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The Pharmaceutical Industry’s Role in U.S. Medical Education

In 1993, the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure concluded that diuretics and beta-blockers are the preferred choice for initial hypertension drug therapy because they have been shown to reduce cardiovascular morbidity and mortality in controlled clinical trials. Surprisingly, between 1992 and 1995, prescriptions for diuretics decreased by 50 percent and for beta-blockers by nearly 40 percent. On the other hand, prescriptions for calcium channel blockers, a heavily-promoted, expensive, newly developed hypertension treatment, rose by 13 percent. Why are these more expensive, possibly inferior drugs being prescribed instead of clinically recommended, evidence-based medications?

One reason is that during this time, the pharmaceutical industry spent more than $14 billion marketing their products in the form of samples, direct mailing and pharmaceutical representative consultations. The industry has been criticized for its marketing practices, with marketing expenditures nearly double that of research and development costs at three of the largest US pharmaceutical manufacturers. The industry spends at least $5 billion annually on marketing, which is more than $8,000 per physician. This marketing effort directly affected physicians, enticing them to prescribe the latest pharmaceuticals. Though not obvious, the relationship between physicians and the pharmaceutical industry begins long before doctors have the power to prescribe medication.

Medical students are subjected to a barrage of advertising that inevitably leads to a physician-industry connection that can be harmful to our health care system. Medical students’ exposure to pharmaceutical marketing begins early, growing in frequency throughout their training. Students receive gifts such as free meals, textbooks, pocket texts, small trinkets and even drug samples. Forty to 100 percent of medical students report exposure to the pharmaceutical industry, with clinical students being more likely than preclinical students to report exposure. The number of students recalling over 20 exposures to marketing rose from 33.3 percent to nearly 72 percent as students entered their clinical training. Pharmaceutical companies, recognizing the formative nature of the clinical years of medical education, seek to form relationships with medical students years before they are ready to independently practice medicine.

These interactions intensify throughout a physician’s training, ranging from trivial gifts such as pens and pads to more questionable large honoraria and consulting fees. Some resident physicians report an average of six pharmaceutical gifts annually, up to 70 industry sponsored lunches, and nearly 75 promotional items in one year, and a survey showed that 41 percent of emergency medicine departments allowed their residents to be taught by drug company representatives. Physicians meet with pharmaceutical representatives an average of four times a month. Though these examples may seem shocking, they underscore the inherently intertwined physician-pharmaceutical relationship.

As medical students are increasingly subjected to pharmaceutical marketing throughout their education, their skepticism towards the practices of the pharmaceutical industry gradually diminishes. Multiple studies report a relationship between exposure to the pharmaceutical industry and positive attitudes about industry interactions. As students’ exposure to the pharmaceutical industry increases, their ability to determine industry bias decreases. In losing their ability to detect bias and analyze pharmaceutical marketing statements objectively, medical students hinder their future ability to practice evidence-based medicine.

Pharmaceutical industry influence can harm the social and moral character of students. In medicine, the traditional virtues of benevolence, compassion, integrity, respectfulness, honesty and justice are valued over commitments to money, power and self. Medical school seeks to impart these values, helping to train doctors that act morally in their profession. When a pharmaceutical representative gives a gift to a student, the student either feels indebted or entitled. If a student feels indebted, they are likely to alter their future prescribing habits based on industry recommendations, impairing their ability to practice medicine in an unbiased manner. If a student does not feel indebted, they are in danger of developing an unwarranted sense of entitlement. Fein et al found that nearly one-third of students at UCLA thought that a drug company should pay the cost of printing notes for them, and almost half the students felt that a meal, textbook and paid travel to a conference were appropriate gifts. A something-for-nothing experience has created a sense of entitlement among these future physicians.

As medical students become physicians, the physician-pharmaceutical industry interaction becomes increasingly linked and affects the prescribing habits of physicians. On one hand, physician-industry interactions help keep physicians informed about the latest drugs which can be invaluable as the pace of scientific discovery can exceed dissemination of application information. Some physicians also report the substantial benefit to patients in the form of free sample medication. On the other hand, the industry-physician relationship has many negative consequences. In a review of 16 studies, interactions with the pharmaceutical industry lead to physicians being more likely to request the addition of company drugs to the hospital formulary and to prescribe the company’s medication over generic drugs. These changes resulted in the use of medications that were costly and had no therapeutic advantage over older ones. Medicine relies on objective evidence, and the pharmaceutical industry’s influence underlies the short-cutting of this essential process.

Another negative consequence of physician industry-interaction is the faltering credibility of the medical profession. Weber et al report that some schools have strict policies regarding faculty-industry relationships, but fail to enforce them. For example, Stanford University banned physicians from giving paid promotional talks for pharmaceutical companies, yet more than a dozen of the school’s doctors were paid speakers — with two earning more than six figures during these speaking appointments. The American College of Physicians noted “a perception that a physician is dispensing medical advice on the basis of a commercial influence is likely to undermine a patient’s trust not only in the physician’s competence, but also in the physician’s pledge to put the patient’s welfare above self-interest.” If the patients begin to view physicians as being tainted by industry influence, then the public’s entire faith in the medical system could be eroded.

In order to prevent our future physicians from becoming puppets of the pharmaceutical industry, the current medical education system must undergo key reform. Wofford et al devised a 90-minute workshop which aimed to increase student knowledge and awareness about pharmaceutical company representatives’ (PCR) marketing techniques, address appropriate interactions with PCRs, and discuss the ethical issues surrounding PCR interaction. After the workshop, student perception of the degree of PCR influence on prescribing habits increased from 44.2 percent to 62.1 percent. Though this workshop only addressed PCR interaction, other workshops like it could address related issues such as acceptance of gifts and bias in clinical decision-making. A revamping of medical school curricula to include these supplemental educational courses would help students counter the growing influence of the pharmaceutical industry.

The pharmaceutical industry and the medical field are inextricably entangled. One creates the necessary medications, and the other delivers the medications to patients in need. Driven by capitalism, the pharmaceutical industry exerts an influence over medical students, creating an atmosphere in which students come to value the industry’s input in patient care that can lead to patient and societal harm. In order to counteract this influence, medical education must reform to help students react to these issues.

Image credit: Photo from Images Money.

Priscilla Vu Priscilla Vu (1 Posts)

Contributing Writer Emeritus

University of California, Irvine School of Medicine

Priscilla Q. Vu is a medical student at the University of California, Irvine School of Medicine. She recently matched into UC Irvine's Ophthalmology Residency Program. Her interests include international travel, research/technology, community service, humanism in medicine, and medical education.

Rijul Kshirsagar Rijul Kshirsagar (1 Posts)

Contributing Writer Emeritus

University of California, Irvine School of Medicine

Born and raised in Cincinnati, OH. Studied Bioengineering at UCSD and now finishing medical school at UC Irvine. Applied for residency in Otolaryngology-Head and Neck Surgery.

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  • Sarah Smith

    This is a huge issue for those of us with a loved one receiving involuntary care for ‘psychosis’ in the U.S. broken mental health system. It is very challenging to know about the undue influence of Big Pharma in the field of mental health, and have to bury this knowledge when talking to a treatment provider. It is despairing to know that there are evidence based alternatives which ‘first do no harm’ and are effective and more humane than forced drugging but that they do not exist in our communities because the harms of the current label and medicate system have been ignored or discounted and the evidence of other approaches have been buried (unpublished). Below is a quote from Dr. Mosher MD, who held a central position in American psychiatric research and was one of the most truthful and dedicated researchers in the field of psychiatry in our times but his findings went unpublished, let alone integrated into clinical practice due to the influence of big Pharma.Consequently, many people have died from either the physical effects of their treatment (organ failure, obesity, diabetes, extra pyramidal, etc.) or the psychological despair of being institutionalized, incarcerated, over medicated, restrained, isolated, etc.). Ironically, his research is being resurrected in the form of a large (E.A.S.A.) study by the Robert Woods Foundation as if this early intervention with limited reliance on neuroleptics is something ‘new’ and ‘novel’ but it isn’t new. It’s just a new generation calling for a different approach just as loudly as gay activists called for AIDS research in the eighties. And we are not calling for new and better chemical restraints for our children; we are calling for an honest reappraisal of the entire ‘label and medicate’ approach to mental illness in general caused by lazy doctors allowing an entire culture of misinformation and mythology to take root paid for by billions of big Pharma marketing, and featuring oversimplified and misleading chemical brain imbalance theories, none of which can be proven and held up to scientific scrutiny.

    Dr. Mosher: He was the first Chief of the Center for Studies of Schizophrenia at the National Institute of Mental Health, 1969-1980. He founded the Schizophrenia Bulletin and for ten years he was its Editor-in-Chief. He led the Soteria Project.

    The Soteria research demonstrated that there is a better way: A better way to treat schizophrenia and other psychoses that destroy the lives of so many young people. The Soteria research showed that the prevalent excessive destructive psychiatric drugging of all these young people is a huge and tragic mistake.The psychiatric establishment was offended. Prestige and Money won. Truth and Love lost.When Dr Mosher died he was Director of Soteria Associates, San Diego, and Clinical Professor of Psychiatry, School of Medicine, University of California, San Diego. Here is a letter from his resignation from the APA:

    Here is an excerpt from his letter of resignation from the APA.

    “After nearly three decades as a member it is with a mixture of pleasure and disappointment that I submit this letter of resignation from the American Psychiatric Association. The major reason for this action is my belief that I am actually resigning from the American Psychopharmacological Association. Luckily, the organization’s true identity requires no change in the acronym.

    Unfortunately, APA reflects, and reinforces, in word and deed, our drug dependent society. Yet it helps wage war on “drugs”. “Dual diagnosis” clients are a major problem for the field but not because of the “good” drugs we prescribe. “Bad” ones are those that are obtained mostly without a prescription. A Marxist would observe that being a good capitalist organization, APA likes only those drugs from which it can derive a profit — directly or indirectly. This is not a group for me. At this point in history, in my view, psychiatry has been almost completely bought out by the drug companies. The APA could not continue without the pharmaceutical company support of meetings, symposia, workshops, journal advertising, grand rounds luncheons, unrestricted educational grants etc. etc. Psychiatrists have become the minions of drug company promotions. APA, of course, maintains that its independence and autonomy are not compromised in this enmeshed situation. Anyone with the least bit of common sense attending the annual meeting would observe how the drug company exhibits and “industry sponsored symposia” draw crowds with their various enticements, while the serious scientific sessions are barely attended. Psychiatric training reflects their influence as well: the most important part of a resident’s curriculum is the art and quasi-science of dealing drugs, i.e., prescription writing.

    These psychopharmacological limitations on our abilities to be complete physicians also limit our intellectual horizons. No longer do we seek to understand whole persons in their social contexts — rather we are there to realign our patients’ neurotransmitters. The problem is that it is very difficult to have a relationship with a neurotransmitter — whatever its configuration. So, our guild organization provides a rationale, by its neurobiological tunnel vision, for keeping our distance from the molecule conglomerates we have come to define as patients. We condone and promote the widespread use and misuse of toxic chemicals that we know have serious long term effects — tardive dyskinesia, tardive dementia and serious withdrawal syndromes. So, do I want to be a drug company patsy who treats molecules with their formulary? No, thank you very much. It saddens me that after 35 years as a psychiatrist I look forward to being dissociated from such an organization. In no way does it represent my interests. It is not within my capacities to buy into the current biomedical-reductionistic model heralded by the psychiatric leadership as once again marrying us to somatic medicine. This is a matter of fashion, politics and, like the pharmaceutical house connection, money.

    In addition, APA has entered into an unholy alliance with NAMI (I don’t remember the members being asked if they supported such an association) such that the two organizations have adopted similar public belief systems about the nature of madness. While professing itself the “champion of their clients” the APA is supporting non-clients, the parents, in their wishes to be in control, via legally enforced dependency, of their mad/bad offspring: NAMI with tacit APA approval, has set out a pro-neuroleptic drug and easy commitment-institutionalization agenda that violates the civil rights of their offspring. For the most part we stand by and allow this fascistic agenda to move forward. Their psychiatric god, Dr. E. Fuller Torrey, is allowed to diagnose and recommend treatment to those in the NAMI organization with whom he disagrees. Clearly, a violation of medical ethics. Does APA protest? Of course not, because he is speaking what APA agrees with, but can’t explicitly espouse. He is allowed to be a foil; after all – he is no longer a member of APA. (Slick work APA!) The shortsightedness of this marriage of convenience between APA, NAMI, and the drug companies (who gleefully support both groups because of their shared pro-drug stance) is an abomination. I want no part of a psychiatry of oppression and social control.

    “Biologically based brain diseases” are certainly convenient for families and practitioners alike. It is no-fault insurance against personal responsibility. We are all just helplessly caught up in a swirl of brain pathology for which no one, except DNA, is responsible. Now, to begin with, anything that has an anatomically defined specific brain pathology becomes the province of neurology (syphilis is an excellent example). So, to be consistent with this “brain disease” view, all the major psychiatric disorders would become the territory of our neurologic colleagues. Without having surveyed them I believe they would eschew responsibility for these problematic individuals. However, consistency would demand our giving over “biologic brain diseases” to them. The fact that there is no evidence confirming the brain disease attribution is, at this point, irrelevant. What we are dealing with here is fashion, politics and money. This level of intellectual /scientific dishonesty is just too egregious for me to continue to support by my membership.

    I view with no surprise that psychiatric training is being systematically disavowed by American medical school graduates. This must give us cause for concern about the state of today’s psychiatry. It must mean — at least in part that they view psychiatry as being very limited and unchallenging. To me it seems clear that we are headed toward a situation in which, except for academics, most psychiatric practitioners will have no real, relationships — so vital to the healing process — with the disturbed and disturbing persons they treat. Their sole role will be that of prescription writers — ciphers in the guise of being “helpers”.

    Finally, why must the APA pretend to know more than it does? DSM IV is the fabrication upon which psychiatry seeks acceptance by medicine in general. Insiders know it is more a political than scientific document. To its credit it says so — although its brief apologia is rarely noted. DSM IV has become a bible and a money making best seller — its major failings notwithstanding. It confines and defines practice, some take it seriously, others more realistically. It is the way to get paid. Diagnostic reliability is easy to attain for research projects. The issue is what do the categories tell us? Do they in fact accurately represent the person with a problem? They don’t, and can’t, because there are no external validating criteria for psychiatric diagnoses. There is neither a blood test nor specific anatomic lesions for any major psychiatric disorder. So, where are we? APA as an organization has implicitly (sometimes explicitly as well) bought into a theoretical hoax. Is psychiatry a hoax — as practiced today? Unfortunately, the answer is mostly yes.

    What do I recommend to the organization upon leaving after experiencing three decades of its history?

    To begin with, let us be ourselves. Stop taking on unholy alliances without the members’ permission.

    Get real about science, politics and money. Label each for what it is — that is, be honest.

    Get out of bed with NAMI and the drug companies. APA should align itself, if one believes its rhetoric, with the true consumer groups, i.e., the ex-patients, psychiatric survivors etc.

    Talk to the membership — I can’t be alone in my views.

    We seem to have forgotten a basic principle — the need to be patient/client/consumer satisfaction oriented. I always remember Manfred Bleuler’s wisdom: “Loren, you must never forget that you are your patient’s employee.” In the end they will determine whether or not psychiatry survives in the service marketplace.

  • faun

    Very good article.

    As someone who believes in science I must say, with sadness, that after studying the medical field and the way the pharmaceutical industry and the regulatory agencies work, for the last 3 years, I no longer feel I can trust my doctor to take decisions for me based on evidence-based medicine. Nor do I believe I have the full picture of a drug or medical procedure risks and benefits to take a course of action based on informed-consent.
    Maybe I’ll be back someday!

  • Someone Else

    As one who has been researching primarily the psycho / pharmaceutical industries for the past 12 years, I do appreciate Sarah’s comment, and send my sympathies in regards to her child. Love the Mosher quote, too, so true. But in order to even research those industries, one must learn to read the language of medicine itself. And I agree with faun, and am pleased to see this article, because it is perhaps the first I’ve read that points out that the credibility of the entire medical industry may be destroyed by the pharmaceutical industries’ fraudulent research and publication biased medical journals. I agree, I no longer trust mainstream doctors, not because they’re bad people, but because they are being brainwashed and misled with misinformation from the pharmaceutical industry.

    Any person, including a doctor, is only as trustworthy as their sources of information. And today’s mainstream medical industry’s sources of information have not been credible for decades now. Not to mention, how incredibly un-insightful it was for the mainstream medical industry to have bought into the historically known as fraudulent, psychiatric industries’ BS. Today’s psychiatrists, with the help of the mainstream doctors, have now killed more Americans in the last couple decades, with the scientifically invalid DSM medical fictions and drugs, than the Nazi psychiatrists killed Jews in all of WWII. It is truly heartbreaking, when one realizes the magnitude of the deception, lies, and iatrogenic harm.

    I hope the medical students wake up, and realize advocating belief in the psychiatrist’s fraudulent theories and toxic drugs, merely because their drugs can cover up your malpractice or fill your hospitals with patients suffering from iatrogenic harm, does not make you ethical doctors, or acceptable human beings, it makes you no better than the Nazi doctors. “Loren, you must never forget that you are your patient’s employee.” In the end they will determine whether or not psychiatry survives in the service marketplace. The pharmaceutical industry chose to step in instead, and to the detriment of millions of patients’ lives. This does not represent a free market, nor are psychiatric stigmatizations and forced druggings anything resembling the historical American belief system, they are the opposite, they are Naziesque.

  • Bradford

    “The pharmaceutical industry and the medical field are inextricably entangled. One creates the necessary medications, and the other delivers the medications to patients in need. Driven by capitalism, the pharmaceutical industry exerts an influence over medical students, creating an atmosphere in which students come to value the industry’s input in patient care that can lead to patient and societal harm. In order to counteract this influence, medical education must reform to help students react to these issues…..”<–FROM the Article, above…. So what's my response? DENIAL is NOT a river in Egypt. Or, *BULLSHIT*. First, that ""inextricable" entanglement" is in fact a self-imposed and self-chosen symbiotic parasitism. In the 65 years since Thorazine, HOW MANY people have DIED, from psych drugs? I can't believe the answer is less than "millions". It's a CHOICE on the past of medicine, in a way that it's not, on the part of PhRMa. PhRMa does NOT produce what medicine consumes, so that driver is fallacious. Medicine pushes what PhRMa pushes medicine to push. The economic greed driver is PhRMa, not medicine. Probably 1/2 of all Rx are NOT medically necessary, but they are FINANCIALLY necessary, for PhRMa. And of psych meds, probably 75% are unneeded. Especially long-term. Please stop playing Pimp for PhRMa. Yes, I am a surviving victim of the lies of the pseudoscience drug racket of biopsychiatry. (Can you at least begin to see, how the whole "CMHC" scam was set up by PhRMa, to grossly over-prescribe psych drugs?)
    Please stop killing people with the poison pills of PhRMa.

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  • Jan toff

    What! “you will receive the best education” you say. How about the best, “biased” education. By the time they finish training you, you will think exactly the way they want you to think. Actually it sounds like they already finished with you.
    If I had listened to my doctor instead of Dr Google, I would be on statins now rather healthy and numbers all good.
    Doctors are victims of their training.

    -http://www.nogracias.eu/wp-content/uploads/2014/01/deben-las-revistas-dejar-de-publicar-articulos-de-la-industria-bmj.pdf Clinical trials are now less reliable than tobacco studies ever were.