BY: BRIAN HURLEY, MD, PHARMFREE
The American Medical Student Association celebrated the first National PharmFree Day five years ago with a "pen drop" at the headquarters of Pfizer, Inc., in New York City. Just outside the front door, students deposited thousands of pens and other paraphernalia emblazoned with the names of pharmaceutical companies.
Brian Hurley, MD, who just ended a term as the association's president, was there. "It was a great event," recalled Hurley, who was a medical student at the University of Southern California. "(The association) had asked medical students to mail in pens and notepads given to them, and students from across the country sent tons of stuff. Our pen drop provided a dramatic expansion of PharmFree's presence in the media."
PharmFree is a national campaign dedicated to reducing conflicts of interest at medical schools and academic medical centers. The medical student association began the movement in 2002. Last March, PharmFree was honored with an Award of Excellence from the American Society of Association Executives and the Center for Association Leadership, recognizing associations that improve the quality of life in America.
Today the American Medical Student Association sells its own pens — as well as pins and shirts — all imprinted with PharmFree's logo. Asked if he thinks some pens are indeed mightier than swords, Hurley, 28, laughed heartily.
Hurley graduated from medical school in May 2008, also earning an M.B.A. from the University of Southern California's business school. His term as national president of the medical student association ended this past May, and, in June, he began a psychiatry residency at Boston's Massachusetts General Hospital. He took a year off between medical school and clinical training for his leadership role.
"The (association) has always been a group of dedicated, passionate activists, and to serve as national president — well, that was an once-in-a-lifetime experience," he said. Founded in 1950 and based in Reston, Va., the student association has 68,000 members.
The association reports that the pharmaceutical industry spends an estimated $28 billion to $46 billion per year on targeted marketing, providing physicians and medical students with "free lunches, gifts, medication samples and carefully selected medical literature." The medical device industry also aggressively markets products, and both industries are said to pay high consulting fees and provide trips to luxury resorts for presentations on new products. Combined, the two industries spend at least an average of $35,000 per year on each physician. The association states these presentations and personal relationships are designed "to influence doctors to prescribe more drugs" (often more expensive drugs) and "have often become a substitute for objective medical evidence." (See article in this issue.)
Critics anticipate that changes lie ahead. In March, for instance, the Pharmaceutical Research and Manufacturers of America adopted an ethics policy banning all "non-educational gifts" (including pens, notepads and calendars) to physicians and medical students. Under its new policy, free drug samples still are permitted. This ethics policy is voluntary.
Hurley says the periodic announcements of such codes "serves as an example the industry can point to of 'making things better' as more physicians and the public become aware of how egregious industry-physician relationships can be."
When the Pharmaceutical Research and Manufacturers of America announced a similar code in summer 2008, Hurley called the revised policy inadequate. He said the pharmaceutical organization's new code leaves holes, such as allowances for "occasional meals" and "the absence of a clear enforcement structure for these voluntary guidelines." Without consequences, Hurley said, the revised policy does not translate to better patient care.
Hurley makes it clear that the American Medical Student Association recognizes the pharmaceutical industry as a valuable resource for research and development of new and potentially lifesaving medications. "What PharmFree questions is the level of interaction between pharmaceutical companies and doctors," Hurley said.
"We need these companies to do the research on new medications, but we believe that every prescribing decision a physician makes needs to be based on scientific evidence, not on marketing efforts. Patients now feel they cannot trust their doctors because of the business practices of the pharmaceutical companies. Many doctors are swayed by the availability of samples, the marketing gimmicks, or a good lunch."
Are doctors so easily influenced?
No Free Lunch, a not-for-profit organization founded by Bob Goodman, MD, a PharmFree mentor, contends that doctors are indeed influenced by promotional products. On the organization's website, www.nofreelunch.org, Goodman reports that numerous studies during the past decade have concluded that "doctors' prescribing behavior as well as other behaviors (for example, requests to the hospital formulary) are influenced by promotions and interactions with sales representatives. Though many physicians may believe otherwise, there is no reason to think that they are immune."
In an article in the August 2005 issue of American Journal of Medicine titled "Do Drug Samples Influence Resident Prescribing Behavior?,"co-authors Richard Adair and Leah Holmgren, both MDs, concluded that access to drug samples in clinics influences resident prescribing decisions, and could affect resident education and increase drug costs for patients.
None of this surprises Hurley. "Pharmaceutical companies are the most profitable industry in the world," he says. "Most patients see that these companies are involved in life-saving activities, but these companies also are involved in a lot of activities that do not improve patients' lives. If more patients understood the level of profit, they would be more skeptical."
In medical school, Hurley learned a lot about pathology, disease and treatment, but little about the health care delivery system. "Health decisions are made in the context of a system, so I went to business school to get an M.B.A. so I could better understand health systems," he said. "That's when I began to be aware of what does — and does not — generate value for patients."
Hurley is particularly proud of the medical students association's PharmFree Scorecard, which tracks conflict-of-interest policies at 153 academic medical centers. The first one was released in 2007. Last year, Nitin Roper, a medical student at the University of Connecticut and Scorecard director, put it online at www.amsascorecard.org.
"The Scorecard is an important tool for medical centers to assess how they are doing in relation to their peers, and also a tool to improve existing policies," Roper said. "In just two years, we've seen a couple dozen schools develop new policies. That's exponential growth."
Initially, the scorecard graded schools on the presence or absence of a policy regulating interactions between medical campuses and the pharmaceutical and device industries. Last year, the association provided resources to medical centers to address conflicts of interest, and reassessments are made as schools adjust policies. Some academic medical centers are taking steps to alter the ties.
Some states have laws requiring pharmaceutical companies to report all gifts to physicians; others have laws prohibiting the practice of selling prescribing records to pharmaceutical companies so they can better target marketing efforts. Also, Congress is considering The Physician Payment Sunshine Act, which would require manufacturers and group purchasing organizations to report on payments to physicians and physician-owned entities.
Hurley thinks government regulation may be the ultimate solution to financial conflicts of interest. In April, the Institute of Medicine asked Congress to pass a law requiring public disclosure of all payments made to doctors by pharmaceutical companies and medical device manufacturers. The report echoes similar concerns expressed by the Association of American Medical Colleges.
In the meantime, PharmFree's work will continue. "Everything PharmFree stands for makes sense from the patients' point of view — as doctors, we need to practice better medicine for our patients," Hurley said.
Copyright © 2009 by the Catholic Health Association of the United States
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