自己犠牲と贈答の容認


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 利益相反(conflict of interests ; COIs)の報告が、ここ20年くらい増加しています。

 2007年のN Engl J Medでは、「一人診療の診療所ほどMRとの接触回数が多い」と報告されています。一方、大規模な病院は「処方システムが自動的で医師の個別判断が少ない」「MRとの接触制限がある」「教育システムが病院内でしっかりしている」「MRに頼らなくても医療情報に困らない」そうです(NEJM 1742-1750:2007)。また、「やり手」とされている医師ほど「win-winの関係なら、何ら問題なし」との考えている(医学書院/週刊医学界新聞(第2891号 2010年08月09日)。

 このwin-winは、医療従事者ー製薬会社が双方にwinなので、患者は不在。当人たちは、患者のために営業をし、患者のために医療をしているのですが、win-winをつなぐハイフン(ヨコ棒)の部分は「製薬会社からの贈答」と「医療者側からの配慮(製品の宣伝や研究、講演などの援助から、実際の処方や調剤)。贈答の関係があると、医療者側は配慮という姿勢をとらざるを得ない。適切な医療を受ける患者利益と権利が歪むことは、確か。ここが相反している部分。

 一方、2008年米国医科大学協会(AAMC)、2009年米国科学アカデミー医学研究所(IOM)の勧告では「ボールペンなどの低額なギフト」も贈答の禁止を勧告している。

 本当は適切な関係を望んでいるのに、どのような関係が「適切」なのか、判断できない。

 これが、私が利益相反に取り組む理由です。

 小児科・一般診療科の研修医 301 名を 3 群に無作為に割り付け、業者からの贈答に対する容認性をオンラインで調査。教育課程の自己犠牲Personal Sacrificeを思い出させる設問をした群は対照群より贈答を容認する。

 さらに自己犠牲+贈答の正当性を示唆する設問をした群で容認性が高かった(オッズ比 1.45 )。

Effect of Reminders of Personal Sacrifice and Suggested Rationalizations on Residents’ Self-Reported Willingness to Accept Gifts

JAMA. 2010;304(11):1204-1211. doi:10.1001/jama.2010.1310

Context Despite expanding research on the prevalence and consequences of conflicts of interest in medicine, little attention has been given to the psychological processes that enable physicians to rationalize the acceptance of gifts.

Objective To determine whether reminding resident physicians of the sacrifices made to obtain training, as well as suggesting this as a potential rationalization, increases self-stated willingness to accept gifts from industry.

Design, Setting, and Participants Three hundred one US resident physicians from 2 sample populations (pediatrics and family medicine) who were recruited during March-July 2009 participated in a survey presented as evaluating quality of life and values.

Intervention Physicians were randomly assigned to receive 1 of 3 different online surveys. The sacrifice reminders survey (n = 120) asked questions about sacrifices made in medical training, followed by questions regarding the acceptability of receiving gifts from industry. The suggested rationalization survey (n = 121) presented the same sacrifice questions, followed by a suggested possible rationalization (based on sacrifices made in medical training) for acceptance of gifts, before the questions regarding the acceptability of gifts. The control survey (n = 60) asked about the acceptability of gifts before asking questions about sacrifices or suggesting a rationalization.

Main Outcome Measures Physician self-stated acceptability of receiving gifts from industry.

Results Reminding physicians of sacrifices made in obtaining their education resulted in gifts being evaluated as more acceptable: 21.7% (13/60) in the control group vs 47.5% (57/120) in the sacrifice reminders group (odds ratio, 1.81; 95% confidence interval, 1.27-2.58; P = .001). Although most residents disagreed with the suggested rationalization, exposure to it further increased the perceived acceptability of gifts to 60.3% (73/121) in that group (odds ratio relative to sacrifice reminders group, 1.45; 95% confidence interval, 1.22-1.72; P < .001).

Conclusions Providing resident physicians with reminders of sacrifices increased the perceived acceptability of industry-sponsored gifts. Including a rationalization statement further increased gift acceptability.

これから)安全委員会、システム委員会、利益相反の研究計画書準備

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