May 2, 2008

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Graham Ramsay Jason Sanders

Is Pharm-free the Right Move?

Unexpected Answer

Patient–Doctor III provided an opportunity to sit on a student panel to present questions to our guest speakers Charles Sanders and Jerome Kassirer. The intersection of business and medicine was one of the main topics. My query was about the ways in which medical schools could facilitate constructive interactions between young trainees and the pharmaceutical industry. As a second-year student, I had attended a session sponsored by our pharmacology course director that tackled difficult issues relating to the drug industry; I hoped to learn about ways to expand such programs. Much to my chagrin, Dr. Kassirer succinctly responded that there should be no interactions whatsoever, “next question, please.”

Growing Movement

The influence of pharmaceutical suppliers on health care providers remains contentious, and the public sentiment is cynical. An Annals of Internal Medicine editorial (May 15, 2007) estimated pharmaceutical expenditures on physician marketing at $23 billion, and a New England Journal of Medicine survey (April 26, 2007) of more than 3,100 physicians showed that 94 percent reported some type of relationship with the pharmaceutical industry (ranging from 83 percent receiving food in the workplace to 28 percent receiving payments for consulting, lectures, and clinical trial enrollments). A group of physicians including Troyen Brennan and David Blumenthal presented evidence in the Journal of the American Medical Association (Jan. 25, 2006) from psychology and social science research that even small gifts affect decision-making.

Several groups have started to take action to raise awareness, author voluntary ethics guidelines, or enact compliance standards. Starting in 2001, the American Medical Student Association began a “PharmFree” campaign, which has included initiatives such as “No Free Lunch” and “Transforming the Culture of Medical Education.” The National Physicians Alliance has similarly launched the “Unbranded Doctor” campaign. The American Medical Association has taken a more guarded approach, stating in its policy explanation that gifts are permissible as long as they primarily benefit patients and are of modest value (around $100).

Congress has followed the situation closely, especially as bills for Medicare Part D hit the federal budget bottom line. Current legislation under review includes the Physicians Payments Sunshine Act, which would mandate that drug or medical device companies earning over a certain revenue threshold report all “transfers of value” greater than $25 to physicians and their affiliated organizations. Counter-detailing efforts such as those provided by the Independent Drug Information Service run by Jerome Avorn of Brigham and Women’s Hospital, aim to neutralize drug industry influence on physicians through evidence-based information on drugs.

Biased Assumptions

What nearly all physicians must agree on is the primacy of patient care. This is the pledge you take each morning as you look in the mirror, not just at white coat inductions and medical school graduations. Yet many obstacles, both seen and unseen, undermine our ability as physicians in partnership with patients to be healers. Two roadblocks germane to this pharmaceutical debate are the scarcity of resources and the limits of science.

The former is the unpleasant barrier with which Americans will grapple even after we provide some form of affordable health insurance to all our members. Technology is a solution for creating more abundant and effective goods and services from the same inputs, and holds great promise to overcome many scourges of disease. But such innovations historically have required relationships between the public and private sectors, between academic medical centers and industry. Even granted technological progress, health care providers will need to figure out ways to allocate a limited supply of resources. To do this well, physicians must engage with the economics and self-interests of multiple stakeholders who negotiate prices in a quasi-market-based system.

Simply encouraging medical students to ignore these forces seems to set a poor precedent, ineffectively preparing them to advocate for patients. Brand-name drugs are just one of many cost drivers in health care delivery, and in this category alone we need to train physicians who can sift through the merits of high research and development costs on the one hand ($600 million to $1 billion dollars per successfully approved drug) and high marketing costs on the other.

The latter issue, the insufficiency of science, is faced by providers every day: if we only had a better understanding of Alzheimer’s disease, if we only could predict who would fail a new HAART medication, if we only knew what was causing this patient’s debilitating muscle weakness. While groups are fighting to preserve the purity of what we do know, the best science is a moving target. Yes, sales representatives provide information that influences a prescriber’s behavior, but so, too, do many other people.

Young doctors, in particular, are shaped by the views of their ward attendings, medical school lecturers, online reference materials, and even scholarly journals, not to mention their own cultural background. Editors of peer-reviewed literature strive for the best data, the elusive truth, but the task is Sisyphean. Why should we then isolate medical students from the fray, creating a veneer of intellectual safety within the halls of medicine so long as industry voices are kept outside? Why not rather stress the sacred responsibility of diagnosing and treating patients, of writing a prescription based on the best available knowledge in an imperfect world?   

Pragmatic Approach

I still reflect on whether Dr. Kassirer had the right answer, and not just because its implications would cast doubt on the utility, even rectitude, of a combined degree in medicine and business administration. Drawing a bright line in the sand is appealing, since it protects against the interminable gray zones of compromise. But I am doubtful that this is the best way forward. I believe in diplomacy, in political moderation, in reaching out across the aisle. I am afraid that by erecting barriers between physicians and the drug industry, all in an effort for good, we actually will be undercutting our goals, fanning the flames of emotion and misunderstanding. I am still looking for answers to preparing medical students to enter the good fight, to hold constructive dialogue with industry, and to carry the mantle of their patients in a complex, rapidly changing world.

Reflection in Action Steps Up on Stage

On April 15, students, parents, teachers, artists, and health leaders came together to celebrate the sixth annual Reflection in Action program, sponsored by the HMS Office for Diversity and Community Partnership. The program invites sixth-, seventh-, eighth-, and ninth-graders from Boston and Cambridge to submit a visual, written, or performance piece responding to health topics prevalent in urban communities. This year, the themes included heart, lung, and blood disease; sleeping disorders; oral health; and urban health disparities. At the event, the winners display or perform their projects.

Jeff Thiebauth

Nearly 300 entries from 371 students were submitted to the 2008 contest. Above, students from the Jackson/Mann K–8 School in Allston, also known as the Young Fly Steppers, perform their winning dance routine.

The second annual Ruth M. Batson Social Justice Award was also presented at the event. John Auerbach, commissioner of the Massachusetts Department of Public Health, received the honor partly for work in his former position as executive director of the Boston Public Health Commission, where he implemented initiatives on public health issues such as tobacco control, emergency preparedness, and health disparities.

Shown above are (left to right) Claude-Alix Jacob, chief public health officer for the City of Cambridge and director of the Cambridge Public Health Department; Nancy Oriol, HMS dean for students; Susan Batson, first recipient of the Social Justice Award; Auerbach; Joan Reede, HMS dean for diversity and community partnership; and Sheila Nutt, director of educational outreach programs in the Office for Diversity and Community Partnership.

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Copyright 2008 by the President and Fellows of Harvard College