Eating lunches and feeling guilty is something we are supposed to do when we are older after we have gained some weight. But now young medical students are having second thoughts on the meals they share with pharmaceutical reps.
We have written extensively about the growing “conflict of interest mania” that has swept across our nation over the past few years. One of the places this “mania” has touched the greatest is academic medical centers (AMCs) and/or medical schools. In fact, each year, the American Medical Students Association (AMSA) publishes a yearly “PharmFree Scorecard” that evaluates the conflict of interest (COI) policies ant American medical schools.
Of 152 US medical schools in 2012, 28 received “A”s (18%), 74 “B”s (49%), 15 “C”s (10%), and 13 “D”s (9%). The areas that garnered the greatest number of perfect scores were those addressing industry support of scholarships, off-campus continuing medical education, purchasing, and gifts. New areas of growth appear to be seen within the following three domains: curriculum, speaking, and consulting. Specifically, curriculum experienced the largest net growth in new schools with model policies (22 additional schools). Speakers relationships and consulting experienced an increase in an equal number of schools (16 schools) and the scholarships, gifts and off-campus education experienced large increases as well.
Consequently, “researchers” recently surveyed 1,610 first- and third-year medical students and 739 residents regarding conflict of interest policies. Among first-year students
- 1/3 reported receiving gifts from pharmaceutical companies and
- 17% said they had talked with a pharmaceutical representative in the prior six months.
Those percentages were significantly higher for third-year students.
- Nearly four in five reported receiving gifts, which could include food, trinkets such as pens and paper, drug samples, or financial support.
- 44% said they had interacted with drug reps.
- The rates for residents were somewhat similar.
The story, reported by the Boston Globe, quoted students at Brown University’s Alpert Medical School, who are prohibited from accepting gifts or meals from pharmaceutical companies and drug salespeople. Yet, when she was training in a primary care clinic, student Reshma Ramachandran said drug salespeople stopped by often -- sometimes four times each week -- bringing lunch for the staff. The realities of practice clashed with her school’s policy.
“The preceptor would encourage us -- and it was kind of a weird pressure -- to go and sit with the sales rep or to sit with them as they talked to the sales reps,” said Ramachandran, who is a fellow with AMSA, partly focused on conflict of interest polices at medical schools. It is unclear why this would be “weird,” especially if her preceptor was just trying to show his/her students the realities of practice.
The reality is, physicians—at all stages of their training—need to have interactions with industry. Not only are such relationships beneficial for continuing medical progress and innovation, advancing medical care, and improving patient outcomes, but interactions also teach medical students and residents about the nature of the pharmaceutical and medical device industry. More importantly, such interactions—particularly in the medical device world—are critical for teaching students and young physicians how to properly use a device or perform a procedure. And such interactions and training are typically mandated by FDA in the devices’ clearance and mandatory medical device reporting requirements.
Thus, medical schools and AMCs should encourage and in fact require medical students and residents to interact with industry—not only to experience what such interactions have to offer, but also to better prepare them for their career. Medical students need to realize that sales reps and medical affairs staff exist for a reason: because physicians don’t have enough time in a day to learn about all the new research, advances and updates in clinical care—including FDA REMS, safety updates, or black-box warnings.
Moreover, as we wrote last year, physicians who restrict access to sales reps or who ignore sales rep are slower to respond or adjust their prescribing and treatment habits in response to negative news about the drug. The authors of the study found that physicians with very low access to representatives had the lowest adoption of a new therapy and took 1.4 and 4.6 times longer to adopt than physicians in the low- and medium-access restriction categories, respectively. In responding to the black box warning for rosiglitazone, the authors found that physicians with very low access were 4.0 times slower to reduce their use of this treatment than those with low access.
Likewise, there was significantly less response in terms of changing prescribing to the negative news with the lipid therapy for physicians in more access-restricted offices. Overall, cardiologists were the most responsive to information changes relative to primary care physicians. These findings emphasize that limiting access to pharmaceutical representatives can have the unintended effect of reducing appropriate responses to negative information about drugs just as much as responses to positive information about innovative drugs.
Nevertheless, despite the growth in COI policies, even at institutions with the strictest rules, the new study claims that “many doctors-to-be are exposed to pharmaceutical marketing throughout their training, according to study published this week by the Journal of General Internal Medicine and led by researchers at Harvard Medical School.”
Those students who attend schools with more comprehensive policies, measured on the medical student association’s scorecard, were no less likely to have those contacts with salespeople, the study found.
“Having the policy on the books is one thing,” said senior author Dr. Aaron Kesselheim, a Brigham and Women’s physician and assistant professor of medicine at Harvard Medical School. “Making sure that it’s implemented and isn’t being skirted around with off-campus interactions and interactions at hospitals which the medical students might then go to is also important.”
Blaming her school’s policy, Ramachandran would politely decline the chats with drug salespeople. But, she said, it was difficult for some classmates to reject invitations, sometimes to fancy pharma-sponsored dinners, from supervisors who were responsible for grading their performance.
One-third of first-year and most third-year students reported observing physicians or residents interact with a sales representative. Kirsten Austad, a fourth-year medial student at Harvard and lead author on the paper said medical school is “a process of socialization,” and doctors learn what is ethical and appropriate not just from what they are taught but in how they see physicians behave.
Marcia Boumil, assistant dean for conflict of interest administration at Tufts University School of Medicine, said though many physicians believe they are beyond being influenced by free lunches and samples, drug companies spend money on such efforts because they do affect prescribing practices.
Tufts professors start talking about the effects of marketing to first-year students and repeat the message often throughout their training, Boumil said. Students are prohibited from meeting with drug salespeople or accepting meals from them, on or off campus, but “whether or not we can monitor and enforce it is another story,” she said.
Boumil said young doctors are changing the ethical standards in medicine as more who are trained in conflicts of interest begin their practice. “A generation from now, I hope that the discussion will have changed, but just think about how much its changed in the past 10 to 20 years,” she said. “It’s gone from routine drug lunches every day, without question, to a lot of schools and hospitals having policies and talking about it and teaching about it and devoting class time to it.”
Notable AMSA Trends
One area deserving of particular attention is the growth of restrictions on speaking arrangements. Seventeen of the thirty-two schools with restrictions on speaking arrangements took the lead by explicitly banning participation by their faculty on speaker’s bureaus. The following is a list of domains and the number of perfect scores:
- Scholarships – 108; from 94 in 2010, 66 in 2009 and 29 in 2008
- Off-campus continuing medical education – 88; from 75 in 2010, 49 in 2009 and 23 in 2008
- Gifts & Meals– 81; from 66 in 2010, 44 in 2009 and 19 in 2008
- Purchasing – 70; from 65 in 2010, 47 in 2009 and 22 in 2008
- Curriculum – 69; from 47 in 2010, 28 in 2009 and 12 in 2008
- Consulting – 64; from 48 in 2010, 27 in 2009 and 12 in 2008
- Speaking – 32; from 18 in 2010, 10 in 2009 and 4 in 2008
- Samples – 31; from 26 in 2010, 20 in 2009 and 12 in 2008
- Disclosure – 29; from 20 in 2010, 5 in 2009 and 1 in 2008
- On-campus continuing medical education – 20; from 15 in 2010, 3 in 2009 and 5 in 2008
- Sales representatives – 2; unchanged from 2 in 2010, and both 1 in 2009 and 2008