Residency Program Addresses Drug Company Influence

In an attempt to maintain its psychiatry residents’ objectivity and avoid either real or perceived conflicts of interest, a major Canadian medical school has adopted a set of guidelines for interactions with the pharmaceutical industry. The guidelines are the culmination of efforts to combat the ever-growing amount of time, energy, and money that the pharmaceutical industry spends on “detailing” physicians, beginning early in residency.

“There are few issues in all of medicine that will bring clinicians into such a heated debate as the interactions between the pharmaceutical industry and the medical profession,” said Ashley Wazana, M.D., a fifth-year psychiatry resident at McGill University School of Medicine in Montreal. Wazana cited several surprising statistics at an annual meeting session in New Orleans in May.

According to some studies, Wazana said, the pharmaceutical industry in 1999 spent more than $11 billion in the U.S. on promoting and marketing its products to physicians. Five billion of that amount went directly to pharmaceutical sales representatives whose job it was to sell their products to those prescribing physicians. In 2000 that number rose to $15 billion on marketing, with $8.3 billion being spent directly on a rapidly increasing number of industry representatives. Indeed, the number of representatives nearly doubled between 1996 and 2000, to an astonishing 83,000 representatives working on selling pharmaceuticals to nearly 900,000 physicians across the U.S.

“That amounts to between $8,000 and $15,000 spent by the industry on each physician, depending upon the particular statistics in individual studies,” explained François Primeau, M.D., a staff psychiatrist at McGill University and chair of the annual meeting symposium. “Another way to look at it is to say that the pharmaceutical industry spends nearly $100,000 and devotes one representative to every 11 physicians in the U.S.”

Unfortunately, Primeau continued, there are few specific guidelines available for residents with regard to their interactions with the pharmaceutical industry.

Nor is there consensus on what the real impact is of the free samples, gifts, complimentary meals, travel subsidies, sponsored teaching, and supported symposia used by the industry to try to influence physicians’ prescribing habits. In one study, according to Wazana, 85 percent of the medical students surveyed believed it was improper for politicians to accept a gift, but only 46 percent found it to be improper for themselves to accept a similarly valued gift from a pharmaceutical company.

Most medical associations either have or are developing guidelines for their own members regarding gifts from industry, according to Primeau. APA follows the American Medical Association’s policy on “Gifts to Physicians From Industry” and the AMA’s Council on Ethical and Judicial Affairs’ “Clarification of Gifts to Physicians from Industry,” which give broad guidelines on how to handle industry gifts. However, even within the AMA there has recently been a movement toward developing a more specific policy that would limit the types and amounts of gifts that physicians can accept from pharmaceutical companies.

Many inside the AMA often refer to the association’s policy on gifts as “our most ignored ethical opinion.” A recent study by Michael A. Steinman, M.D., a fellow in internal medicine at the University of California, San Francisco (UCSF), seems to back up that feeling. The results of a survey of first- and second-year residents at UCSF, which appeared in the May 1 issue of the American Journal of Medicine, revealed that about 42 percent of the residents said it was OK for a company to pay for their travel to an educational conference, and 15 percent said that they would accept luggage for the trip from a drug representative. Neither of these “gifts” would be acceptable under the AMA’s current guidelines.

Believing that the AMA guidelines are not specific enough or strict enough, the McGill psychiatry faculty decided to formulate their own guidelines, geared toward residents’ interactions with industry. The psychiatry faculty felt it was especially important to focus on residents because of the uniquely vulnerable and impressionable point at which they are in their careers, according to Annette Granich, M.D., the psychiatry residency training director at McGill.

The McGill psychiatry residency program put together a Pharmaceutical Industry Relations Committee (PIRC), headed by Granich. The committee includes two resident representatives and two faculty representatives, one of whom must have expertise with ethics.

The committee’s guidelines address educational activities such as industry-supported symposia; gifts such as textbooks, meals, and travel; and fundraising efforts such as fellowships, and in addition provide guidelines for presentations to residents and the academic community by industry representatives. The PIRC also developed training for residents on proper interactions with the pharmaceutical industry. This training occurs early in a resident’s program, and no meetings with a pharmaceutical representative may occur until this training has been completed.

The pharmaceutical industry has vehemently denied any wrongdoing and has said recently that the industry’s efforts are aimed at education. According to a spokes-person for the Pharmaceutical Research Manufacturers of America (PhRMA), which represents the industry’s leading pharmaceutical and biotechnology firms, the companies adopted the AMA guidelines into their own “Code of Pharmaceutical Marketing Practices.”

However, the faculty at McGill is only one of a growing number of residency faculties throughout North America that are looking to restrict industry-resident interactions.

“We have a duty to educate residents on how to deal with these often complex ethical questions,” Granich told Psychiatric News. “We owe it to them to make sure they are prepared to deal with industry once they have finished their residency programs.”

AMA Policy E-8.061, “Gifts to Physicians From Industry,” and its clarification are posted on the Web at www.ama-assn.org/ama/pub/category/2947.html.