The paper deals with the Romanian consumer’s profile, analyzed in terms of household expenditure structure, by main destinations for food,non-food, services and taxes components, and household’s consumption, in terms of size and structure of food consumption. Synthetic images of quantitative parameters were made using national and international statistical data, between 1991 and 2009. We took into account the total expenditure of households, total consumption expenditure, the structure of monetary consumption expenditure, the average consumption of main food products, in structure and dynamics. Diagnostic analyses were performed by multi-annual approach of these indicators, important warning signals in the evolution of the household consumption. The multi-country and multi-annual benchmarking contributes to the highlighting of the national consumer profile, compared to those of the other 30-40 countries. These issues underline the extent of the economic crisis seen by the national households like an influence in shaping the consumer’s mentality.health industries; relationship marketing for healthcare organizations

CRĂCIUNAŞ, Diana

CRĂCIUNAŞ, Sorin

English

Research Papers in Economics

23
DANCING WITH THE PHARMACEUTICAL INDUSTRY –
MEDICAL PRACTICE BETWEEN ETHICS AND BUSINESS
Sorin C. CRĂCIUNAŞ, M.D. 
Neurosurgery Department, Toronto Western Hospital, 
University of Toronto, Canada
Diana V. CRĂCIUNAŞ, Lecturer Ph.D. 
Faculty of Finance and Banking
Spiru Haret University, Bucharest
Abstract
The relation  between  physicians and  the  pharmaceutical companies 
has been increasingly discretted issue over the last several years. 
Moreover,  such  relations  have  been  proven  to  influence  the 
prescribing  patterns  to  stimulate  drug  supplying  within  hospitals,  to 
encourage  publications  and  research  articles  and  even  to  contribute  to 
critical article non-publication.
There is a complex relation between physicians, medical organizations 
and  academic  departments,  on  the  one  hand  and  industry  on  the  other. 
Therefore, industry makes its living from the physicians prescriptions and 
from the devices and services they purchase. 
Yet  physicians,  medical  organizations,  and  academic  departments 
commonly receive money and other benefits from the industry.
This  paper  reviews  specialist  literature  and  addresses  the  real 
dimension  of  the  physician-health  related  industry  worldwide  interaction. 
Unfortunately, Romania has not provided any data yet, because this issue has 
not been officially analyzed in our country.
Key-words: health industries, relationship marketing for healthcare 
organizations
JEL Classification: I11, I18, M31
 Background
A  growing  body  of  literature  continues  to  seriously  question  the 
correctness of most types of physician–industry relations and to suggest ways to 
remove them. So for, physicians have continuously and faithfully preserved their 
partaking  of  industry  generosity because they consider themselves too smart to 
have their medical decision influenced by industry’s marketing strategy (Rutledge 
P., 2003). This approach has survived although it is not factually supported and is 
highly arguable. According to an axiom that is hard to grasp when dealing with 
health related industries all industries have one purpose: to make money (Goldratt 
E., 2004). No professional ethics can obstruct this aim. 
These legends and similar ones persist in spite of an extensive and broadly 
accepted  body  of  literature  that  categorically  shows  that  industry–physician 24
conflict  of  interest – including  industry’s  expanding role  in continuing  medical 
education (Spingarn, Berlin, and Strom 1996) – increases the cost of healthcare to 
the  detriment  of  the  public,  the  medical  profession,  and  the  patients  (Wazana, 
2000). In order to face and maybe to repel the physician-industry relation concerns, 
the  American  Medical  Association  (AMA),  the  pharmaceutical  industry,  and 
medical  organizations  have  formulated  guidelines  to  deal  with  such  concerns 
(America, 2004; Popp et al., 2004; Association, 1998). On the other hand, a closer 
look  at  these  guidelines  reveals  their  bran  interpretation  possibility.  Conflict  of 
interest  has always been a part of medicine.   With  every patient treated,  every 
physician it involved in a conflict of interests (Tonelli, 2007).
Literature provides a lot of information on industry’s attempts to maneuver 
physicians  away  from  their  responsibility  to  serve  the  best  interests  of  their 
patients. In the end, it is physicians who, as gatekeepers, control industry’s success 
through  the  prescriptions  they  give  and  the  devices  they  procure.  Undoubtly, 
industry uses large amounts of money to persuade physicians, but by means of a 
technique that makes physicians consider that they are not being influenced (Chren, 
1999). A 2006 report by Steinman and associates deals with the precise issue of 
Parke-Davis’s  illegal  marketing  of  its  medicine  Neurontin  for  off-label  uses 
(Steinman et al., 2006). More than $40 million were spent on marketing the off-
label use of the drug to physicians. This activity was illegal. Prescriptions for off-
label use climbed. Much of the marketing campaign involved activities with hidden 
marketing intention such as funding for speakers bureaus and key opinion leaders. 
Unexpectedly, the industry – pharmaceutical and device – acts like any other for-
profit entity, seeking. The interesting part, though, is the extent in which industry 
hazes the distinction between marketing and education (Steinman et al., 2006) and 
lucrative investments the physicians naïvely facilitating the industry efforts. 
The physician perspective
For  physicians  industry  is  a  stimulating  environment.  It  is  unfair  to 
generalize and say that every physician has the same motivations when dealing 
with industry, but it is important to evaluate a few persuasive ones, one or more of 
which may be relevant to a particular individual.
Firstly,  the  doctors  may  see  themselves  as  being  entitled  to  whatever 
industry offers them (Hayashi, 2001). This sense of entitlement could have more 
reasons. Sometimes, they believed they worked very hard and that those freebies 
were a proof of the  company’s appreciation. The  gifts continued and  increased 
during residency and practice –  lunches brought in  by  medicine representatives 
during  a  seminar  about  a  new  treatment,  or  simply  as  an  opportunity  to  eat 
conveniently. 
Consistently,  industry  speakers  support  the  physicians’  prescribing 
behavior by affirming that it is an affront to physicians’ intellect even to suggest 
that  their  honesty  can  be  bought  for  a  dinner  or  a  pen.  If  prescribing  patterns 
(Greene, 2007) and, perhaps, personal features are promising to a company, they 
may be invited to a resort for an “advisors” summit or the like – some way to raise 25
the ante toward further eliciting our thanks in the form of more prescriptions for the 
company’s products and, maybe, becoming a company presenter to help persuade 
others to recommend more of these drugs. 
A  second  possible  reason  for  the  physician  –  industry  interaction  is 
recognition.  Many  of  them  enjoy  to  be  acknowledged  as  experts,  and  when 
industry turns them into experts by choosing one of them on the circuit, his name 
and sometimes his photo are printed in programme. When he speaks at a meeting, 
fellow physicians come to hear him. This can be an exciting feeling. Then, they are 
sometimes tapped as key opinion leader and think that this makes them special, 
although this acknowledgment makes it obvious that they have been converted into 
salespeople for industry (Network, 2004). 
 By responding to the acknowledgment industry arranges for physicians, 
they are helping industry to cover sophisticated marketing techniques under the 
appearance of teaching. Some of them may be so good at what industry gets them 
to do that they are invited to be on a company’s scientific advisory board. This 
recognition makes them believe that they are even more allowed to expenses from 
industry because, after all, the statement advice entails that they are using their 
knowledge and intelligence to assist the company. Actually, they may think that 
they  are  entitled  to  large  payments  for  being  on  this  advisory  board.  Although 
industry does have physicians who provide them with essential guidance regarding 
drug  development  and  marketing,  many  industry  scientific  advisory  boards  are 
simply  ways  to  set  up  appreciation  and  enhanced  allegiance  among  renowned 
physicians. Industry’s business policy is to convert its “advisors” into salespeople.
The  companies  the  advisory  boards  of  which  consist  of  world-wide 
members are even more inspired, because they are organize board conferences in 
remote  and  interesting  places.  The  international  acknowledgment  for  advisory 
board members is even puffier. Physicians may believe they are entitled to money 
and fancy trips, but they are not aware of the fact that by accepting the money and 
the trappings, they generate conflict, and contribute to expensive drug prescription, 
to uncertified device purchase, and to non-evidence-based tests ordering. All these 
increases the patients’ expulses and the cost of health. Why would industry spend 
millions of dollars on such as honoraria, traveling, and on steak dinners for the 
attendees if industry did not know that such expenditures world lead to more drug 
prescriptions or to increased device purchase? (C., 2004).
Another reason underlying the physician-industry relation is the sense of 
belonging that such a relation creates. For the individual practitioner, an invitation 
to  a  fine  steakhouse  for  dinner  provides  the  chance  to  mingle  with  colleagues 
whom  the  company  believes  are  worth  inviting.  The  sense  of  being  special  is 
created by the company. Moreover, he has the chance to mingle with the out-of-
town speakers. Physicians who do not care to partake of industry’s largesse face a 
particularly difficult problem because attendance to meetings and interacting with 
colleagues is part of physicians’ professional responsibilities and necessary often 
simply for them to do their jobs.
A  fourth  reason  for  physicians  to  go  into  and  preserve  relation  with 
industry, which is, in fact, the underlying reason is money. Industry pays them for 26
being    speakers,  for  participating  in  an  advisory  board,  and  for  giving  advice. 
Perhaps they believe that the inexorable decrease in reimbursement for our medical 
services is a good reason to accept some money from the industry to offset what we 
believe is inequitable loss of practice income. Or, they may believe that what they 
are doing for industry is a service to medical profession and to the colleagues who 
come to hear them speak. At any rate, they like money. They even like the indirect 
benefits that they do not receive as cash: receptions and dinners paid for by the 
industry, or tax-excerpt courses or courses requiring a reduced registration fee. All 
these benefits mean money they do not have to spend 
Industry perspective
Their bottom-line duty is to augment value to their stockholders: to make 
money (Goldratt E., 2004). If a company sells soap, refrigerators, drugs, or medical 
devices, the stockholders want to see profit. If a company makes what seems to be 
an altruistic donation, it is a business-centred act. The gift may do some good in a 
community  or  in  other  ways,  but  the  company’s  stockholders  do  not  want  the 
company  to  act  like  a  charity  entity  and  to  spend  money that  has  no  business 
purpose. What is, then, industry buying with some of the $57.5 billion it spends 
annually on marketing to physicians – $ 61,000 per physician – or nearly twice as 
much as the expenditure for research and development?
Industry buys access, authority, and appreciation. These are knotted. When 
a company sets up a steakhouse dinner reunion, it needs a lecturer to make the meal 
simply  incidental  to  a  didactic  activity  and,  therefore,  tolerable  under  various 
physician–industry gifting guidelines.
Companies do much of their marketing to physicians by means of their 
ever-increasing influence on CME and through payments or gifts to both physician 
teachers  and  meeting  attendees.  In  2006,  industry  covered  the  cost  of  61%  of 
Continuous Medical Education Courses in US, spending nearly $1.45 billion, or 
more than three times what it spent in 1998. In the circumstance of advancing its 
shareholders’ joint interests, this activity is simply business motivated. 
Industry aims at leaders because of their reputation and the admiration held 
by their colleagues. In academia, there are verdicts on pharmaceutical formularies 
and on research projects and policies that industry has an interest in influencing 
and  that  academic  institutions  should  have  an  interest  in  keeping  free  from 
industry’s  influence  (Ehringhaus  et  al.,  2008;  Rothman,  2008).  In  professional 
organizations, the clinical care guidelines they create are an attractive prey for the 
industry; having grateful committee members on these guideline panels can yield 
positive results to industry’s products (Steinbrook, 2007). 
Academic perspective
Academic physicians author many of the articles published in journals and 
they are involved in research that may be of interest to industry. Thus, academic 
departments are high importance targets  of industry  and are  lured by the same 27
stimulus  as  their  faculty  and  community  physicians  –  entitlement,  recognition, 
belonging, and money – to become comfortable with industry representatives.
It  may  be  a  visiting  professor  agenda  that  industry  is  enthusiastic  to 
sponsor.  Finally,  the  department  has  to  fight  to  meet  its  financial  plan  and 
industry’s  money  is  simply  money  that  the  department  will  not  have  to  spend. 
Maybe the company offers money for the department to test a new device or to join 
in a clinical trial. These examples are ways in which industry can gain influence 
with the chair and faculty of the department and with its house staff. 
Campbell and associates surveyed  department chairs at medical schools 
and at US’s 15 largest teaching hospitals (Campbell et al., 2007). Sixty per cent of 
chairs had some form of personal relation with the industry such as being a paid 
consultant or a scientific advisory board member or participating in a speaker’s 
bureau. In addition, some 80% of clinical departments had one or more connections 
with  industry,  including  funding  for  food  and  for  CME.  Most  chairs  did  not 
perceive anything wrong with these personal or departmental affairs. 
Conclusions
Even though industry has brought to market many of the products that have 
helped improving  medicine, there is major concern and strong confirmation that 
industry’s successful marketing tactics have entailed an unreasonable increase  in  
the cost of health. Individual physicians have proven to be sitting targets for the 
pharmaceutical and device industry and it is least likely to change their behavior, 
unless  bold  steps  are  taken  in  order  to  support  and    even  to  implement  such 
changes.
In the end, it is essential to reiterate that this perspectives does not put an 
end to the physician-industry relation. On the other hand, we hope that physicians 
will  identify their physician-industry voluntary financial relations for  what they 
are: a conflict of interests over their responsibility to patients and to the public. The 
difference needs to be made, though, between interactions that have very specific 
aims, goals that stand to our patients’ and public advantage and those that simply 
increase the cost of care through encouragement of needless drugs and tests or the 
writing of prescriptions for costly drugs when a less expensive one is just as good. 
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ACCF/AHA consensus conference report on professionalism and ethics,

Conflict of interest in clinical practice,

Do doctors rely on pharmaceutical industry funding to attend conferences and do they perceive that this creates a bias in their drug selection? Results from a questionnaire survey, Pharmacoepidemiol Drug Safety 12:663-667,

Free meals from the pharmaceutical industry.

Guidance for guidelines,

Institutional academic industry relationships,

Medical Association, Updated clarification on opinion E-8.061: gifts to physicians from industry,

Narrative review: the promotion of gabapentin: an analysis of internal industry documents,

Pharma goes to the laundry: public relations and the business of medical education, Hastings Cent Rep 34:18-23,

Pharma Marketing, Key opinion leader,

Pharmaceutical marketing research and the prescribing physician,

Physicians and the pharmaceutical industry: is a gift ever just a gift?

Research and Manufacturers of America, PhRMA code on interactions with healthcare professionals,

Responses of medical schools to institutional conflicts of interest,

The goal: a process of ongoing improvement,

When pharmaceutical manufacturers' employees present grand rounds, what do residents remember?

DANCING WITH THE PHARMACEUTICAL INDUSTRY – MEDICAL PRACTICE BETWEEN ETHICS AND BUSINESS

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DANCING WITH THE PHARMACEUTICAL INDUSTRY – MEDICAL PRACTICE BETWEEN ETHICS AND BUSINESS

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