No Free Lunch (Paul Jung)

PREFACE: It is no secret that drug com- panies operate in a world of high risks and potentially high gains. Recouping large in- vestments made in new drug research and development and maximizing corporate profits depend on persuading the medical community to prescribe as much of specific medications as possible. That persuasion takes many forms, including funding re- search, sponsoring educational events, and providing a variety of promotional gifts to physicians. The ubiquity and expense of these efforts raise difficult ethical ques- tions for physicians and the public. Paul Jung, an internist recently out of residency, and Howard Brody, a veteran medical educator, explore the vulnerabilities of physicians to the blandishments of drug promotion. Jung is concerned about physi- cians’ hunger, real and metaphorical, and Brody about a sense of entitlement that tends to drop physicians’ guard to poten- tial intellectual compromises. Frank Davidoff, editor emeritus of the Annals of Internal Medicine, recounts his ex- perience struggling with the conflicts of interest inherent in manuscripts submit- ted by authors whose research was spon- sored by drug firms. Commenting on the articles from the perspective of the industry, Bert Spilker, a senior vice-president of the Pharmaceutical Research and Manufacturers of America, explains the valuable role that drug representatives can play in educating physicians about new drugs and, in turn, improving treatment for patients.

Afew months after settling into my internship four years ago, I found a pack of M&M candies in my mailbox. As- suming that the chief residents were rewarding their charges with a little treat, I took the packet, then noticed the sticker: “Compliments of Boehringer Ingelheim Pharma- ceuticals, maker of Atrovent and Combivent.” The same packets sat in most of the other residents’ boxes, and empty wrappers littered the corner trash can. I immediately wrote a note to our program direc- tor, attached the M&Ms, and placed both in his in-box. His secre- tary could tell that I wasn’t pleased.

Every year U.S. pharmaceutical companies spend an estimated $10,000 per physician on advertis- ing. About half of the more than $11 million that the industry annually invests in advertising goes toward equipping sales representatives with trinkets and toys that they dis- pense to physicians and residents at hospitals, clinics, and private prac- tices. Debate rages over whether such practices affect physicians’ prescribing behavior. And some consumer groups blame high drug prices on these marketing costs. Regardless of any such link, the ethical question remains: Should physicians accept gifts—large or small—from a company that may influence, or at least appear to influence, our medical decisions?

Gifts And Good Food

Pharmaceutical companies sponsored two or three free lunches a week throughout my residency. These occurred dur- ing our noon educational conferences. Each buffet was ar- ranged so that while standing in line for food, residents had to pass by one or two drug reps, trained to talk up their drug and reinforce their message with freebies such as pens, notepads, rubber “stress” balls, stuffed animals, refrigerator magnets, and laminated index cards with helpful dosage formulas. Americans bash HMOs on the grounds that their decisions are based on money rather than medical need. How would they feel if they knew that doctors’ prescription decisions may hinge on who pays for lunch? One study shows that 85 percent of medical students feel it is improper for a politician to receive corporate gifts, yet only 46 percent believe that physicians should refrain from accepting handouts. We physicians apparently hold politicians to higher standards than those for ourselves.

After reading my note, the residency program director issued a policy prohibiting any further gifts or ads in our mailboxes. He invited me to review the policy on resident interactions with drug reps so that I could propose changes to the program director’s committee. My recommendation: No more ad-vertisements or gifts at our lunch conferences and no one-on-one interactions between drug reps and hospital physicians. Instead, the reps could contribute to a fund to pay for lunches and receive recognition for doing so at the year-end graduation banquet.

I felt so strongly about this because the issue of undue influence is most critical during residency training, when young physicians’ knowledge and decision-making skills are being nurtured. New medical developments are constantly emerging, to be sure, but resi- dents should be hearing about them from faculty at educational conferences—not from drug reps at drug company–sponsored lunches.

Trying To Change Minds

At the next program director’s meeting we dis- cussed my proposal. Comparing noon conference sign-in sheets between days with free lunches and days without revealed no large differences in attendance. Hoping to sway opinion, I distributed copies of my annotated literature search, “There’s No Such Thing as a Free Lunch.” The research it cited provided scien- tific evidence of the effects of pharmaceutical gifts on physicians’ prescribing behavior. For instance, literature shows that physicians who interact with drug reps favor the advertised drugs. This finding holds true for direct financial gifts and for less direct interactions such as free meals and brief conversations with drug reps. Studies also indicate that residents who attend educational programs given by drug reps tend to overprescribe and misprescribe the advertised drug. Surveyed residents and physicians agree that such interactions compromise medical judgment yet insist that they personally are not affected. Despite this evidence, fellow residents on the committee were ambivalent about my proposal. So much for evidence-based practice.

At that meeting our program director gave us three options: the status quo, the “Jung plan,” or the “high road,” as he called it—a ban on all pharmaceutical interactions. As the discussion ended, he reached over and pulled a penlight out of my coat breast pocket. Expecting to see a pharmaceutical name on it, instead he found our hospital’s logo. Relieved, he raised one eye- brow. “I didn’t even know we made these pen- lights,” he said. We ended the meeting with no final decision. He cautioned the resident rep- resentatives that no matter what our personal opinions, our first responsibility as committee members was to gauge the opinions and con- cerns of the house staff.

Discussions with other residents revealed a common attitude: Residents were overworked and underpaid, so why not allow us a free lunch now and then? At one noon conference a fellow resident pulled me aside to ask why I was trying to take away our free lunches. After a fairly heated exchange, he exclaimed,

“You want us to buy our own pens?!”
Later I learned that the hospital’s pharmaceutical and therapeutics committee had taken up the matter and decided to propose the high road—barring all pharmaceutical reps and their money from the hospital. We were told that this proposal obviated the need for a departmental policy. I let the committee’s decision rain from above; it was guaranteed to be unpopular. As a chief resident put it, “There are good arguments on both sides, but no one wants to be known as the Grinch who took lunches away from the residents.”

Back To Square One

Eventually the proposal went before the hospital’s full graduate medical education (GME) committee. Almost everyone in that group opposed the ban. As the debate un- folded, one gastroenterologist remarked that a hospitalwide prohi- bition against house staff’s interacting with drug reps would not adequately prepare us for the real world, where we would be bombarded with larger, potentially more corrupting gifts such as drug company–sponsored research funds or plane tickets to sponsored conferences. The cheap toys we were given in residency were only the tip of the iceberg. In addition, if all lunch interactions were banned, residents would be flooded with offers for off-campus, extracurricular dinners. These would not only be unsupervised but would provide free alcohol. Better instead to keep the interactions in house, with faculty supervision.

His solution was to require a faculty member to attend all confer- ences where drug reps were present. This would be easy to do; as a rule, many faculty attended educational conferences. The GME committee agreed that this was a good idea—akin to holding our hands as we crossed a busy street instead of prohibiting us from crossing at all. The definition of and conditions for supervision, however, were not made explicit. No one mentioned that pharmaceutical lunches with faculty “supervision” might convey tacit ap- proval, even encouragement, to accept favors.

After this new default policy went into effect, faculty were indeed present at resident conferences. But their specialties did not coin- cide with the products being pushed, leaving them in a poor posi- tion to evaluate the information the drug reps were dispensing, let alone to screen it for residents. Rheumatologists appeared at lunches sponsored by Viagra, cardiologists at conferences spon- sored by Cipro. And faculty never “supervised” the reps; maybe they didn’t know it was their newly assigned duty to do so. They usually sat on the other side of the room, enjoying their subsidized lunch.

Practicing physicians are not immune to drug company goodies. In the home of an older, well-to-do cardiologist, I once sighted an Evista clock on the living room wall and a box of Vioxx tissues in the bathroom. At a meeting I saw an endocrinologist wearing a watch displaying a Humulin logo with a small fork and knife as hour and minute hands. One would think that becoming a practicing physi- cian with quadruple the income of a resident would curb the need for cheap baubles, but that’s not what I have observed.

One infectious-disease faculty member pulled me aside and joked that instead of moonlighting, residents could simply rent the space on the back of their white coats for pharmaceutical ads. If athletes can have corporate logos on their jerseys and race cars, he said, laughing, why couldn’t we do the same?

A Stopped Buck

I didn’t think that the agreement to have faculty supervise drug-sponsored lunches went far enough, so I continued to try to set up a more effective policy. Without much support from my peers, I relied on our program director, a genial man who brought his own lunch to work every day. He was responsible for all final decisions about the residency program and often pointed to a plac- ard on his desk that said, “The Buck Stops Here.” I considered this a good sign, because he felt the same way I did about pharmaceutical marketing. However, a contentious issue required discussion in his committee and among the residents. Prohibiting drug lunches proved to be impossible when all but one resident opposed the idea.

Two years later, as a senior resident, I observed no change in the drug lunch situation. I was about to request a reconsideration of my original proposal, but more immediate concerns took over. The clos- ing of several smaller hospitals in the city combined with a flu epidemic to swell our admission rates. Things got so bad that we were forced to board medicine patients on psychiatry and rehabili- tation floors. House staff were swamped with work. My quest for an ethically clean residency training program, at first so clear, became muddied. In times like these, it was difficult to think that a free lunch here and there wasn’t a small reward for our hard work. One final meeting with my program director near the end of my resi- dency revealed an administration thrown headfirst into the health care crisis. I decided to let my point ride until things settled down, which they never did. I finished my residency with no significant change in the hospital’s drug rep policy.

Feeding The Soul

One way to help physicians-in-training avoid the temptation of drug-sponsored lunches might be to have the hospital supply them instead. At $4 per meal for a class of thirty residents, an internal medicine residency program would spend less than $100,000 a year on providing free lunches every weekday. This is pocket change compared to a teaching hospital’s total budget. Perhaps instead of trying to restore diminishing GME funding in Medicare, Congress could simply instruct the Centers for Medicare and Medicaid Services to provide free lunches to house staff nationwide.

Residency programs are charged with training and guiding this country’s future physicians. These programs should provide an educational environment that sets us on a straight path toward appropriate medical care. Allowing pharmaceutical companies to pander to our hunger under the guise of exposing us to “real-world” situations is an excuse for convenient lunches. “An army runs on its stomach,” my program director had said to me during my futile struggle to end drug company–sponsored lunches. In difficult times for public hospitals like the one in which I was trained, I can’t deny this. But we must spend less time worrying about residents’ stomachs and more time worrying about their souls.

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