• In the social and culinary wasteland that was residency training, it had been easy for Cheryl, a bubbly brunette in her mid-30s, to become our den mother. She never tired of listening to our grousing, had unerring taste in take-out, made it a point to come to our parties when invited and every so often brought in a plate of her homemade brownies.

But Cheryl was no den mother. She was a pharmaceutical rep.

That she managed to slip a plug for her wares into every conversation or tuck copies of studies promoting her product into our white coat pockets as we polished off her brownies was awkward. But we always overlooked the salesmanship because it was such a familiar part of our residency routine. As trainees in a large teaching hospital, we knew numerous sales reps by name and the products they peddled; and it was odd, even disappointing, to go to an educational conference where one of them wasnot standing next to a table laden with tchotchkes, information brochures and free take-out.

But in retrospect, such docile acceptance was problematic. In an environment where no one, including senior doctors, ever questioned the presence of sales reps, we didn’t think too hard about why they might have been as friendly and helpful as they were. We didn’t ask where the money for all these giveaways was coming from and we were rarely curious about who these reps actually were (I only ever knew their first names).

It wasn’t that I or the other residents preferentially prescribed their products. But I do know that more than once when faced with a decision about what to prescribe, the first thought that came to mind was not what I needed to do to find the latest evidence-based recommendation, but what Cheryl had just told us over lunch.

All of this became painfully clear after Cheryl suddenly disappeared. At first, the other trainees and I thought she had been fired, so we avoided bringing her absence up with the rep who replaced her. But when I ran into someone from her company at a national medical conference a year later, I learned otherwise.

“Oh, she got promoted,” the rep said, smiling broadly. “Now she’s an executive in the central office.”

I remembered Cheryl and the other reps from medical school and residency when I read a recent study in The Journal of General Internal Medicine on interactions between trainees and industry.

For years, the pharmaceutical and medical device industry has devoted enormous effort and billions of dollars to cultivating relationships with doctors. While consulting and lecture fees for influential physicians, sponsored lunches and dinners for busy clinicians and a blizzard of emblazoned pens, notepads and medication samplers make up the bulk of promotional expenditures, hundreds of millions of dollars are alsofunneled into educational programs, particularly the continuing medical education lectures and conferences that doctors attend in order to fulfill mandatory state licensing and hospital credentialing requirements.

A significant proportion of medical schools and teaching hospitals end up the beneficiaries of such promotional largesse. But in recent years, leaders in medical education and, more notably, a growing contingent of medical students, have called for changes in a professional culture that accepts interactions with industry as the “norm.” In 2007, the American Medical Students Association published the PharmFree Scorecard, a rating system that grades medical schools on the strength of their policies regulating interactions between industry and students and faculty. Around the same time, the Association of American Medical Colleges and several medical schools issued policy statements calling for a decrease in the influence of industry in education.

Observers hailed these initiatives as transformative, but in the years since it’s not been all that clear that a transformation has actually occurred.Smaller studies, focusing on the prescription habits of newly minted doctors at one school or in a single specialty have revealed some effects, but exactly how much contact medical students and residents still have with industry on a national level is unknown. Are trainees still receiving free pens, mugs and meals? Are they being exposed to not only evidence-based but also industry-biased medicine?

The answer is yes. And no.

A group of researchers asked more than 1,500 medical students and more than 700 doctors-in-training from across the country about their contact with representatives from drug or medical device companies. They discovered that even though students and trainees were interacting with industry less than before, roughly half of all medical students and residents had received some kind of gift from industry. While most of these gifts were things like company pens and notepads and donuts and pizza doled out on campus, more than a quarter of the trainees had been treated to meals outside their hospitals and medical schools, beyond the official jurisdiction of institutional rules and regulations.

In addition, almost 10 percent of students in their first year of school and nearly 15 percent in their last year had received free drug samples, a finding that is alarming given that medical students are not licensed to prescribe medications.

“It’s hard to see how these interactions are fulfilling the goal of teaching trainees,” said Dr. Aaron S. Kesselheim, senior author of the study in The Journal of General Internal Medicine and an assistant professor of medicine in the division of pharmacoepidemiology and pharmacoeconomics at the Brigham and Women’s Hospital in Boston.

A medical school’s rating on the PharmFree Scorecard or the robustness of a medical school’s official policy on conflict of interest turned out to have little to do with how often students received gifts. Instead, a more accurate predictor was the amount of funding that a school received from the National Institutes of Health. Students who attended medical schools with higher levels of N.I.H. funding were less likely to have interactions with industry than their peers at less research-intensive institutions.

One explanation may be that pharmaceutical and medical device companies are less interested in building relationships with trainees headed for research careers rather than those who will become prescribing physicians. Another possible reason is that medical schools with high levels of N.I.H. funding must have strong conflict of interest policies in place to be eligible for grants from a government agency.

But a more worrisome possibility could be that academic centers with less financial support from big-ticket research grants might be more dependent on outside funds to support their educational programs. “That would be a significant health policy issue because having these kinds of relationships in medical school can influence physician practices and ultimately patient outcomes,” Dr. Kesselheim observed.

Despite their findings to the contrary, Dr. Kesselheim and his co-investigators believe that ranking systems like the PharmFree Scorecard and strong institutional policies are important, particularly for the medical educators, students and trainees who would like to see industry-free education as the new, and only acceptable, norm.

“These are people who have a noble and uplifting message and who draw strength from statements made by national professional organizations and even their own institutions,” Dr. Kesselheim said. “They want a better educational environment, and they want to change the culture of their institutions, even if it means, at least in the case of students who carry a crushing educational debt, that they must pay for more out of their own pockets.”


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