Most medical students understand the preclinical years barely resemble anything they will encounter for the remainder of their professional careers. Beginning in the third year, learning is done in the hospitals and the clinics, and is no longer confined to the classrooms and laboratories. During this time, many of us will be thrust into the middle of a complex network of relationships between physicians, nurses, staff, administrators and patients. Our relationship with these various groups is often well-defined. There is, however, a hospital presence that we get little to no information regarding: health industry representatives.
Concerning “Big Pharma” and medical students, we do not hear from sales representatives at all during the first two years of our schooling. When we are in the classroom, there is no official school-sanctioned time allotted to these groups unless specifically invited by a student organization. There are no events or talks sponsored by companies, and all faculty must divulge any real or perceived conflicts of interest when lecturing.
This changes in the clinical years, when we are often left to our own devices and are sometimes in rooms with Big Pharma representatives during presentations for a new product or during demonstrations of a new surgical device. The “good” representatives will gravitate towards the students after they have made their pitch to the higher-ups and start chumming it up with those at the bottom of the totem pole, those with the least decision-making capacity.
My first encounter with a sales representative was right before entering the OR. Gowned in scrubs, all entrants into the OR look nearly identical and no hierarchy can be discerned readily, like it can be up on the patient floors. On the floors, doctors wear long white coats, nurses wear scrubs and students wear short white coats paired with a look that can only be described as confident confusion. There, the pecking order is clear. However, the OR is murkier — we are all wearing blue scrubs: the nurses are dressed like the doctors, who are dressed like the students. The man approached me and asked if I was a student, after which we began chatting. I assumed this guy was of some importance — he was tall, he spoke confidently and he knew the names of everyone entering the OR. As the conversation shifted from what my first few days at the hospital were like, he started extolling the sophistication and ease of use his new surgical device would offer for this particular operation. Then it hit me: this guy was a salesman.
He knew who I was, right? Him selling me on his product would do absolutely nothing for his company’s bottom line and his quarterly sales. He gave me his card and told me to be on the lookout for his company’s representatives in all my future endeavors. “Man,” I thought, “he was such a nice guy.” As the weeks went on, I encountered other representatives while in the hospital. All of whom were just as nice. What an endearing industry.
Drexel had done a superb job at shielding its first- and second-year students from the influences of third-party companies. We had almost no exposure to the sales pitches coming out of the mouths of these charismatic salespeople. We were being released to the world as naïve students. Were these representatives being nice for the sake of being nice? Of course that is a possibility. What is much more probable, however, is that they are all planting the seeds of merchandising as soon as they are able. I would not be advising any hospitals to buy any new surgical devices, nor would I be prescribing any medications for a few years, but when the time comes, I will already have that brand recognition stored somewhere in my brain.
As students, we are never given formal training in how pharmaceutical companies operate or what we can expect to deal with for the rest of our careers, regardless of our specialty. At Drexel, we have a “Business of Healthcare” course that does a great job of outlining the history of U.S. health care, how it came to be the way it is today and how insurance companies fit into the puzzle that is the U.S. health care system. I once believed that it was a good thing that medical schools limited exposure to Big Pharma, and that this limited access to medical students would offset some of the pernicious effects of physicians becoming beholden to a drug company. As our system is set up now, students or recent medical school graduates will be inundated with free luncheons, demonstrations and gifts that are designed to both inform and persuade physicians and future physicians to prescribe certain medications. There seems to be real value in these demonstrations, as it is a way for those in health care to stay current with advances in research and technology.
The FDA and Big Pharma continue to battle about how much free speech the for-profit pharmaceutical companies can claim when marketing their drugs and devices. Students are not given much information regarding the politics of what is going on in Washington, D.C. Doctors need to be versed in the discussions going on in the capital so that they can learn about how our health care system works and to truly be advocates for their patients. Perhaps to steer clear of politics and controversy, medical schools opt to leave this discussion out altogether.
In order for physicians to best advocate for our patients and their health, we need to know the rules of the game. Medical schools need to find the balance between creating competent, knowledgeable physicians who understand their field very well and physicians that are aware of all of the players in the game and what’s at stake. I’ve found that many of my colleagues find the political aspect of medicine tedious, boring and too time consuming to delve into the intricacies of policy creation. It is this lack of knowledge or fundamental misunderstanding of the relationship between physicians, pharmaceuticals and the government that makes doctors more susceptible to persuasion by the sales representatives.
The relationship between pharmaceutical and biotech companies with medical schools should not be adversarial, but when the goals of the health care provider and health care-related companies do not coincide, the physician and the patients need to be made aware. Talks by prominent physicians that are on the payroll of drug companies need to be scrutinized. Papers applauding new breakthrough treatments need to be rigorously investigated because even peer-reviewed journals are not free from bias.
There is no ideal time during the course of our education that this information would naturally fit, but it is vital and it should be taught early on so that when we are released into the hospitals, we will have practice with critiquing sources and being mindful of current legislation concerning what parties are spending money and where they are spending it. If we’re not educating future doctors on how to effectively combat an (at best) unfair or (at worst) corrupt system, then who can we rely on to give patients a better handle on their own health?