Study authors: On medical school conflict of interest policies, more enforcement needed

Students at Brown University’s Alpert Medical School are prohibited from accepting gifts or meals from pharmaceutical companies and drug salespeople. Yet, when she was training in a primary care clinic, student Reshma Ramachandran said drug salespeople stopped by often—sometimes four times each week—bringing lunch for the staff. The realities of practice clashed with her school’s policy.

“The preceptor would encourage us—and it was kind of a weird pressure—to go and sit with the sales rep or to sit with them as they talked to the sales reps,” said Ramachandran, who is a fellow with the American Medical Student Association, partly focused on conflict of interest polices at medical schools.

Many schools have adopted policies restricting drug salespeople from working on campus and requiring professors to avoid or at least disclose their ties to industry. But even at institutions with the strictest rules, many doctors-to-be are exposed to pharmaceutical marketing throughout their training, according to study published this week by the Journal of General Internal Medicine and led by researchers at Harvard Medical School.

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Researchers surveyed 1,610 first- and third-year medical students and 739 residents. Among first-year students, one-third reported receiving gifts from pharmaceutical companies and 17 percent said they had talked with a pharmaceutical representative in the prior six months.

Those percentages were significantly higher for third-year students. Nearly four in five reported receiving gifts, which could include food, trinkets such as pens and paper, drug samples, or financial support. Forty-four percent said they had interacted with drug reps. The rates for residents were somewhat similar.

Those students who attend schools with more comprehensive policies, measured on the medical student association’s scorecard, were no less likely to have those contacts with salespeople, the study found.

“Having the policy on the books is one thing,” said senior author Dr. Aaron Kesselheim, a Brigham and Women’s physician and assistant professor of medicine at Harvard Medical School. “Making sure that it’s implemented and isn’t being skirted around with off-campus interactions and interactions at hospitals which the medical students might then go to is also important.”

Blaming her school’s policy, Ramachandran would politely decline the chats with drug salespeople. But, she said, it was difficult for some classmates to reject invitations, sometimes to fancy pharma-sponsored dinners, from supervisors who were responsible for grading their performance.

One-third of first-year and most third-year students reported observing physicians or residents interact with a sales representative. Kirsten Austad, a fourth-year medial student at Harvard and lead author on the paper said medical school is “a process of socialization,” and doctors learn what is ethical and appropriate not just from what they are taught but in how they see physicians behave.

Sometimes, she said, when her professors informed their class that they have no industry ties to disclose, they would add a joke: “But I wish I did.”

“It’s quite common, in fact,” Austad said.

Marcia Boumil, assistant dean for conflict of interest administration at Tufts University School of Medicine, said though many physicians believe they are beyond being influenced by free lunches and samples, drug companies spend money on such efforts because they do affect prescribing practices.

One recent study from Yale University researchers found that medical school gift bans can lessen the effects drug marketing may have on doctors’ later prescribing practices.

Tufts professors start talking about the effects of marketing to first-year students and repeat the message often throughout their training, Boumil said. Students are prohibited from meeting with drug salespeople or accepting meals from them, on or off campus, but “whether or not we can monitor and enforce it is another story,” she said.

Boumil said young doctors are changing the ethical standards in medicine as more who are trained in conflicts of interest begin their practice.

“A generation from now, I hope that the discussion will have changed, but just think about how much its changed in the past 10 to 20 years,” she said. “It’s gone from routine drug lunches every day, without question, to a lot of schools and hospitals having policies and talking about it and teaching about it and devoting class time to it.”

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