Department of Psychiatry, Columbia University, New York, NY 10032, USA.
Harv Rev Psychiatry. 2010 Sep-Oct;18(5):255-65. doi: 10.3109/10673229.2010.507038.
Psychiatrists' relationships with the pharmaceutical and device industries have been a growing focus of attention, with questions raised about the impact of those relationships on prescribing practices, diagnostic criteria, practice guidelines, continuing education, conduct and reporting of research, and patients' and public trust. Indeed, these concerns exist for the medical profession as a whole, with various remedial measures proposed. We suggest that such relationships can be understood as giving rise to a "principal-agent problem," which occurs when an agent (here, a physician) is engaged to advance the interests of another party, the principal (typically a patient), but also faces incentives to promote other interests. Studies suggest that at least some relationships--which include attending industry-sponsored presentations, meeting with marketing representatives, and accepting samples--can alter psychiatrists' and other physicians' behavior in ways that can compromise patients' interests, and that industry-funded research may create bias in the medical literature. These effects are difficult to detect in specific cases, however, because of asymmetries of information and may not be apparent even to physicians themselves. Principal-agent analysis suggests that the possible responses to such problems, including appeals to ethical principles, monitoring behavior, and managing risk-inducing situations, should include consideration of aligning agents' incentives with principals' interests. This type of analysis underscores the similarity of the issues raised by physicians' relationships with industry to problems that arise more generally in society, thus reducing physicians' potential affective responses to these issues and efforts to address them. Finally, such analysis directs attention to the benefits and costs of each alternative, thereby encouraging reliance on evidence as a basis for policy.
精神科医生与制药和医疗器械行业的关系一直是人们关注的焦点，人们对这些关系对处方实践、诊断标准、实践指南、继续教育、研究的行为和报告以及患者和公众的信任产生的影响提出了质疑。事实上，这些担忧不仅存在于整个医疗行业，而且还提出了各种补救措施。我们认为，这种关系可以被理解为产生了“委托代理问题”，即当代理人（这里是医生）受雇为另一方（通常是患者）的利益服务，但也面临着促进其他利益的激励时，就会出现这种问题。研究表明，至少有一些关系——包括参加行业赞助的演讲、与营销代表会面以及接受样品——可以改变精神科医生和其他医生的行为，从而损害患者的利益，而且行业资助的研究可能会使医学文献产生偏见。然而，由于信息不对称，这些影响在具体情况下很难被察觉，即使对于医生自己来说也可能不明显。委托代理分析表明，针对这些问题的可能反应，包括诉诸伦理原则、监督行为和管理风险诱导情况，应包括考虑使代理人的激励与委托人的利益保持一致。这种类型的分析强调了医生与行业关系所引发的问题与社会中更普遍存在的问题之间的相似性，从而减少了医生对这些问题的潜在情感反应，并努力解决这些问题。最后，这种分析将注意力集中在每种替代方案的收益和成本上，从而鼓励以证据为基础制定政策。
