Annals of Emergency Medicine
Volume 45, Issue 1 , Pages 27-31, January 2005

One resident perspective: Resident education and the pharmaceutical industry:

One resident perspective: Resident education and the pharmaceutical industry

  • Corita R. Grudzen, MD

      Affiliations

    • Corresponding Author InformationAddress for correspondence: Corita R. Grudzen, MD, Department of Emergency Medicine, Bellevue Hospital Center, 1st Avenue and 27th Street, New York, NY 10016; 917-204-5855, fax 718-381-9057

From the Department of Emergency Medicine, Bellevue Hospital Center/New York University, New York, NY

published online 06 December 2004.

[Ann Emerg Med. 2005;45:27-31.]

Article Outline

 

Eager to learn and ambitious but with few resources to attend conferences or fund their own research, residents are especially vulnerable to pharmaceutical industry influence. Because they don't have set prescribing patterns, residents are also an ideal target for drug companies promoting their products. Further compounding this susceptibility is that residency programs have limited funding for graduate medical education. This article will present the existing guidelines for interaction between physicians and the pharmaceutical industry, outlining the ethics and evidence behind them. The current practices and consequences of resident interaction with industry will also be examined. We will argue that because dwindling resources have hastened the arrival of postgraduate funding at a crossroads, attention must be focused on innovative funding ideas to prevent the erosion of the ethical standards of our specialty.

Although pharmaceutical company support of physicians once went almost unchecked, there has been a movement toward limiting the industry's contact with physicians. In the late 1980s and early 1990s, the relationship between industry and physicians came under scrutiny by medical journals, professional organizations, and the popular press because of large sums of money that were being spent on physician gifts and continuing medical education.1 In 1990, the American College of Physicians (ACP) published the first ethical guidelines in relation to physicians and the pharmaceutical industry.2 The statement discouraged the acceptance of all gifts and emphasized using the opinion of patients, colleagues, and the public to gauge whether a gift was problematic. In 1992, the American Medical Association's Council on Ethical and Judicial Affairs issued its first position statement, indicating that gifts to physicians should entail a benefit to patients and not be of substantial value or relate to prescribing patterns.3 Cash reimbursements and gifts that directly or indirectly relate to prescribing patterns were deemed unacceptable. The American College of Emergency Physicians4 (ACEP) and the Society for Academic Emergency Medicine5 (SAEM) issued similar statements the same year, stating that gifts should be of minimal value and should either benefit patients or serve an educational function. Both policies state that residents and faculty should not accept direct subsidies from industry to attend conferences and that faculty are required to disclose all industry support. References for guidelines are provided in the Table.

Table. Web sites for ethical guidelines for gifts to physicians.
OrganizationWeb Site Address
American College of Physicianshttp://www.annals.org/cgi/content/full/136/5/396
American Medical Associationhttp://www.ama-assn.org/ama/pub/category/5689.html
American College of Emergency Physicianshttp://www.acep.org/1,575,0.html
Society of Academic Emergency Medicinehttp://www.saem.org/download/industry.pdf
Canadian Medical Associationhttp://www.cma.ca/index.cfm/ci_id/8504/la_id/1.htm.
British Medical Associationhttp://web.bma.org.uk/ap.nsf/Content/incentives+to+GPs+for+referral+or+prescribing
Royal Australian College of General Practitionershttp://www.racgp.org.au/document.asp?id=516

The ACP guidelines emphasize using the opinion of patients and the public to gauge whether a gift is problematic.2 The media has focused attention on the physician-pharmaceutical company relationship, thereby educating the public and placing further pressure on physicians to monitor their actions. Among the largest news groups that has shone a spotlight on these activities was Primetime for ABC News, which ran a segment in February 2002 entitled “Influencing Doctors—How Pharmaceutical Companies Use Enticement to ‘Educate’ Physicians.” Using undercover cameras, Primetime entered a sponsored dinner party by Pfizer at the Museum of Modern Art.6 In Canada, W-Five presented a special edition on CTV News entitled “Just Say No” in May 2002, which featured invitations to physicians from Boehringer Ingelheim for a 3-day, expenses-paid trip to Jamaica.7 More recently, The New York Times featured “Medical Marketing—Treatment by Incentive; As Doctor Writes Prescription, Drug Company Writes a Check” in June 2004. This story covered sham clinical trials that “included paying doctors large sums to prescribe its drug … and to take part in company-sponsored clinical trials that were little more than thinly disguised marketing efforts that required little effort on the physicians' part.”8 The British Medical Association also emphasizes public perception in their guidelines of gifts to physicians: “The doctor must not only act in the best interest of the patient, but also must be perceived to do so.”9 Interactions with the pharmaceutical industry thus threaten to tarnish the reputation of the medical community in the eyes of the public, a reputation which is both unique and valuable.10

It has also been shown that patients believe gifts are more influential and less appropriate than physicians. A survey in 1995 revealed that only 32% of patients were aware that physicians took personal gifts from the pharmaceutical industry.11 Another survey in 1998 found that between 29% and 56% of patients thought that gifts influenced physicians, when asked about gifts ranging from a pen to a lunch, a dinner, or a trip, respectively. These results were statistically different from the proportion of physicians who thought the gifts were influential.12

Awareness of pharmaceutical company influence on physicians, including residents, has reached an all-time high. The Accreditation Council for Graduate Medical Education (ACGME), which is responsible for delineating educational standards for more than 7,700 residency programs, officially mandated a curriculum for resident education on interaction with the pharmaceutical industry in 2002.13 Recognizing that change begins with education, in January 2004 the Council of Emergency Medicine Residency Directors (CORD) also mandated that residents receive training regarding conflicts of interest with the pharmaceutical industry and critical appraisal methods and instructed residency programs to create policies to help guide residents in their interactions with industry.14 The pharmaceutical industry has begun to implement its own restrictive policies as well. The Pharmaceutical Research and Manufacturers of America, an organization that represents the leading pharmaceutical and biotechnology companies, adopted a new marketing code in 2002 that restricted its own interactions with physicians.15 Similar to guidelines instituted by professional medical organizations, the code specified that interactions should be educational, should not include entertainment, and that gifts to physicians should be for the benefit of patients and not of substantial value (less than $100). However, the effectiveness of these guidelines may be called into question by many news reports, such as the one featured in The New York Times in June 2004.8

Formal policies are one way to control the industry's influence on physicians in training. In a Canadian study, residents in a program that restricted interaction with pharmaceutical representatives were less likely to find their information beneficial in guiding practice.16 Although many residency directors have their own set guidelines for relating with pharmaceutical companies, it remains unclear how many today have developed formal written policies. In 1992, a survey of 272 internal medicine residency directors revealed that only 35.3% had developed formal regulations and only 25.7% provided residents with formal education on marketing.17 This occurred despite the belief that half of residency directors were “moderately” or “very” concerned about the effect pharmaceutical representatives could exert on residents' future attitudes toward industry and prescribing patterns. More recently, a survey of 106 emergency medicine program directors found that 62% were at least “somewhat” familiar with the ACGME commercial support standards.18 However, while all but 1 of 106 respondents agreed with the statement, “Pharmaceutical company sponsorship of residency activities is a promotional attempt to affect prescribing practices of physicians,” only 52% of program directors replied that they “never” or “very rarely” allow pharmaceutical representatives to give residents free drug samples at work, and only 46% replied they “never” or “very rarely” allow pharmaceutical representatives to teach residents. Twenty-nine percent allow industry travel support for residents even if the funds are contingent on the resident attending an industry seminar or event. The majority (66%) requested ethical guidelines from CORD. Whereas the ACGME requirements and CORD guidelines are necessary, this level of compliance suggests that they are not sufficient.

Despite position statements by professional medical organizations, few residents are aware of these recommendations. In a 1993 study of emergency medicine residents, only 50% knew of these policies.19 In a more recent study of internal medicine residents at an academic medical center, less than 10% were familiar with these policies.20 In addition, the policies themselves still leave tremendous room for industry impact on physicians. Both ACEP4 and SAEM5 approve industry-funded subsidies for emergency physician-faculty travel to conferences. SAEM stipulates very specific circumstances: the funds are given to the academic or training institution; the training institution confirms that the educational program provides independent, unbiased information to the trainees; and the selection of students, residents, or fellows is made by the training institution. However, these travel scholarships may require attendance at special sessions run by pharmaceutical companies. At such sessions, both ACEP and SAEM guidelines stipulate that the lecturing faculty member must disclose industry support of a lecture; however, disclosure does not prevent bias. Indeed, it has been shown that physicians who have attended symposiums, been paid to speak at a conference, or are engaged in research on a drug are more likely to request these drugs be added to hospital formularies.21

Research has also shown that alterations in prescribing patterns occur despite physicians' beliefs that they are unaffected by pharmaceutical company enticements. At a time when pharmaceutical company gifts to physicians remained wholly unregulated, Orlowski and Wateska22 showed that physicians who accepted all-expenses-paid trips to popular sunbelt vacation sites to attend industry-sponsored symposia had a statistically significant increase in prescribing of the company's drugs. These prescribing patterns differed significantly from national patterns and occurred despite physicians' beliefs that they would not be influenced by such enticements. In the plenary abstract presented at SAEM in 2003, Gill et al23 presented similar findings in emergency medicine residents. Using a computer tracking system database, the authors tracked subscriptions in the 2 weeks before and the 2 weeks after weekly drug company–sponsored lunches and monthly dinners. They found an increase in outpatient prescriptions for the featured drugs of 116%, and administration of featured drugs in the emergency department increased by 33%.

While the pharmaceutical companies' ability to influence physicians' prescribing patterns is almost unquestionable, some argue that industry may improve patient outcomes by keeping physicians abreast of the latest therapies.24 Historically, pharmaceutical companies were instrumental in promoting treatment of hypertension in the 1970s, thrombolysis for acute myocardial infarction in the 1980s, and anticoagulation for atrial fibrillation in the 1990s. However, this benefit is distorted by the overall quality of information provided by pharmaceutical companies, which is selective, favorable to the product, and often inaccurate. A study in The Lancet reviewed references in pharmaceutical advertisements and found that 41% of promotional statements were not supported by the reference, most frequently because the drug was recommended for a patient group other than that assessed in the study.25 Therefore, while one patient group may benefit, the other groups are given a drug that may be of no benefit to them, which subsequently increases drug costs. Although the US Food and Drug Administration attempts to closely regulate pharmaceutical companies' print and electronic information, personal interactions between pharmaceutical companies and physicians and verbal information are even more difficult to monitor. A study in JAMA of presentations by pharmaceutical representatives showed that 11% of the information provided contradicted information in the Physicians' Drug Reference.26 In addition, whereas the pharmaceutical industry may promote beneficial treatment for some patients, they may also suppress negative results; the recent controversy over suppression of negative results of Paxil in children with depression has led to calls for a public registry of company-sponsored research,27 and a lawsuit by the New York State Attorney General against GlaxoSmithKline.28 A comprehensive assessment of the value of drug promotion by the pharmaceutical industry must include the drawbacks, which may offset the benefits.

Another argument for accepting pharmaceutical funding is that medical education could suffer from lack of sponsorship.29 Unfortunately, this may be true. Recently, the Health and Hospital Corporation of New York City, composed of 11 inpatient facilities with more than 1,000 residents, has placed restrictions on resident interaction with pharmaceutical representatives. Journal clubs and daily conferences no longer offer food provided by pharmaceutical representatives. Although there is the need for such restrictions, the lack of funding for academic meetings often results in poor attendance. In a study of resident journal clubs, food was one of the most important factors associated with number of attendees and continued attendance.30

On a larger scale, the need for educational funding is at odds with rejecting industry support because of reductions in hospital reimbursements for graduate medical education. This shortfall in funding is enthusiastically filled by drug companies eager to influence physicians in training. Whereas academic medical centers were historically rewarded for producing more physicians, the Balanced Budget Act of 1997 altered the way in which graduate medical education is subsidized.31 The federal government, mainly through Medicare, is the largest source of financial support for physicians in training. Direct and indirect reimbursements are made to hospitals on the basis of numbers of residents in training and the proportion of inpatient stays accounted for by Medicare beneficiaries. In 1997, the government placed limits on residency expansion and mandated reductions in indirect medical education reimbursements. Further hindering the financial health of academic medical centers, many educational funds provided by health maintenance organizations were reclaimed by the government as a result of the same Balanced Budget Act.32 These significant reductions in graduate medical education make physicians in training and residency programs all the more vulnerable to pharmaceutical company influence; it is imperative that we acknowledge the change and address the need before industry does.

The pharmaceutical industry spent almost US$8 billion in 2002 to promote their products,33 with an estimated US$8,000 to US$13,000 spent yearly per physician.34 Although it is clear this has a substantial effect on physician behavior, further studies must evaluate the impact on patient outcomes. A study on the cost to patients and society found that money spent on promotional materials and gift-giving to physicians ultimately is paid for by patients as part of the cost of the item.21 This is not unexpected, given that the primary ethic of the physician is to promote the patient's best interests, whereas the primary ethic of industry is to promote profitability.33 Reversal of this pattern can only occur through a concerted effort by individual physicians, educators, and policymakers. The process must begin with education. It remains unclear today how many residency programs have instituted curriculum for resident interaction with pharmaceutical industry, although it has been clearly mandated by the ACGME. Furthermore, given the decrease in graduate medical education resources, it is imperative that we develop innovative ideas now to fund resident academic activities such as journal clubs and conferences. Departments can raise money through conferences and courses offered to other health professionals, grants, and donations from alumni who have completed their training. Only in this way can the future of our specialty avoid being guided by the principles of the pharmaceutical industry rather than that of unbiased evidence.

Medical students, representing the future of our profession, suggest that a true shift in our ethical standards is in sight. The American Medical Student Association, representing many future leaders in medicine, has instituted a PharmFree pledge: “I am committed to the practice of medicine in the best interests of patients and to the pursuit of an education that is based on the best available evidence, rather than on advertising or promotion. I pledge to accept no money, gifts, or hospitality from the pharmaceutical industry; to seek unbiased sources of information and not rely on information disseminated by drug companies; and to avoid conflicts of interest in my medical education and practice.”35 As residents, we too must make a pledge not only to our patients but also to society and each other to uphold the ethics of our profession and remain vigilant in our quest for unbiased knowledge.

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This column was edited by Clare Atzema, MD, Resident Fellow 2003-2004.

Back to Article Outline

References 

  1. American College of Emergency Physicians. Background regarding gifts to emergency physicians from the biomedical industry (June 1993). Available at: http://www.acep.org/1,574,0.html. Accessed August 20, 2004.
  2. American College of Physicians . Physicians and the pharmaceutical industry. Ann Intern Med. 1990;112:624–626
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 The author reports this study did not receive any outside funding or support.Reprints not available from the author.

PII: S0196-0644(04)01463-5

doi:10.1016/j.annemergmed.2004.09.018

Annals of Emergency Medicine
Volume 45, Issue 1 , Pages 27-31, January 2005

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