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Letter on Drug Industry Influence on Medical Residents

Letter to the Accreditation Council for Graduate Medical Education
Letter to the Association of American Medical Colleges

April 26, 2001

David Leach, M.D.
Executive Director
Accreditation Council for Graduate Medical Education
1515 North State Street Suite 2000
Chicago, IL 60610-4322 

Dear Dr. Leach, 

A survey of 117 residents at University of California at San Francisco (UCSF) teaching hospitals (105/117 residents or 90% responded) found that many considered expensive drug industry promotional items such as a free educational trip  (43%) or luggage (15%) to be appropriate. A larger proportion, 86%, considered a free dinner lecture sponsored by a drug company to be appropriate. Even among those residents who did not consider such items to be appropriate, many said they had accepted or would accept them if they were offered. Although only 39% of these doctors stated that industry promotions influenced their own prescribing, 84% thought that it did have an effect on the prescribing of other physicians. There was an appalling lack of education of these physicians about the ethics of physician-drug industry interactions with 86% stating they had little or no such education in medical school and 94% having had little or none in their residency programs. Nonetheless, approximately two-thirds thought that rules on interactions between industry representatives and residents and faculty were appropriate. The study was done by Drs. Michael Steinman, Michael Shlipak and Stephen McPhee of the Division of General Internal Medicine, Department of Medicine, University of California, San Francisco and San Francisco Veterans Affairs Medical Center and appears in the May, 2001 issue of the American Journal of Medicine (embargoed until 5 PM, April 26, 2001). Those surveyed were residents in the UCSF Department of Medicine, working in four hospitals (UCSF Medical Center, San Francisco VA medical Center, San Francisco General Hospital Medical Center, and UCSF Medical Center at Mt. Zion).

Public Citizen's Health Research Group concludes that this study confirms previous concerns about the scope of the pharmaceutical industry's largesse towards residents at this early and vulnerable phase of their careers as doctors-prescribers. The clear documentation of the massive denial of influence on the residents themselves flies in the face of a growing number of studies documenting the influence of such promotional activities on doctors’ prescribing practices. The widespread absence of educational programs on the ethics of such interactions in the large number of medical schools from which these residents must have come mandates the inclusion of such evidence-based education — including a review of published studies documenting the drug industry’s influence on doctors — in medical school curricula as well as residency training. In addition, it is urgent that teaching hospitals adopt policies to restrict the contact between drug industry representatives and medical students, residents and faculty. A previous study of family medicine residency programs found that in those programs with restrictions on such contacts there were fewer gifts to residents and less perceived benefit of drug industry promotional information.[1] Other studies have documented the influence of the pharmaceutical industry on doctors’ requests for specific drugs to be added to hospital formularies[2] and on physicians’ own prescribing practices.[3]

We are writing to the Accreditation Council for Graduate Medical Education (ACGME) because your organization accredits residency training programs to ask that you require much more education of residents concerning these issues and that you also urge widespread adoption of a model set of restrictions — based on the more stringent of those now in effect — to limit, if not eliminate, pharmaceutical industry contact with residents. We are also writing to the Association of American Medical Colleges to urge that they incorporate much more education about these issues into medical student education and similarly promote model, stringent restrictions on pharmaceutical industry/resident interactions. We would be glad to meet with you to discuss these issues.

Sincerely,

Sidney M. Wolfe, M.D.
Director

Peter Lurie, M.D., M.P.H.
Deputy Director
Public Citizen’s Health Research Group


 

References

[1] Brotzman GL, Mark DH. The effect on resident attitudes of regulatory policies regarding pharmaceutical representative  activities. J Gen Intern Med. 1993 Mar; 8(3):130-4.

[2] Chren MM, Landefeld CS. Physicians' behavior and their interactions with drug companies. A controlled study of physicians who requested additions to a hospital drug formulary. JAMA. 1994 Mar 2; 271(9): 684-9.

[3] Orlowski JP, Wateska L. The effects of pharmaceutical firm enticements on physician prescribing patterns. There's no such thing as a free lunch.  Chest. 1992 Jul;102(1):270-3.                      


Letter to the Association of American Medical Colleges

April 26, 2001

Jordan Cohen, M.D.
President, Association of American Medical Colleges
2450 N. St, NW
Washington, DC 20037 

Dear Dr. Cohen,

A survey of 117 residents at University of California at San Francisco (UCSF) teaching hospitals (105/117 residents or 90% responded) found that many considered expensive drug industry promotional items such as a free educational trip  (43%) or luggage (15%) to be appropriate. A larger proportion, 86%, considered a free dinner lecture sponsored by a drug company to be appropriate. Even among those residents who did not consider such items to be appropriate, many said they had accepted or would accept them if they were offered. Although only 39% of these doctors stated that industry promotions influenced their own prescribing, 84% thought that it did have an effect on the prescribing of other physicians. There was an appalling lack of education of these physicians about the ethics of physician-drug industry interactions with 86% stating they had little or no such education in medical school and 94% having had little or none in their residency programs. Nonetheless, approximately two-thirds thought that rules on interactions between industry representatives and residents and faculty were appropriate. The study was done by Drs. Michael Steinman, Michael Shlipak and Stephen McPhee of the Division of General Internal Medicine, Department of Medicine, University of California, San Francisco and San Francisco Veterans Affairs Medical Center and appears in the May, 2001 issue of the American Journal of Medicine (embargoed until 5 PM, April 26, 2001). Those surveyed were residents in the UCSF Department of Medicine, working in four hospitals (UCSF Medical Center, San Francisco VA medical Center, San Francisco General Hospital Medical Center, and UCSF Medical Center at Mt. Zion).

Public Citizen's Health Research Group concludes that this study confirms previous concerns about the scope of the pharmaceutical industry's largesse towards residents at this early and vulnerable phase of their careers as doctors-prescribers. The clear documentation of the massive denial of influence on the residents themselves flies in the face of a growing number of studies documenting the influence of such promotional activities on doctors’ prescribing practices. The widespread absence of educational programs on the ethics of such interactions in the large number of medical schools from which these residents must have come mandates the inclusion of such evidence-based education — including a review of published studies documenting the drug industry’s influence on doctors — in medical school curricula as well as residency training. In addition, it is urgent that teaching hospitals adopt policies to restrict the contact between drug industry representatives and medical students, residents and faculty. A previous study of family medicine residency programs found that in those programs with restrictions on such contacts there were fewer gifts to residents and less perceived benefit of drug industry promotional information.[1] Other studies have documented the influence of the pharmaceutical industry on doctors’ requests for specific drugs to be added to hospital formularies[2] and on physicians’ own prescribing practices.[3]

We are writing to ask that the Association of American Medical Colleges require much more education of medical students and residents concerning these issues and that you urge widespread adoption of a model set of restrictions — based on the more stringent of those now in effect — to limit, if not eliminate, pharmaceutical industry contact with medical students and residents. We are also making this request of the Accreditation Council for Graduate Medical Education (ACGME), that accredits residency training programs. We would be quite willing to discuss this important issue with you and your staff.

Sincerely,

Sidney M. Wolfe, M.D.
Director

Peter Lurie, M.D., M.P.H.
Deputy Director
Public Citizen's Health Research Group 


References

[1] Brotzman GL, Mark DH. The effect on resident attitudes of regulatory policies regarding pharmaceutical representative activities. J Gen Intern Med. 1993 Mar; 8(3):130-4.

[2] Chren MM, Landefeld CS. Physicians' behavior and their interactions with drug companies. A controlled study of physicians who requested additions to a hospital drug formulary. JAMA. 1994 Mar 2; 271(9): 684-9.

[3] Orlowski JP, Wateska L. The effects of pharmaceutical firm enticements on physician prescribing patterns. There's no such thing as a free lunch.  Chest. 1992 Jul;102(1):270-3.

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