Everyone, right now, please check your pen.
Chances are very good that your pen is emblazoned with the name of a new drug on the market, perhaps a variant of the classic standby but promising longer lasting, faster acting, and easier-on-the-stomach results. Despite the growing adoption of computerized medical records and digital prescriptions, everyone still carries a pen. Everyone believes that they will not be influenced by the drug company, and yet advertising works. It seems harmless enough—a logo, probably one of thousands you will see throughout the day—but studies have shown that small gifts from pharmaceutical companies, such as free lunches, pocket texts, and yes, pens, contribute to a subconscious influence that lead physicians and physicians-in-training to prescribe medications they may otherwise have avoided. The pharmaceutical industry's influence on clinical decision making is undeniable, and the best way to raise awareness in physicians is through education and discussion, starting at the medical school level.
At the University of Washington School of Medicine, students have the unique opportunity to see both urban and rural medicine practiced throughout the WWAMI (Washington, Wyoming, Alaska, Montana, and Idaho) region, and like many of our graduates, I was fortunate to sample disparate environments including private practice clinics in Washington, Montana, and Alaska, a tertiary care setting at the University of Washington Medical Center, and a government-run setting at two different Veterans Affairs (VA) hospitals. This variety only reinforced the need to learn the practice of medicine because one might spend one week presenting ICU patients to a dozen academic pulmonologists and infectious disease experts and the next week walking through −40°F temperatures to deliver a baby whose mother came to the hospital by snowmobile from her Inuit village 200 miles away.
One of the many differences between an institutional setting and an isolated private practice is the approach taken towards the pharmaceutical industry. At each of the small town clinics, pharmaceutical representatives came by daily with free drug samples and enormous platters of catered lunches, only asking for a few minutes to expound upon the virtues of their medication. During one encounter, a drug company advertising incontinence medication invited the entire physician staff, including the medical students, to the most expensive restaurant in town, and implored us all to order whatever we wanted. This was an annual event, and the staff jokingly referred to this dinner as a “conference” to discuss the latest treatments for stress incontinence. Since I was a medical student, the company representative had no intention of pushing the drug on me, but instead focused on trying to give me pens and pads of paper adorned with the name of the company, in what felt like an attempt to associate the generosity of the “conference” with the company logo. Over the next month, whenever a patient with stress incontinence came to our clinic, my preceptor would laugh and ask me, “What about trying X?” He was kidding, but I noticed more than once that physicians in the clinic prescribed drug X for patients with newly diagnosed stress incontinence.
On the other hand, at the university and at the VA hospitals, free lunches and gifts are not allowed. On many rotations at the University of Washington Medical Center, there is such an emphasis on keeping the practice of medicine as free from the pharmaceutical industry as possible that students and residents are reprimanded for using drug trade names instead of generic names during presentations. From my experience, the result of this practice was a greater sense of suspicion towards new medications, a desire to learn about medications from less biased sources, and the tendency to favor generic equivalents over marketed trade names to cut costs for the patient.
It is difficult to completely condemn the role of pharmaceutical representatives. Often, economic realities pressure providers to give free samples to their patients, who might otherwise go without. Outlawing free lunches is an unpopular decision, one that fosters unhappiness within the staff. In addition, many physicians find it difficult to stay current with the latest medications, and sometimes the simplest way to keep current is to invite representatives into the clinic to learn about drugs that their patients read about in magazine advertisements or saw in television commercials. In an ideal scenario, there would exist a frequently updated, easily accessible, unbiased source of information on new medications in order for physicians to make decisions based on science rather than marketing clout.
What is necessary for all physicians is proper education on the magnitude of pharmaceutical advertising, and this starts at the medical school level. At the University of Washington School of Medicine, we have discussed a “pharm-free” policy to prevent pharmaceutical industry representatives from having contact with the medical students. No matter which side one supports, our students can all agree that having discussion amongst peers has brought this issue to light and made us more aware of the influence that advertising has on clinical decision making. I believe that similar discussions, held at every medical school during the preclinical years, would raise awareness in the student population as a whole and at least give us pause before accepting yet another “free” pen.
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.