By BRAD FLANSBAUM

Not long back, I departed a pharma-sponsored research project. I based my decision to leave in something I occasioned over a decade ago. I thought it was time to share the episode and the lessons learned given the attention being paid to physician conflict of interest nowadays (as well as the annual Open Payments review and dispute period approaching).

When I finished training, very few docs practiced hospital medicine—or even knew what the term hospitalist meant. Several forward-thinking medical centers hitched their wagons to the hospitalist model, as did some astute information technology and staffing companies.

However, few healthcare players embraced the hospitalist movement in a serious fashion like the pharmaceutical industry. They realized hospitalists prescribed a narrow band of products, in big lots, within a centralized location. The higher ups in the pharma sector saw the benefits in directing reps our way.

Consistent with those goals, a physician leader at a large pharmaceutical company wished to capitalize on the new trend with the aim of securing a hospital doc to speak to his sales team. He got my name, given my early involvement in the movement, and searched me out. He dialed me up and politely made me an offer to come chat with his groups and enlighten them of “all the great stuff happening in my field.”

The subject would not be a lot of acute conditions unique to ward-based practice or a clinical approach to a single disease, but a view into the hospitalist fishbowl. He wanted a primer on inpatient medicine and how hospitalists operated on the floors. He also requested some background on how we differed from ambulatory and house docs, the nature of our interactions with specialists, and how we made decisions regarding medication use and our role on the pharmacy and therapeutics (P&T) committee.

Because of my enthusiasm for inpatient medicine (obviously, I was far from impartial), and knowing collaborations with pharma reps would occur irrespective of my cheerleading, I did not view the undertaking as conflicted. In fact, I saw the opportunity as something mutually beneficial. Furthermore, and not the least bit dissuasive, I would receive a nice paycheck.

(I should add, in medical parlance, we call a paycheck an honorarium—a term I never could understand. “Will I receive my honorarium?” sounds so much more dignified than, “here’s my bill.” We absolve our transgressions just like every other profession, I suppose.)

In hindsight, I did not appreciate the nuance of what industry might be seeking from me and how these “informal talks” might assist in casting a shadow on my nascent field.  Nevertheless, I viewed the effort as an exciting one; a newly minted graduate does not perceive conveying a description of his workday or the receipt of a $500-1000 honorarium in a troubling light. To boot, many of my teachers and mentors engaged in similar pursuits, which helped lend an air of credibility to the whole affair.

As word spread of my activity on the speakers’ circuit—which I did enjoy, I picked up more gigs. I worked for about a year and a half, off and on, and developed a solid reputation within pharma circles. Commensurate with the praise, I also increased the number of companies with whom I had ties.

The addresses went well, and I always sensed the reps saw the material I covered as something different from the usual exhortations they received from the corporate playbook. They had long days, and I provided a good diversion with some humor and drama thrown in for good measure. Again, I hawked no wares and discussed no products; my conscience was clean without conflicts, and I felt good about the service I performed.

Then one day, something happened.

Typically, when outside speakers give their talks, they occur at regional campuses during week-long retreats for reps (think pharma boot camp). The reps fly in and get their refreshers on upcoming product releases and engage in exercises to bone up on their sales skills. They then meet hospitalists like me to get some bonus learning.

One evening, I arrived at a campus early. The local medical director, a pleasant urologist, greeted me.  I spoke with her a bit and sized her up as a pretty kind soul who probably downshifted her career after some difficult years in private practice. In fact, most medical directors I met within the pharma sphere arrived at their stations for similar reasons: burnout. They all seemed to exude the same forlorn expression when recounting their years in the exam room (I always asked). Too many years practicing in an office shredder and they could no longer stand the early morning shriek of the alarm clock nudging them out of bed into daily drudgery. A story we hear all too often nowadays, and an industry directorship was just one of several “break glass in case of emergency” escape routes I suppose. Regardless, after we finished exchanging pleasantries, my new urology friend sat me down to observe the goings-on.

To my surprise, she dropped me into a full classroom of reps in the midst of a role-playing exercise. I saw two people on the stage. One of the volunteers in the improvisation, a salesperson, was tasked to play themselves—a rep, and the other stood in as the “obstinate” ICU director.

As the script instructed, they engaged in a tete-a-tete over a product—a just released “me-too” antibiotic. The director had no desire to switch compounds, and it was also clear from the script as it unfolded that he was to remain distrustful of the message regardless of the nature of the pitch. The assigned rep worked it though and persisted at the sell.  Success, however, was not to be. You don’t fly into sales school to get a cookie and a pat on the back.  As such, it was time to deconstruct the proceedings and the fizzled negotiation.

Having done their assigned reading—books at the ready, they dissected and reimagined the exchange. In version 2.0, the pen of the ICU director moved to an alternate checkbox on the prescription pad.  To no one’s surprise, not the least mine, it was for the company’s soon to be released quinolone.

The elapsed years have not dulled my recollection of the experience. It was a master class on influence and persuasion.

In short order, I grasped the reps were learning more than the art of physician education, and it did not take a hammer strike across my scalp get it. This affair was about closing the deal and nothing more—and I doubt the Ph.D.’s back in the home office had this in mind while they toiled in their labs behind their fume hoods.

I always liked a Warren Buffet quote: “If you are playing poker and you have not figured out who the patsy is after 30 minutes, it’s you.” Well, I realized a paycheck and praise from a corporate titan was no longer an adequate enough dividend to keep me at the table. I had sufficient newbie common sense to realize something was amiss and needed to reexamine my side pursuit and the purpose of my gains.

I left the campus that day more seasoned with a good deal on my mind. You can glean the lessons learned, but money, motives, and self-interest all played an interconnected role. I felt guilt and knew my activity was not in accord with the type of physician I wanted to be.

Since that time, I have not looked back. Other than fleeting interactions with pharmaceutical companies in the course of streaming by reps or booths at meetings or briefly chatting out of courtesy in appropriate venues, I weigh relations with industry carefully. I defer CME, meal, or industry perks and avoid interactions my patients, if hypothetically assisting me in these choices, would disapprove of. That’s my sniff test and do my best to live up to the standard (these days, it’s sometimes hard to tell who is underwriting what).

Research support presents a greater problem as the matter is more complicated than gifts and goodies; but again, for me, I feel a sense of conflict. The project I embarked upon, the one referenced earlier, made me apprehensive—and not because of any undue influence by the sponsor–none existed, but with my unease at the questions I began to ask myself. Nothing shady, but they would require more space to elaborate on than space here allows and you can probably fill in the blanks.

With industry reassessing and forging forward in its role in commercial free speech and the erosion of funding in academia, my experience in the pharma domain has relevance to others who might face similar choices. Transparency has increased, but the notion of conflict remains as controversial as ever—as Lisa Rosenbaum’s pioneering series in NEJM last year attests. Interests do have consequences, and despite beliefs in our impartiality, the professional patterns we exhibit do not line up. We still have a lot to learn and a long way to go to countenance our diverging views.

This is my experience, and I made the correct choice for me—but I convey my “look behind the veil” as a cautionary account. Industry connections are seldom about real education, in my judgment. The incentives we must juggle impress upon both on our decision-making skills as well as the image we present to the public.

We need industry. We need innovation and collaboration, I recognize—and to get at those themes, again, I need a far richer page.  But that is not my point today.

Remember why we call industry, industry.  It’s a business. They sell, and we buy. That’s my message so do with it what you will. You must make your decision and bestow your own verdicts.

Bradley Flansbaum, MD is a hospitalist a Lennox Hill hospital. He blogs at the Hospital Leader where this post first appeared.