Medical Schools Grapple With Drug-Industry Influence

Surveys on the relationships between medical academia and the pharmaceutical industry have raised concerns over potential conflicts of interest. To address the issues, more medical schools are establishing policies and taking steps to limit the pharmaceutical industry's presence and influence on campus, though with different approaches.

Academic experts have expressed growing concerns about the pervasive presence of industry in undergraduate and post-graduate medical education. Medical students and residents are exposed to this influence through meeting pharmaceutical sales representatives; accepting small gifts such as pens, mugs, and pads; and attending sponsored lunches and lectures.

More than 800 third-year students at eight U.S. medical schools reported that they encountered on average one gift or activity provided by pharmaceutical companies per week, according to a survey by psychiatric educator Frederick Sierles, M.D., and colleagues that was published in the September 7, 2005, Journal of the American Medical Association (JAMA). Almost all (93 percent) had been asked or required by a physician to attend at least one industry-sponsored lunch.

At a public meeting in Washington, D.C., in March organized by the Institute of Medicine (IOM) Committee on Conflict of Interest in Medical Research, Education, and Practice, a number of academic leaders offered viewpoints and recommendations on industry presence in medical education. Almost everyone acknowledged that its presence was “ubiquitous” (see Original article: Experts Disagree on Impact of Medicine, Industry Relationship).

Some Schools Ban Industry Presence

A number of medical schools have recently adopted policies intended to eliminate industry influence in medical education. In January, for example, Vanderbilt University issued rules forbidding its faculty and residents to accept any gifts and meals provided by the pharmaceutical industry on campus. Similar policies have been implemented at Yale University, University of California at Davis, University of Pennsylvania, and Stanford University.

At the IOM meeting, Philip Pizzo, M.D., dean of Stanford University School of Medicine, described the school's policy, which prohibits all industry-funded free lunches at seminars and grand rounds, gifts to students and faculty, and the presence of company representatives in the medical school and affiliated hospitals without specified and approved purposes.

There was some initial faculty grumbling when these rules were approved in October 2006. “There was a sense of dependence on the commercial sources for providing education,” Pizzo said. He told the IOM committee that this policy has been well accepted for the past year and a half without any negative consequences.

It is not so easy, however, to extricate academic medical institutions from extensive relationships with industry.

In a nationwide survey published in the October 17, 2007, JAMA, 60 percent of the responding department chairs in medical schools and the 15 largest teaching hospitals in the United States reported having some form of personal relationship with industry, including serving as a consultant, a member of a scientific advisory board, or a paid speaker. Half of the clinical departments reported having received industry discretionary funds to purchase food and beverages, 65 percent received support for continuing medical education, and 37 percent got support for residency or fellowship training. Overall 80 percent of clinical departments had at least one form of relationship with industry.

Influence Affects Every Area

“Data suggest that there is no aspect of medicine that is not in some ways influenced by industry,” Eric Campbell, Ph.D., the lead author of the survey and an assistant professor at the Institute for Health Policy at Massachusetts General Hospital and Harvard Medical School, told Psychiatric News. “Every institution has deep connections [with the industry]. University departments have relationships. People who serve on IRBs [institutional review boards] and run department administration have relationships. It is ubiquitous in academic medicine.”

The survey showed that more than half of the clinical department chairs felt that unrestricted industry grants are beneficial for the department's ability to provide independent, unbiased education and training. “Like everything else, this phenomenon has its benefits and risks. It is up to the decision makers in medical education—the deans of medical schools, residency program directors, department chairs—to decide whether the industry presence in medical school is beneficial or not,” said Campbell.

The Association of American Medical Colleges (AAMC) has formed a Task Force on Industry Support for Medical Education to “review the current policies of medical schools and teaching hospitals for managing industry support of educational activities and industry practices of presenting gifts to students, residents, faculty, and staff,” according to an AAMC press release. This report and proposed guidelines are expected to be released in May.

Medical Students a Concern

“The most concerning influence from drug companies may be on medical students,” Linda Pessar, M.D., chair of APA's Committee on Medical Student Education and a professor of psychiatry at the University of Buffalo School of Medicine, told Psychiatric News. “[The representatives] provide free lunches, hand out papers to students, and give out branded items such as pens and mugs to students. There are different opinions among educators on what should be the stance toward the relationships between the industry and academic institutions.”

She does not believe, however, that medical schools should eliminate all presence of pharmaceutical companies on campus. “In undergraduate education, teaching medical students about the boundaries between physicians and pharmaceutical representatives is a bit like sex education,” she commented. “Blanket policies designed to protect students completely from industry influence do not teach them how to deal with all the temptations and bombardment of messages as soon as they step into practice in the real world. That's like abstinence-only sex education; it won't be very effective.”

At the University of Buffalo, Pessar said, the faculty makes a concerted effort to teach students how to manage industry-medicine relationships.“ We do not ban drug company representatives from presenting papers, but have faculty members present to guide discussions afterward. We try to make it explicitly clear that the purpose of the flyers and gifts are sales and marketing.”

In addition, second-year students are given lectures on how to evaluate published articles critically, recognize commercial bias, compare industry-funded studies and NIMH studies, and learn about research on the psychological influence of taking gifts on physicians' attitudes and prescribing behaviors.

“Our attitude is that medicine needs drug companies. To cast them as the devil is unrealistic and unproductive.... We have to teach students how to interact [with industry] through exposure and sophisticated education,” Pessar stated.

This view was echoed by David Korn, M.D., senior vice president for biomedical and health sciences research at the AAMC; he is leading its task force on industry influence and medical education.

“How do we prepare trainees to interact with industry in a principled, ethical way after they leave the 'germ-free' academic environment?,” he asked at the IOM meeting. He pointed out that there is little research on effective strategies to help medical educators teach students how to deal with the many shades of conflicts of interest with which they may be faced.

An abstract of “Medical Students' Exposure to and Attitudes About Drug Company Interactions” is posted at<jama.ama-assn.org/cgi/content/abstract/294/9/1034>. An abstract of “Institutional Academic-Industry Relationships” is posted at<jama.ama-assn.org/cgi/content/abstract/298/15/1779>.▪