Some medical schools say no to drug reps' free lunch
■ Stanford, Yale and the University of Pennsylvania have adopted policies to create a brighter line between medicine and marketing.
By Myrle Croasdale — Posted Oct. 9, 2006
On Oct. 1, Stanford University School of Medicine in California closed its last avenue for pharmaceutical marketing on campus, shutting down drug company freebies no matter what their size.
The ban includes everything from free lunches to pens touting the latest medication to hit the market. Also, pharmaceutical sales representatives must make appointments if they want to talk with physicians. The stricter rules come after the school prohibited drug samples several years ago, except at medical students' free clinics.
Stanford is one of a handful of academic medical centers expanding conflict-of-interest rules beyond research to include smaller gifts aimed at influencing physicians' clinical practices, namely prescribing.
Although there is no hard number on how much is spent, Stanford estimates that drug companies lay out about $250,000 annually on meals there. Nationwide, the pharmaceutical industry estimates that it spends $21 billion a year on marketing, though some contend that this figure is too low.
"There's a growing awareness that pharmaceutical promotions subtly, and not so subtly, impact physicians' decisions," said internist Clarence Braddock, MD, MPH, an associate professor at Stanford and a member of the Stanford Center for Biomedical Ethics. "Even if [you believe] there's not a real impact, the public perception of us cozying up with industry was not something we felt comfortable with."
Proponents of stringent policies see them as a way to build public trust in the medical profession and ensure that the most appropriate drug is prescribed, not the most marketed. They also hope to set an example for the next generation of physicians.
"If you embed these standards in them as students, hopefully they'll continue as they go into practice," said Jordan J. Cohen, MD, Assn. of American Medical Colleges immediate past president.
But skeptics of the new policies say that the average physician doesn't have the financial backing of a large academic medical center and can't afford to pass by free drug samples. Even the marketing dinners can be helpful, though they aren't accredited education, critics say.
Internist and blogger Kevin Pho, MD, of Nashua, N.H., has been discussing this issue on his Web site, (link).
"Academic medical centers are able to absorb the cost of not having pharmaceutical samples," Dr. Pho said via e-mail. "A small rural practice, however, does not. Physicians in these settings may rely on samples for their patients or attending pharmaceutical-sponsored [events]. It's difficult to apply what goes on in an academic center to a community practice."
At Stanford, Dr. Braddock said faculty voiced several concerns before the policy was adopted. For example, those who organized resident education wondered where they would find money for events, and some faculty believed that students wouldn't be as well prepared for interaction with sales reps once they completed residency. Some were concerned that limiting sales reps' access ultimately would hurt patient care by ending training demonstrations for new devices and products.
Dr. Braddock said the policy addressed some worries. For example, a curriculum on how to handle relationships with the drug industry is being developed. Also, sales reps may meet with physicians and staff, but only by appointment and only in areas free of patient care, unless it's for training on a new device.
Yale, Penn also ban gifts
Stanford's move comes after a group of leaders within medicine challenged academic medical centers to ban faculty from accepting drug company gifts of any size. The call came in an article in the Jan. 25 Journal of the American Medical Association.
The University of Pennsylvania School of Medicine put a policy similar to Stanford's into effect July 1. Yale University School of Medicine in New Haven, Conn., banned all drug company gifts to physicians in 2005 but still allows free drug samples.
American Medical Association policy, which has been widely adopted, holds that physicians may accept gifts that are not of substantial value, such as $100 or less.
David Coleman, MD, Yale's interim internal medicine chair, said the school's changes are now part of the culture, adding that faculty and staff don't miss the free food. "It does create circumstances where there's no money for certain activities that we had before, but it's been easier to implement and sustain than many of us thought," he said.
Pulmonary and critical care physician Paul Lanken, MD, who teaches professionalism at the University of Pennsylvania, said life had not changed much beyond the absence of free lunches. As a medical educator, it had bothered him that students were training in an environment where there was a lot of drug company gifting.
"This is a better model," Dr. Lanken said. "I think the climate and culture does influence the interns and residents."
Patrick J. Brennan, MD, chief medical officer of the University of Pennsylvania Health System, said the hospital banned drug samples several years ago. Now the ban covers all UPHS sites, and many physicians are concerned that their indigent patients will suffer. In response, a program at the hospital that allows patients to get a voucher for medication instead of samples has been expanded to the other sites. Also, free generic samples soon will be available at primary care offices through a company that works with local insurers.
Another point of contention was one that touched physicians' income. Pharmaceutical companies often hire physicians to speak at educational meetings, a practice Penn's new policy no longer allows. The content of the talk might be the same as at an accredited CME event, Dr. Brennan said, but these are marketing activities, which don't go through the CME vetting process.
Lastly, the end of free meals was met with animosity. "I was told on more than one occasion that we were cutting off an employee benefit," Dr. Brennan said.
While Dr. Brennan said it was too soon to know if prescribing patterns had changed, he has noticed a decline in the number of sales reps visiting the university, and he's heard that some have turned in their ID badges because they didn't feel it was worth the effort to make appointments.
He guessed that drug firms had been spending somewhere in the high six figures each year on meals for UPHS staff of 1,500 physicians, 1,000 house officers and 15,000 employees.
"Our goal here was to remodel the relationship, not to keep people out," Dr. Brennan said. "Many of the reps said, 'You're cutting off the flow of information.' Well, if the doctors think it's valuable, you can make an appointment and meet with them."