MRSA has nothing on the pharma-branded pen. At hospitals around the country, colonization by the latter is approaching 100%. Along with my medical school colleagues, I have read the studies detailing prescribing changes in physicians plied with lavish gifts from the pharmaceutical industry. So two years ago, I emptied my pockets of everything with a logo. I felt a momentary pang of reluctance as I handed my prized Bristol-Myers-Squibb laser pointer to someone else, but now when the inevitable happens—when yet another story breaks on pharmaceutical marketing practices—I breathe a sigh of relief. At the beginning of my career, at least, I am not buying into the tactics of Big Bad Pharma.
My training progressed, and I started spending more time around oncologists, the specialty I eventually hope to join. Whether working with patient samples in the laboratory or rounding with the oncology team, I started to notice something. Many oncology patients were on a clinical trial, participating in cutting-edge research either at the clinical or laboratory level. And nearly all of these interactions involve extensive back-and-forth with pharmaceutical companies. I remember one patient who had relapsed on standard therapy, then on salvage therapy. When I saw him, he was alive thanks to a developmental compound that had shown some efficacy in early clinical trials but did not yet even have a marketing name. The company was overnighting a supply of the drug to the hospital so the patient could receive his infusions. And now I was starting to grow confused. Was the pharmaceutical industry really that bad if their drugs kept patients alive? Where is the line between unacceptable marketing and medical advancement in fields that are so inextricably linked to new drug development?
I was still trying to answer these questions when I found myself, the youngest member of a group of medical professionals, sipping aperitifs in one of the most famous restaurants in Chicago. Upon arriving with the clinical mentor who had secured my invitation, one woman in particular was eager to introduce herself. When she found out I was an MD/PhD student with interests in hematology–oncology, it was as though I was a long-lost cousin. “I'll look forward to working with you,” she said, and I realized with a start that she wasn't kidding. As the representative responsible for coordinating the evening's dinner and presentation on leukemia, her career is driven by relationships with oncologists. And physician–scientists are truly the jackpot in a research-driven field like oncology because the line between therapy and discovery is so intertwined.
The dinner presentation on current therapeutic strategies in chronic myelogenous leukemia was both informative and immediately useful as I was able to incorporate data from a published paper into an upcoming presentation on my own research. The speaker was a respected member of the academic community, not a representative of the drug company, and the products of the company sponsoring the dinner were neither highlighted nor promoted. In fact, except for the filet mignon and the watchful eye of the pharma representative, the talk could have been part of a plenary session at a national meeting.
And this, it seems, is the challenge facing physicians as medicine becomes ever more driven by research advancements. It is easy to decry blatant attempts to influence physician prescribing behavior, but what about the complexities of physician–pharma relationships? Where is the line when learning about the latest therapies, providing the best care for one's patients, and advancing translational research in the laboratory requires collaboration with pharmaceutical companies? Preclinical medical school ethics courses have made me acutely aware of the pitfalls of accepting exorbitant speaker's fees or recruiting bonuses—the marketing side of the industry—but I am finding that a reflexive, categorically antipharma position is not always useful when actually practicing medicine. Drug development requires physician involvement, so how do we define ethical professionalism in this setting? Was I selling out by accepting an overly extravagant dinner in order to learn about a disease and disease management? I don't know. But I do know this issue won't go away, so I am looking for answers. As my career unfolds, I am hoping for increased efforts focused not on eliminating physician–industry contact but rather on defining its boundaries and educating physicians how to sidestep marketing ploys while maintaining a professional relationship that benefits those who matter most: our patients. Throwing out a handful of pens is not the hard part. The challenge before us is avoiding the pens without ignoring the pharmacy.
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.