Sunday, September 22, 2013

We live by fiction: The psychology of gift giving in medicine

The psychology of gift giving is fascinating.

When human beings receive gifts from other human beings, their psychological states change: as recipients, they feel indebted to their gift-givers. In turn, these receivers of gifts start telling themselves stories; stories to justify why they deserve the gifts. This process of self-deception by fiction may be a universal human tendency. Thus, our best approach to this challenge may be to embrace human fallibility and then hedge against this inborn tendency by recognizing it openly and reflecting appropriately to protect ourselves from behaving unethically.

In medicine, this process of self-reflection is critical because clinicians' behaviors affect their patients' lives. The following anecdote illustrates this phenomenon well (shared by one of my friends who lives in India):

Recently, I attended a relative's wedding in a fairly rural area of India, and several doctors were visiting. I walked into the middle of a conversation between my cousin and a local doctor. The doctor had just claimed that a pharmaceutical company gave him a pre-paid debit card worth about $200 (in Rupees) to spend as he wished. As my cousin expressed his outrage, the doctor waved him down: he said this was nothing, and he didn't know the half of it. The gist is that the major pharma companies in India hand out very lavish gifts and all-expense-paid vacations to doctors who have built up a reasonable practice. In the past, it was done quite openly, but it is now being routed through more legitimate-sounding channels ("conference invitations") as the government tries to crack down on the practice. Once a doctor accepts such trips and other perks, there is a lot of pressure applied on him/her to regularly prescribe medicines manufactured by that specific company.

The thing that gave me chills was when the doctor mentioned that if, by chance, there was a run of patients for whom none of that company's products made sense to prescribe, and the doctor was running through a dry patch with respect to prescribing products from said company, he would prescribe a short course of antibiotics manufactured by that company since it was "harmless to the patient." In response, I brought up antibiotic resistance, and he readily admitted that this unethical practice was one of the causes driving resistance. At the end of the conversation, he said that he tells himself every year that this year he won't accept any "gifts," but he can't bring himself to stop.

The practice is common and entrenched. This doctor has an 8-year old practice and is otherwise quite respectable.

We live by fiction, for better or for worse.

Perhaps, for physicians, reflection about story systems might help maximize the good.

To good health,

Brent

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