A Word From The President:

Let's Look a Gift Horse in the Mouth

Photo of Jordan J. Cohen, M.D.
When I became a residency program director in internal medicine some 20 years ago, I was surprised to discover that pharmaceutical sales representatives were frequent sponsors of the noon educational conferences scheduled by my new department. The reps themselves routinely attended the conferences, mounted drug displays, and promoted their products directly to the residents. The residents clearly enjoyed the "free" meals, as well as the occasional gifts bestowed on them for simply showing up to hear the sales pitches.

I had heard that such practices were common in some quarters, but this was my first "up close" encounter and, frankly, I didn't like what I saw. I wasn't exactly sure why. The sales reps were bright, well-meaning, mostly young men who seemed sincerely interested in providing useful information to the residents. But somehow it didn't smell right to me. I had the old-fashioned idea that the residents would be better off getting their information about pharmaceuticals - even brand-new ones - from the faculty and from peer-reviewed journals.

My immediate reaction was to ban the sales reps from all educational conferences and from all personal interactions with residents anywhere in the hospital. The sales reps seemed largely unfazed, and most of them quickly accepted, as an alternative, my invitation to make an unconditional donation to the department's educational fund (with suitable acknowledgement). My residents, by contrast, were visibly and audibly incredulous - but only initially. With time and with a bit of explaining about the need to guard against relying on potentially biased information from proprietary sources, virtually all of them came to appreciate the inappropriateness of the previous arrangements. Some even thanked me for taking a principled stand on the matter and thought the change had strengthened our training program.

Since that time, several studies have appeared that I interpret as vindicating my unease with the practices I had encountered. We now know that interactions with drug reps in educational settings clearly influence the prescribing practices of physicians, often in ways unsupported by scientific evidence and out of keeping with sound, cost-conscious behavior.

What's even more notable, studies indicate that such influence is often unrecognized by those whose behavior is clearly affected. A study in the January 2000 issue of the Journal of the American Medical Association shows that residents (and practicing physicians) meet with pharmaceutical representatives an average of four times each month and that medical students typically have such encounters as well. Indeed, pharmaceutical firms spend an average of $8,000 to $13,000 per year per physician on education, promotion, and marketing directed at doctors. This level of expenditure in itself evidences the certainty with which the firms themselves know how malleable prescribing behaviors are.

Studies also have documented the generally favorable views that residents harbor about their interactions with drug reps. A recent example is a survey published in the May issue of the American Journal of Medicine, which reported on the attitudes about drug company promotions held by 105 (90 percent) of the first- and second-year residents from one prestigious internal medicine program.

Despite the fact that 39 percent of the residents thought promotional gifts from drug companies influenced their own prescribing practices and 84 percent thought other physicians would be so influenced, the overwhelming majority saw nothing inherently wrong with accepting all but the most expensive items offered. Even among those who thought such gifts were inappropriate, most had nevertheless accepted or would accept them given the chance. Close to half of the respondents thought a free CME trip was within appropriate bounds, and 15 percent indicated they would accept a gift of expensive luggage.

What's wrong with this picture? Just ask the man on the street. My guess is that he would express outrage that we allow an industry with an overt, albeit legitimate, interest in profiting from its products to have such influence on the education of young physicians - the very individuals who can make or break any one of those products.

But if we choose to set this picture right, we will have to start with ourselves. To quote the authors of that recent study: "From the beginning of training, most physicians observe their colleagues and mentors receiving a wide variety of gifts (from the pharmaceutical industry). By allowing and sometimes encouraging these activities, university and residency program leadership also lend an implicit seal of approval."

I would urge all residency program directors and GME faculty to examine their policies and procedures regarding the involvement of pharmaceutical reps in their educational activities, as well as their own interactions with those reps. You may not wish to go as far I as did 20 years ago, but if you choose a less stringent policy, I hope you will have an answer ready for that man on the street.

Jordan J. Cohen, M.D.
AAMC President

11 June 2001