For many years, pharmaceutical companies have supplied free lunches – and even fridges to store them in – in the student lounges of Canadian medical schools. Well, if the association that represents Canada’s medical schools has anything to say about it, there really will be no such thing as a free lunch – at least for medical students. This also means no more talks given by physician experts paid by pharmaceutical companies. No more unsupervised meetings with drug reps.
Recently, several other university medical centres such as Yale University have also barred drug company sales reps from bringing free lunches to staff physicians. (Yale might have been motivated to do so by the recent ‘C’ grade it recently received from the American Medical Student Association, a national group that rates how well medical schools monitor and control drug industry money).
And in September, Stanford University (which rated a ‘B’ grade) announced that its physicians will no longer be able to accept gifts of any size from any type of vendor, including drug companies and medical device makers. Ethicist Dr. Richard Popp at Stanford’s biodesign program explained:
“It’s a slippery slope from pens and Post-Its to bigger gifts. It is more clear cut just to say don’t take anything.'”
The Association of Faculties of Medicine of Canada said their aim is to limit the influence that the pharmaceutical industry has on medical students and residents, as well as to address the public’s concerns about the perceived coziness between medical schools and Big Pharma.
Dr. Irving Gold of the AFMC described from Ottawa the potential impact of drug company relationships on these students:
“There’s no question that the environment within which you’re trained will have an impact on the way you perceive these issues. The public has to trust that the doctors they see do not have any debts to pay to individual pharmaceutical companies or to the sector as a whole.”
The AMSA PharmFree Scorecard – the one that gave the prestigious Yale University that “C” grade last year in its own Big Pharma conflict-of-interest policies – uses letter grades to assess 149 medical schools’ performance in 11 potential areas of conflict. The Scorecard examines potential conflicts of interest created by industry marketing at the level of the individual physician and trainee.
Surprisingly, and despite physicians’ insistence that they are not influenced at all by receiving Big Pharma gifts, a review published in the Journal of the American Medical Association shows that even the smallest of gifts does indeed influence the choices physicians make. Psychologists call it reciprocity—the natural human tendency to want to give something back to the gift-giver. It’s the same phenomenon that prompts charitable organizations to fill our mailboxes with return address labels so we’ll be more likely to feel obligated to make a donation. They do this for only one reason: it works.
Dr. John Santa, former medical director of the Drug Effectiveness Review Project in Oregon, explained the pervasive influence of drug companies on the lives of physicians in a Consumer Reports Health interview:
“Doctors deny it, but the evidence is clear that these financial relationships lead to significant increases in prescribing and sales. If they didn’t, the drug companies wouldn’t spend an estimated $20 billion a year on them. You get invited to dinner at a nice restaurant for a “medical education” speech, and at the end of the night are handed an envelope with $100 cash inside. Or you participate in “research” that drug companies farm out to doctor’s offices. You don’t have to do anything except follow their protocol, and they’ll pay you $300 or $400 for every patient you put in the study.”
Dr. Santa described his own experience after agreeing to participate on a drug company’s “advisory committee” whose sole purpose was to promote the company’s new drug for dementia.
“The company flew my wife and me to Vail, Colorado during spring break and put us up in the best hotel. We got wined and dined, and all amenities were paid for by the company. But I left feeling compromised and decided I was never going to do that again, and I haven’t. Drug companies should not be allowed to give gifts to practitioners, which just adds to already inflated drug costs.”
To explore the extent of the possible influence of these gifts on which drugs physicians ultimately choose to prescribe, Dr. Ashley Wazana of McGill University in Montréal, reviewed 29 studies on doctors’ prescribing behaviour in the U.S., Canada, Holland, New Zealand, and Australia.
In his review, Dr. Wazana noted that:
- free samples, honoraria, and research grants led doctors to be significantly more likely to prescribe that drug
- freebies also led doctors to request the drug for formularies (hospitals’ official lists of drugs that can be prescribed there)
- hearing a drug salesman at a talk led doctors to recommend “inappropriate treatment” more often than other doctors, including treatment that cost more and was more invasive
- residents who heard drug reps speak at lunch rounds were more likely to have inaccurate information about drugs on the market
- accepting a free trip to a company-sponsored conference led doctors to increase prescriptions of that company’s drugs by 80-190%.
- doctors who “occasionally” attended pharma-sponsored meals were 2-3 times more likely than other doctors to request that the sponsor’s drug be added to a hospital formulary
- doctors who “often” ate these meals were 14 times more likely to do so
- most doctors and residents are in some way interacting with drug companies
- four out of five medical residents attended industry-paid meals, with the average resident eating on the corporate dime 14-15 times a year
- interns averaged free meals on the corporate dime 31 times a year
- medical residents got an average of six gifts per year worth $60 each
- 85% of doctors said they had some interaction with drug reps, with an average of three to four encounters a month
- 86% of doctors accepted free drug samples, and half got research grants
- two out of five doctors attended company-sponsored meals, and a similar proportion accepted funding for travel or lodging to attend company-backed conferences
Yet despite all this, just one in five doctors agreed that pharmaceutical reps “fairly portray their product”, and three-quarters of medical residents said reps “may use unethical practices”; 44% said that reps “provide misleading information”.
Paradoxically, many doctors still rely on drug company sales staff more than any other source for information about new drugs – and not just in North America. One-third of U.K. doctors said pharmaceutical industry reps were their most important source of initial information on new drugs, and pharmaceutical ads accounted for another 15%, according to a 2002 survey in the British journal Family Practice. This study also reviewed 616 prescriptions the doctors had written. The doctors cited drug reps more often than any other factor in influencing their prescription choice. The reps were cited 39% of the time, far more than concern about the drug’s side effects (17%) or prescribing guidelines developed by the medical community (15%).
Several American states have already initiated controls on cozy physician-Big Pharma links. Read this Wall Street Journal article on what New Jersey’s Attorney General is now recommending, or this New York Times article called Harvard Medical School in Ethics Quandary.