Free for all

Do you rush off to attend a free lunch and talk on hospital placements? Or is your white coat weighed down by a pocket full of free pens? Upasana Tayal looks into the cost of these freebies

Holding your Viagra pen, you start your essay on your Suscard Buccal paper, with your Imigran ruler, Pulmicort pencil, Diflucan rubber, and Ziagen highlighters close at hand. All is going well as you type up your masterpiece, then drama strikes. In a bid to answer your ringing Adalat phone, you knock over the Combivir cup containing your caffeine boost. No worries though, you mop up the mess with your Tylex tissues.

Clearly drug company spoils can come in rather useful for the impoverished medical student, but they hide a murkier reality. As innocuous as pens and pencils seem, they are but a precursor to a more ostentatious world of gold plated pens, fancy dinners, and lavish holidays. Although we are uncomfortable with the latter,¹ many see little problem with the former. After all, it's just a cheap plastic pen; isn't it?

No free lunches

That old adage, "there's no such thing as a free lunch" could not hold truer than for the relationship between big pharmaceutical companies--known as Big Pharma--and medical students. Drug companies are not totally bad guys, but they are business oriented companies driven by monetary gains. In the United States, drug promotion is estimated at $19bn (£10bn; a15bn) and, in Australia, Peter Mansfield's group estimates the total to be about $A1.5bn (£0.6bn; $1.2bn; a0.90bn).²

The benefits for drug companies include influencing attitudes towards them in the hope that medical students will use them as a source of drug information and one day prescribe based on this information and brand recognition. One Canadian study compared trainee residents from two university hospitals, one restricting contact with drug company representatives and the other not restricting access. The study found that the greater the contact with representatives during training, the more useful the residents later found their information.³ However, confusing education with marketing is a dangerous game; the accuracy and balance of this information is questionable.⁴

"Gifts also open up conversations with sales representatives," says Joel Lexchin, associate professor of health policy and management at York University, Toronto, "Sales representatives are the most effective form of drug promotion and about half of a company's marketing budget is spent on the salaries and expenses of these people."

Ultimately someone has to foot the bill and it isn't going to be the profit margin minded drug companies. In the United Kingdom the NHS picks up Big Pharma's tab, whereas in the United States it is the patients and their insurance premiums.

Few data document whether pharmaceutical companies have access to medical students. In the United Kingdom, students cannot prescribe and many medical schools have no official policy. But this partly stems from a lack of need or awareness and the two groups communicate little directly. Students are most likely to be exposed to pharmaceutical representatives on their general practice placements or at hospital lunchtime meetings, which their senior doctors may attend. The fact that Big Pharma is actively selling in hospital makes the process seem everyday and acceptable.

However, in some countries, medical students can prescribe drugs. In Finland and Guatemala, fourth year students can prescribe under the supervision of medical residents, and in the year before graduation they can prescribe independently.

In Haiti, students are allowed to prescribe after their fifth year. Natahalie Jean, a Haitian student said, "We are supposedly under a resident's supervision. There are all kinds of pharmaceutical companies' representatives that visit us all day long and bring us souvenirs to 'remember' us to prescribe their brand name drugs, while the state is promoting the use of generics. It is not a normal situation."

Establishing a gift relationship

However, it is not really an issue though of whether students can prescribe or not. The strongest argument against these gifts relates to the reciprocity rule. Not only does the recipient of a gift, however small, feel indebted to the donor, they will also wish to repay the favour.⁵

As Joel Lexchin, expert in drug advertising, points out, sometimes people say that they cannot be bought for a piece of pizza or a pen or some other small gift. They may well be correct, but drug companies do not necessarily want that. What they are doing by giving out these small items is establishing a "gift relationship" with medical students. When you get a gift, this act creates a feeling that you need to reciprocate in some way. Think of Christmas cards. If you get a card this year from someone to whom you did not send one, next year that person will be at the top of your list. Similarly, medical students and doctors feel a need to repay the drug companies in some way--by seeing their sales representatives the next time they come around, by agreeing to try a particular product, or by asking that a company's drug be included on the hospital's formulary.

Perversely, it may even just be the attention lavished on students that creates goodwill towards the representatives and their messages. In one US study, medical students in Chicago were asked to recall interactions with pharmaceutical representatives. They reported being sceptical of representatives who ignored them because they were students, but they rated as helpful and informative those who conversed with them or gave them gifts.⁶

Rewarded for being medics?

A common argument in favour of such gifts is that medical students are in some way entitled to them. The harshness of medical school apparently drives us to accept pens and free meals in an effort to improve our quality of life. Jerome Hoffman, visiting professor at Addenbrookes Hospital, Cambridge, and professor of medicine at University of California in Los Angeles, remembers his experiences: "When I was a student in the early 1970s on my very first day you got a gift from a drug company. The first day gift was always something that did not seem crass, like a textbook or an ophthalmoscope. The tone gets set early on. We're selfless. It's just one of the little rewards or perks. As you progress though, the rewards become less academic."

But as soon as it becomes a norm, it becomes hard to imagine that there is anything wrong with it. Jason Dana, a social scientist at Carnegie Mellon University, Pittsburgh, has looked into decision making across a variety of fields and recently specifically at the difference between what people think is right and what "should be punished." He says, "If some people do X and most people do Y, people would not punish group Y. The biggest predictor of punishment is the number of people who do it."

And of course, another vain argument is bandied about. Medical students, a most intelligent species, having fought hard to get into medical school and by doing so becoming highly regarded members of society, are not so foolish as to be sucked in by some cunning marketing ploy--are they? Wrong. Medical students recognise how Big Pharma can bias decisions, but not the decisions that they themselves make.⁵

Pharma ties: a lesson for medical school

Realistically, the ties between academia and industry are a necessary evil. But medical faculties should make every effort to manage this relationship carefully, making sure all medical students are aware of the bigger economic and political world of medicine. Even small amounts of time considering the appropriateness of pharmaceutical gifts can change medical students' attitudes. ⁷

Recognising the need for this approach is affected by key cultural differences. Jerome Hoffman was surprised by the naivety in the United Kingdom: "My impression is that while in the States where money is the national currency for everyone and drug companies are extraordinarily powerful, people are wooed from the very beginning of medical school. In the last few years a much greater sense of danger has developed about their close interaction with doctors and medical students. I am surprised how generally unconscious people [in the United Kingdom] are taking things from drug companies. It represents a potential conflict of interest. Here people don't even think about carrying around drug banners on their pens and badges. Every education meeting here, even those that are purely academic, has some sponsorship."

Jerome Hoffman certainly believes that we should actively raise awareness about the issue and he gives talks about the subject at the University of California in Los Angeles. "In general the only thing that works is education. Drug companies have billions of dollars to spend on physicians. We do have modern tools--for example, the internet, and more power than we've ever had before."

Support your local website

No Free Lunch is an organisation and website set up by American Robert Goodman to end the pharmaceutical industry's promotion in medical practice. Goodman thinks a big part of the problem is that the habit of accepting gifts starts early: "Students see their peers and teachers accepting gifts. It becomes very acceptable. Doctors should serve as better role models but with [No Free Lunch] students can be role models for teachers."

Des Spence is a general practitioner and undergraduate tutor at the University of Glasgow. He acts as a UK spokesman for No Free Lunch. He would like to see students actively question their contact with Big Pharma. "At Glasgow, there is currently no formal discussion on the medicalisation of health, pharma, and marketing. One of the things we'd be interested in is a charter for doctors to declare their contact with pharma. Medical students are more vulnerable. They are in their formative period," he says.

Michael Wilkes, vice dean of medical education at University of California in Davis, takes an even stronger stance; they do not just talk about it but prohibit all pharma exposure to medical students. "We prohibit it but most medical schools don't because most medical schools are in bed with Pharma. There needs to be more research on it but I'd say there's no advantage to it. Just say no. Why would medical students be immune to influence? They are poorer and more dependent on free lunches than anyone else."

Students taking charge

The American Medical Student Association (AMSA) is taking a proactive approach. Students, interns, and residents are urged to pledge to their PharmFree campaign which calls for an end to gifts, free lunches, and paid speaking.⁸

Although there is good reason to believe that gift taking is harmful, at present little published work considers the exact effect on prescribing habits of students exposed to Pharma compared with those who are not. No one is saying that the humble pen that started our tale is the new weapon of mass destruction, guaranteed to bring down the medical profession, but, even as medical students, we must begin to accept responsibility in our relationships with pharmaceutical companies.

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2. McCormick BB, Tomlinson G, Brill-Edwards P, Detsky AS. Effect of restricting contact between pharmaceutical company representatives and internal medicine residents on posttraining attitudes and behavior. JAMA 2001;286:1994-9.
3. Wilkes MS, Hoffman JR. An innovative approach to educating medical students about pharmaceutical promotion. AcadMed 2001;76:1271-7.
4. Lexchin J. Pharmaceutical industry sponsorship and research outcome and quality: systematic review. BMJ 2003;326:1167-70.
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