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.
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