cakes from Betty’s?’ ‘What, someone has got an umbrella?’ ‘Wonder what you have to do for one of those.’

We’ve all been there. I went to a conference earlier in the year and saw a stand with a toy monkey on it. We were just redecorating my son’s bedroom and I thought that would be a lovely little gift for me to take home so that he knew that I had been thinking of him. I greeted the lady on the stand and asked whether I could have a monkey.

‘Are you a prescriber?’ she asked. ‘No, I’m not,’ I replied. ‘Sorry, we are only giving the monkeys away to

people who prescribe or who regularly request supplies of our product.’

She gave the same response to the very nice lady from the National Prescribing Centre. So I went and grabbed a handful of chocolates from another stand.

Gluttony

This is the refusal to accept the natural limits of pleasure and so preserve the natural balance. It can be hard to tell the difference between greed and gluttony. Let’s put it this way. Greed is wanting to get something for free from every drug company representative who walks through the door. Gluttony is wanting to send them out with their pockets empty.

Have you ever seen the people who go up to a stand with their carrier bag and pick up a handful of pens, rather than just the one? That’s gluttony.

Again, think of it from a personal point of view.

How many pens do you really need? What do you do with the surplus? Who is exposed to the adverts as a result?

Other than the proposed solution of buying your own pens (how much do they cost now?), I was fascinated recently to meet with a colleague who had taken an unusual step in redistributing the wealth. She would sand off the logo or other adverts and take pens on holiday with her to Africa and India. Once there, she would distribute the pens to the local schools. Their need was greater than hers.

Lust

How many people have turned straight to this one, dying to know whether I was going to talk about that regional manager who wore the latest designer shades and turned up in a flash car. Or, in the interests of sexual equality, that rather nice brunette from GlobalCorp.

Well, I see lust as the self-destructive drive for pleasure out of proportion to its worth. Another example from my own sins. I was at a conference in Harrogate a few years ago and one of the companies had a competition going. If you could correctly guess what different smells were, then you could win a bottle of champagne.

Let’s just look at this one . First of all, they attracted my greed by doing champagne rather than wine; then they got my gluttony by letting me enter more than once – actually twice a day for all 3 days of the conference. I wanted that wine and would cheerfully, and willingly, stay in the queue at the stand even after the educational sessions had started, so that I could have my go. It meant that I didn’t learn what I had hoped. And on the final day, the chap on the stand, who by this point recognized me, said ‘If you want a bottle of champagne that much, why don’t you just go and buy one?’

Okay, so that made me very cross with the representative (see anger below) but it also made me stop and realize what I had been doing. It wasn’t just the champagne, it was the thought of winning. Well out of proportion with its worth. Lust.

Have you ever missed out on something important to satisfy a personal urge?

Then Dante suggests that we have:

Perverted self-interest

Pride

Pride is in comparing ourselves to others. ‘It should come to me, it’s only right.’ ‘I have worked hard at getting to where I am and have put long hours in.’ ‘I am good at my job and the companies are just recognizing my worth.’

Do you recognize yourself in any of these?

Maybe you’ve implemented a changeover to a more cost-effective product. The new company has recognized the work that you did. We all deserve a bit of recognition and support for the work that we have done, don’t we? However, this is the foot in the door. All medical sales representatives are trained to be your best friend. Our friends recognize our worth, provide support for our self-esteem. But why is the representative your friend?

Envy

Envy is resenting what others receive.

Do you get taken out for nice meals by your sales team? What about your GP colleagues? When you can prescribe, do you think that the food on offer will improve? And we’ve all heard of the doctors going off on conference in Barbados and just playing golf.

Much like the impact of pride in our decision-making processes, feeling real jealousy of what others get generates a strong belief that we should get it too. In turn, this weakens our resistance to doing what is right when deciding whether to accept an offer or not. We are not necessarily doing anything wrong, are we?

I remember a wonderful evening out with work colleagues at a very nice restaurant in a leafy suburb, chilled wine, taxi home, excellent food. Bit of a sales pitch half-way through the evening, but not obtrusive. It was only fair that I recommended their product later that week to say thanks. It didn’t affect patient care badly.

Strange that I would not usually have gone out with those particular colleagues for a meal. But why should they get treated and not me?

Anger

Anger is an impatience with the faults of others.

Anger comes in two ways and is quite a sneaky little visitor: _ We have the anger with a company that does not treat us with the respect that we deserve – don’t they know who we are? Just wait until we can prescribe as well (see pride above). In the example I gave under ‘lust’, my immediate reaction to the impudence of the representative was to delist all the over-the-counter products which that company made. That would show them – ha!

I suppose I didn’t really consider what the patients who chose their product for personal efficacy would

do as a result.

The other side of anger is that which comes with our justification of accepting gifts from the industry. How dare people suggest that you would prescribe or supply simply based on a gift! That’s outrageous. Indeed, a nursing colleague of mine was fortunate enough to be awarded a weekend for two in Paris, after the volume of diabetes monitoring strips she supplied to her patients rocketed to the highest in the primary care trust. How much trouble was I in when I suggested that it was perhaps not appropriate to accept it? After all, we only ever consider patient care and the holiday did not figure into it at all.

Finally, Dante suggests that we have:

Insufficient care

Sloth

Sloth – drifting completely into the sleep of complacency.

It is easy to rely on the information that we receive from our industry colleagues. It is easy to take on trust that we have been supplied with the complete package of evidence. Looking further into a product, and the claims made about it, takes time. It takes effort. No-one can blame us for not always having the time. But what about never making the time?

In England, we are fortunate to have the experience and support of the National Prescribing Centre. Their publications of evidence-based medicines and therapies provide us with a well structured, balanced resource for prescribers. Similarly we have the work done in the production and dissemination of the Cochrane reviews. We should make sure we keep abreast of these, as a minimum, in our areas of expertise and practice.

The temptation factory

The presence of the pharmaceutical industry is a fact of life. No argument there. Without the industry, we would not have the extensive research into, and development of, new life-saving drugs and therapies. However, research has shown that prescribers are more likely to change their prescribing habits based on the influence of a medical sales representative than they are on the advice of the prescribing advisers, despite the latter being impartial and evidence-based.

Proposing a personal resistance framework

Managing to do what is right for the patient, away from the influence of the industry, requires us to do the following:

_ Be aware of what we need our therapy to achieve

_ Engage with the patient in the selection of therapy

_ Monitor outcomes and take appropriate action

_ Monitor our own practice

_ Reflect on the decisions that we make

_ Remember that our capacity for self-delusion is nearly limitless.

So, ask yourself this; when next you are tempted by the pens and mouse pads: Would I spare 25 pence to buy a new pen? If the answer is no, because you don’t need one that much, then leave them with the receptionists.

‘Know Thyself’

Remember sin starts with the sinner, not the temptation. It clouds the conscience and corrupts our judgement of good and evil. To be able to resist, we must be able to undertake thorough reflection and accept our limitations as part of who we are.