Prior to starting medical school, I spent my days as an HIV treatment educator and patient advocate in New York City, where my natural role was to empower patients and work with them to enhance their understanding of living with HIV. On many days, this could include translating for them what their doctor meant when he identified the bump on the back of their neck as lipodystrophy. On others it could mean helping patients write down the questions they had for their doctor. And on still others, it could mean that I would help patients manage the diarrhea they had been having on the only antiretroviral that had been able to keep their viral load levels down. In my role, I was invited to join patients in the care they received, which was such a privilege and a gift. Inspired by the trust that each person placed in me, I became quickly motivated to learn more about each medication and each therapeutic modality that could help enhance the information I could provide to each patient.
Therefore, when I noticed flyers with invitations to pharmaceutically sponsored conferences discussing HIV investigational drugs at luxurious hotels and restaurants throughout the city, they seemed benign in nature. Yet, I remember in January of 2003 being invited by Bristol-Myers Squibb for a presentation of data on atazanavir, a protease inhibitor that was FDA approved in June of that year. As the director of research presented the results of two Phase III trials, I remember industriously jotting down notes as quickly as he spoke. To me his words were golden, and I paid close attention to everything that was shared: resistance patterns, side effects, response rates among treatment-naïve vs. treatment-experienced groups. Eagerly, I consumed the information that was served to me and presented in an environment of food, drink, and the sophisticated ambiance of an upscale Manhattan hotel. The goal of the meeting was clearly met: I left with a deep understanding of how atazanavir worked, and felt positively about what I learned, and how the information was shared with me. It seemed credible, logical, and clearly presented.
Several months after that meeting, atazanavir was approved, and once it was, I felt like a natural resource about it to my patients. The information shared with me at that meeting enabled me to respond to question upon question about the drug from many of my clients. Looking back, I now realize that I was more inclined to speak about atazanavir than about others within the same class. The drug and I were friends—we now knew all about one another. Yet, did I know about other drugs as well? Could I identify ritonavir's resistance patterns? In the end, what I have come to realize is that my attendance at the pharmaceutical meeting had created an informational bias that placed me in a natural disposition to offer individuals more information about the drug than about others.
As I have reflected back on this experience, I have been comforted by the fact that at that time, I was not a physician and so often deferred decisions about HIV treatment to the patients and their doctor. However, as I continue my medical education, I wonder what levels of bias I may be exposed to that I may not even be aware of. One social science perspective piece written by Dana and Loewenstein1 suggests that, as humans, we are vulnerable to a powerful, unconscious “self-serving bias.” When the bias serves a need or advances our perceived interests, we can then have trouble seeing ourselves as being biased. With incentives such as food, office supply trinkets, reimbursement for time, travel, and at times entertainment, physicians are subject to a self-serving bias in addition to an informational bias. By accepting what may be anywhere from office pens to lavish stays at resorts and reimbursements for time, physicians may handicap themselves from detecting the bias inherent in pharmaceutical presentations, as they are meeting their own individual needs from the interaction. And while physicians may have difficulty identifying the informational and self-serving bias that is present, it may indeed have an impact on the care and treatment they recommend to patients. In one review of 16 studies, Wazana found that a wide variety of interactions including meetings with company representatives, the receipt of gifts, free drug samples, and free meals, company support for travel to and lodging at educational events, attendance at pharmaceutical company lectures, acceptance of honoraria, and other relationships were associated with changes in physicians' use of medications.2
Therefore, my hope is that as I continue my medical training, I become increasingly aware of the informational and self-serving bias that pharmaceutically sponsored initiatives create and that I think a second time when I next see a pharmaceutical flyer or a representative offering pens. Every gift comes with a price, and here it could be at the cost of the care we provide to our future patients.
1 Dana J, Loewenstein G. A social science perspective on gifts to physicians from industry. JAMA. 2003;290:252–255.
2 Wazana A. Physicians and the pharmaceutical industry: Is a gift ever just a gift? JAMA. 2000;283:373–380.
The 2008 National Essay Contest on the Relationship Between Medical Students and Pharmaceutical Marketing
In 2008, the Division of Pharmacoepidemiology and Pharmacoeconomics at Brigham and Women's Hospital, Harvard Medical School in Boston conducted a nationwide essay contest to gauge medical students' views of the influence of pharmaceutical marketing practices on their education and to seek out their ideas for how we ought to manage this complex issue. The contest was funded by a grant from the Attorney General Prescriber Grant Program.
Medical students were asked to respond to one or more of these statements: (1) How have your experiences as a medical student shaped your understanding of the interaction between the pharmaceutical industry and the practicing physician? (2) What have you learned in medical school about the relationship between pharmaceutical promotion and physician prescribing, and how could that aspect of your education be enhanced? (3) Describe a notable interaction with a drug sales representative that you have had or observed, and how that interaction will help influence your work as a physician. The contest received more than 130 submissions from 55 different schools of medicine and osteopathy. The country was divided into four regions, and a panel of expert reviewers selected one first-place finisher, three second-place finishers, and five third-place finishers from each region.
We are pleased that Academic Medicine can publish the first-place essays, submitted by Amanda Redig (Feinberg School of Medicine, Northwestern University), Viet Nguyen (University of Washington School of Medicine), Donna M. Kaminski (University of Medicine and Dentistry of New Jersey–School of Osteopathic Medicine), and Elliott Wakeam (Jefferson Medical College). All winning essays can be found on the Division of Pharmacoepidemiology's Website (www.DrugEpi.org).
Aaron S. Kesselheim, MD, JD, and Jerry Avorn, MD
Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.