Drugs companies have long courted US physicians with 'educational'
lectures, meals and gifts. But trainee doctors increasingly spurn such
offers, writes Jon Marcus.
To American medical students saddled with long hours and huge debt a
free lunch can be a pleasant interruption in a long day of studying and
treating patients. But to an increasing number of Sachin Jain's classmates
at Harvard Medical School, it's a bribe.
The lunches are frequently sponsored by pharmaceutical companies, and the
price is usually having to sit through a presentation about a new drug or
"In other industries, there are clear requirements that you have to
disclose what your biases might be," said Dr Jain, a fourth-year medical
student. "But the reality is that we get presented with information
without knowing that a presenter might be a consultant to a particular
pharmaceutical company, or you find out that a luncheon given about a
particular topic was sponsored by a drug company."
US pharmaceutical companies spend more than $22 billion a year (£11
billion) marketing to physicians, according to their own industry
association, including $3 billion on meetings and events such as free
Copious spending on marketing is one of the things critics say have driven
pharmaceutical costs up to 60 per cent higher in the US than in other
Professional associations, concerned that drug companies are trying to
influence physicians' prescribing decisions and thus causing a conflict of
interest, are cracking down on the practice. As a result, the drug
companies have now set their sights on students.
But students are fighting back. ImproveHealthCare.org, an organisation
founded and chaired by Dr Jain, last month held a conference on the topic
in Boston for students from 15 medical schools and undergraduates planning
No Free Lunch, a New York-based organisation founded by a physician,
raises awareness by swapping its coffee mugs, pens and other paraphernalia
for the tons of free gifts lavished on doctors and medical students by
Recently, a group of medical students marched on the New York offices of
the drug company Pfizer and symbolically threw back the free pens they had
received with the company's logo. And the 68,000-member American Medical
Student Association has begun a campaign to limit the presence of
pharmaceutical company representatives in medical schools.
Five leading US medical schools - Stanford, Yale, the University of
Pennsylvania, the University of California, Davis and the University of
Michigan - have responded to the initiative by banning pharmaceutical
representatives from educational and clinical areas. The University of
California, Los Angeles also bars pharmaceutical company representatives
and prohibits its physicians from accepting gifts, including free meals.
That policy is even more restrictive than the guidelines of the American
Medical Association, which allows its members to receive gifts worth up to
$100 from drug companies.
Most medical schools have no such policies and no significant incentive to
resist firms' approaches. With government funding for medical research
stagnant, medical schools rely increasingly on money from the
pharmaceutical industry for research.
"It often is the case, especially with (National Institutes of Health)
funding being flatlined under the current Administration, that there is a
lot of research in medical schools being funded by the industry," said
Jerry Avorn, a Harvard Medical School professor and author of Powerful
Medicines, a book about commercial influences on US healthcare.
A study published in the Journal of the American Medical Association found
that on average third-year US medical students receive one gift or attend
one event sponsored by a pharmaceutical company a week.
Almost all the more than 1,000 medical students surveyed for the study
said they had been asked or required by a senior physician to attend at
least one drug company-sponsored lunch. And while most of those questioned
said that they would not be swayed by free stethoscopes or complimentary
lunches other research says they will.
Asked about what influenced them to prescribe a particular drug,
practising doctors in a separate survey put pharmaceutical company sales
representatives low on the list. But pressed for more detailed information
about the drug they more often repeated what they had heard from the sales
reps than what was published in scientific journals.
"The problem is that these people - the sales reps and promotions people -
are not educators," Dr Avorn said. "They're salespeople. They're here to
sell product. That's their job. It's couched as if it were education, but
it is in the service of increasing sales."
And smart as they are, said Dr Jain, medical students in particular "are
largely naive about these kinds of things because they're so focused on
the task at hand, which is learning medicine, and they don't know what's
coming from where and maybe haven't given deep thought to what their
relationship should be with pharmaceutical companies."
As to whether the drug companies' free gifts have an impact, he said:
"They (companies) wouldn't be doing it if they didn't. These are profit-
Dr Jain added: "Pharmaceutical companies do a lot of important work that
potentially benefits patients. But there should be transparency about
who's paying for what or under what conditions a particular trial was done
... and what the sources of funding are for a lot of research and
programmes in medical education."
The Pharmaceutical Research and Manufacturers of America, the industry
association, said it gives gifts and meals as a way to get the attention
of busy students and physicians and to share information with them. It
said doctors are always free to decline.
"Providing doctors with timely information about the medicines they
prescribe clearly benefits patients and advances healthcare," said Ken
Johnson, an association spokesman.
"Medical students are the future of America's healthcare system, and
pharmaceutical marketing is one of several important ways for the next
generation of doctors to receive the information they need to make sound
Mike Ehlert, president of the American Medical Student Association, said:
"They claim to be involved in education, and they use that as a reason
that they need to be involved with students. But what they call education
is 100 per cent biased. If you need any evidence of that, their education
comes out of their marketing budgets."
Dr Ehlert, who attends Case Western Reserve University School of Medicine,
said that he is offered lunches and gifts by pharmaceutical
"It's pervasive. What's really embarrassing is that we walk around with
stuff hanging off us with drug company logos. We're literally selling
advertising on ourselves," he said.
Whatever the outcome of the debate, it has new momentum, said Dr Avorn,
who remembers the same issue coming up when he was a medical student in
the early 1970s after the drug maker Eli Lilly and Company passed out free
black instrument bags.
"This has gone on for decades," he said. "What's new is that there's more
of a perception that this could be a problem than there used to be.
Students are the ones who are asking the tough questions when actually it
should be the professors doing so."