Medical Residencies Closing The Door On Pharma?
36 CommentsBy Ed Silverman // March 25th, 2011 // 9:11 am
The pharmaceutical industry has traditionally established ties to doctors during their formative years in residency programs, but more recently, drugmakers have been shunned by several high-profile academic medical centers over concerns of undue influence on medical practice. Now, a new study in Academic Medicine finds that a wide array of family medicine residencies are taking similar steps.
The researchers conducted a nationwide survey of family medicine residencies to determine the extent and type of industry interactions with trainees and to identify so-called pharma-free residencies that avoided iindustry influence. And so they e-mailed four questions to residency directors or coordinators at all 460 accredited US family med residencies. In all, 286 replied.
The findings: 75 residencies, or 26.2 percent, were designated as “pharma free,” which meant they did not permit any industry food, gifts, samples, or support of residency activities. The authors maintain this amounts to a “major change from 1992,” when 90 percent of family medicine residencies allowed industry support, according to prior reserarch. Overall, residency programs based at med schools were no more likely than community-based residencies to be free of pharmaceutical influence, they write.
To be more specific, 52 percent refused samples; 48.6 percent forbid industry gifts or food; 68.5 percent do not allow industry-sponsored residency activities and 44.1 percent denied industry access to students and residents at the family medicine center. Among the 211 programs that permitted interaction, 68.7 percent did allow gifts or food, 61.1 percent accepted samples, 71.1 percent allowed sales reps access to trainees in the family medicine center, and 37.9 percent allowed industry-sponsored residency activities (see the abstract).
A few nationally known academic medical centers, such as Yale, have received considerable attention for restricting industry interaction (see this and this), but the results indicate that lesser-known academic medical centers and community-based residencies have also quietly severed industry relationships, the authors write. “Our survey shows that community residencies are in the forefront of the movement to restrict industry relationships, which is iimportant because the vast majority of family medicine residencies - 88 percent - are not located in large university–medical school complexes,” they conclude.
There are obstacles, however, to enacting such policies. One respondent, for instance, wrote that rolling out a pharm free policy “has been a difficult transition because food is addictive,” a reference to the many free meals provided by reps. And these meals would, otherwise, have to come from residency budgets, in most cases. And you know, residencies cannot control everything their residents are doing. ““We have no interaction for 5 years,” another respondent wrote, “and it works well, but residents still go to events on their own.”
Among the limitations: 37.8 percent of family medicine residencies did not respond, so it is possible that programs that allow interaction with pharma may have been less likely to respond. And if every program that did not respond presumably permits industry relationships, the percentage of pharma free residencies would fall to just 16.3 percent.
The survey was conducted by PharmedOut, a project based at Georgetown University Medical Center that is designed to educate physicians about pharmaceutical industry promotions, and the American Medical Student Association, which runs a PharmFree project that frequently ranks medical schools on their policies toward pharma (see this).
Barbie
Great Cost goes up for Med Schools this will add to our already shrinking base of Family Practice docs. Who gives crap if a resident gets some free pizza; we trust their judgment regarding our health but not their moral code. Ed how about some articles regarding managed care formularies and their influence on prescribing? It’s where the real story is and where the impact on care actually happens.
industry insider
I have a nephew who is a PGY 1 working for the type of slave wages I worked for. I’ll forward him the story and will definitely advise him to ask for an additional $2500 in next year’s contract tom pay for the lunches that will now come out of his own pocket. That’s the hidden cost of this whole “No Free Lunch” idiocy. That $2500 could have partially defrayed the cost of going to a scientific meeting where he might have learned something to help him become a better physician.
But then again, nobody thinks of these things in this way…
Searching2000
Since I had to look it up, I might as well share!
Acronym Definition
PGY1 Postgraduate Year 1
Insider
I think it is a good idea to limit interaction since harma went away from Scientific information and now spends most of their time spinning the data to make it work for their product. Our details were oftennot based on fact but just a spin on the data to make the drug look good even if not supported by the research. One DM argued with me that I could not even work for their comany if I did not beleive ALL of our products were superior to the competition. They are not hiring many reps any longer with background in Biology so the rep is more likely to believe anything the manager tells him particularly if he wants to keep his job.
Doc
Insider,
Was it on purpose or a Freudian slip? “Harma”?
Either way I love it! They don’t want people with science anymore, but business.
Barbie
Lies we our undergoing a industry shift towards hiring RN’s and hard science backgrounds. I should know I am one of the DM’s that does the hiring.
Michael S. Altus, PhD, ELS
Industry Insider (March 25th, 2011 10:43)
Who really pays for the lunches that you want your nephew to get for free from pharmaceutical companies? Grandma does. And so do Medicare and Medicaid do so in the form of higher drug prices. There’s no such thing as a free lunch.
Just ask Grandma.
Justice in MI
Needless to say, there’s been a lot of ink on this topic. I’d especially recommend an article by Paul Lichter, one of the premier opthatmologists in the U.S..
http://www.ajo.com/article/S0002-9394(08)00276-6/abstract
Justice in MI
try this version of link…
http://www.ajo.com/article/S0002-9394(08)00276-6/abstract
Justice in MI
Well, if you google Paul Lichter, “Debunking Myths in the Physician…etc.” you’ll find the whole thing on the American Journal of Opthamology cite, no charge.
industry insider
Dr. Altus, with all due respect, if any grandmother knew the “drek” that was on the hospital cafeteria lunch line I assure you that she would much prefer any of her physician relatives to take advantage of the heaping helpings of the free lunch offerings from the drug reps. Not to gross you out, but in my training institution, the hospital kitchen was located in the basement next to the morgue. I never wished to know whether they shared a common water supply.
Pharma Harma
Well, this is good news. Hats off to the organizations behind this, and let’s hope it goes way further…what one learns at the cradle is hopefully carried along to the grave.
Michael S. Altus, PhD, MD
Paul R. Lichter. Debunking Myths in Physician–Industry Conflicts of Interest.
American Journal of Ophthalmology, Volume 146, Issue 2 , Pages 159-171, August 2008.
Free content available at .
Allan J. Flach. Correspondence.
American Journal of Ophthalmology
Volume 147, Issue 3 , Pages 562-563, March 2009. Paid content available at .
Thank you, Justice in MI!
Michael S. Altus, PhD, ELS
Opps, that’s Michael S. Altus, PhD, ELS, NOT PhD, MD. Sorry about that. “ELS” refers to certified as an Editor in the Life Sciences by BELS, the Board of Editors in the Life Sciences (www.bels.org).
John English
Insider, with all due respect and FRI PM humor, sharing a “common supply” is not an issue if the piping for the potable water is properly installed.
If the kitchen was drawing their water in the morgue and carrying it over, now that would be a different situation - ” n’est pas? “
Doc
Barbie,
Our DMs were just told to specifically hire business backgrounds, not pharma or science.
Michael S. Altus, PhD, ELS
As I explain, Industry Insider (March 25th, 2011 10:43), pizza is still permissible. Would you please ask your nephew the PG1 if he would actually go to a pharma-sponsored presentation if meals were not available?
PhRMA’s (Pharmaceutical Research and Manufacturers of America’s) Code on Interactions with Healthcare Professionals (http://tinyurl.com/68yggb2), which took effect in January 2009), has 25 questions and answers. Of the 25, 12 mention the word “meal” or “meals”. As you can see, pizza is still permissible.
Q.7: The Code states that company representatives or their immediate managers working in company field sales organizations may conduct informational presentations and discussions accompanied by occasional, modest meals in the healthcare professional’s office or hospital setting. What types of presentations and meals would this include?
A. An informational presentation or discussion conducted by company representatives or their immediate managers working in field sales may be accompanied by an occasional modest meal in the office or hospital setting. Such modest meals may only be offered provided that the manner of presentation is conducive to a scientific or educational interchange and is not part of an entertainment or recreational event. For example, a sales representative who is providing scientific or educational information regarding a company’s products to one or a few healthcare practitioners working in the same office, could provide a modest meal (e.g., SANDWICHES OR PIZZA [emphasis added]) to physicians and staff attending the representative’s informational presentation in the physician’s office at lunch time. Providing such modest meals on more than an occasional basis would not be appropriate.
Q.9: A field sales representative of Company X provides PIZZA [emphasis added] for the staff of a medical office during lunch time. Is this consistent?
A. Providing an occasional meal would be consistent with the Code if the sales representative will provide an informational presentation to the medical staff in conjunction with the meal of modest value, so long as the location of the in-office presentation is conducive to scientific or educational communication. Merely dropping off food for the office staff, however, would not be consistent with the Code.
Ah, yes, food is addictive!
Michael S. Altus, PhD, ELS
Paul R. Lichter.
Debunking Myths in Physician–Industry Conflicts of Interest
American Journal of Ophthalmology.
Volume 146, Issue 2 , Pages 159-171, August 2008.
Free content available at .
Allan J. Flach
American Journal of Ophthalmology.
Volume 147, Issue 3 , Pages 562-563, March 2009.
Paid content available at .
Thank you, Justice in MI.
Michael S. Altus, PhD, ELS
Darn. Didn’t like my links.
Lichter:
http://tinyurl.com/4lf55km
Flach:
http://www.ajo.com
David Duval
The links here are more challenging than St. Andrews…
Glad that Ernie ELS stepped up.
Insider
Have not seen a bio major in the field for a long time. Since they often have integrity and a caring for the patient, they are not going to last long if asked to make false claims and misleading statements.
outcomes guru®
our hospital (major academic) stands to lose much more money in 2014 on withholds than it saves by giving everyone the cheapest generic available -especially with regard to antibiotics.
It’s always been about the money. Why are our clinical pharmacists, who are paid a bonus based upon drug costs, any different than the rep who is paid a bonus to sell? Eventually the C-Suite will have to hold the pharmacists accountable. Comparative effectiveness works both ways in the future and as ACOs come into reality, the silo mentality of academic centers is in for chaos.
industry insider
Dr. Altus, I’m relieved that pizza is still available. I estimate that pizza represents 20-30% of the weekly caloric intake of a busy hospital resident these days, and for the ER physicians maybe close to 100%, although they usually have to buy their own pizza seeing that they don’t get to many rep-sponsored conferences. In my day, it was the job of the 3rd or 4th year medical student to make the nightly pizza run, the bonus being that he/she got to keep the change.
Outcomes guru, you are correct. I forgot the specific term, but in some managed care setups, pharmacists as well as physicians are paid bonuses based on how much utilization they do NOT provide. The less they provide, the more they pocket. Perverse and true.
Grant
It’s really sad to think that anyone would even be concerned with a free lunch. My personal opinion is that what we have here are too many people worried about the impression about being influenced and not truly able to think independently. Leave it to the student to decide what’s best for him or her in their individual situation.
industry insider
With all due respect, Grant, my PGY1 physician nephew makes $8.40/hour based on his salary and average hourly work week. That’s probably a lot less than most people on this board earn for a heck of a longer work week. Therefore I don’t mind him cutting him some slack with a free slize of pizza or a sandwich for lunch.
Furthermore, ask any busy resident about what the drug company was whose rep gave him the last slice and they will tell you that the name was forgotten by the time the resident reached the end of the hallway or their pager went off. To actually believe that a busy resident, preoccupied with paying back six figure medical school loans and whether he/she will earn more than a lackey’s salary in the future is prone to drug company influence is pure and utter folly.
outcomes guru®
our institution banned all meals with industry. we also banned our faculty from attending industry sponsored talks, even on their own time and even if they pay for the meal themselves. we also banned our faculty from speaking for industry.
it’s pretty interesting that the Deans and C-Suite all sit on boards and accept compensation from industry but that we banned a surgery resident from getting a bagel and coffee from some drug rep
Michael S. Altus
With all due respect, industry insider (march 27, 2011; 9:35 am); consider the following from the FAQs (www.nofreelunch.org/faqs.htm#question12) of No Free Lunch, “health care providers who believe that pharmaceutical promotion should not guide clinical practice. Our mission is to encourage health care providers to practice medicine on the basis of scientific evidence rather than on the basis of pharmaceutical promotion. We discourage the acceptance of all gifts from industry by health care providers, trainees, and students. Our goal is improved patient care [www.nofreelunch.org/aboutus.htm]”
Q. I work long hours, studied for many years, and have paid my dues. Aren’t I entitled to all this stuff?
A. Yes. And you are also entitled to a Nobel Prize; but you aren’t going to get that either. You may be entitled to a high salary, and this is why the physicians’ salaries, in the U.S. at least, are considerably above the National average. But you are not entitled to gifts from the pharmaceutical industry any more than a congress-person is entitled to gifts from lobbyists. And even less so if these gifts drive up drug costs and lead to inappropriate prescribing.
Furthermore, industry insider, what is the evidence that any busy resident about what the drug company was whose rep gave him the last slice will tell you that the name was forgotten by the time the resident reached the end of the hallway or their pager went off?
Michael S. Altus
Let’s turn the situation around:
What are the policies that gift-giving pharmaceutical companies have about their own employees’ receiving gifts?
Effective July 1, 2010, Vermont law banned giving gifts, with some exceptions, to healthcare providers. Before then, Vermont law required pharmaceutical manufacturers to disclose gifts to physicians and other health care professionals. The most recent data, for fiscal year 2009 (July 1, 2008 to June 30, 2009), show that the manufacturers spent about $2.6 million. Physicians and nurses received about $2.1 million of these gifts. Gifts worth less than $25 were exempt from disclosure. The top five spenders for marketing in Vermont during FY 2009 were Pfizer, Lilly, Forest, Merck, and GSK. These data, which do not reveal the actual amount spent by each company, are at http://tinyurl.com/27f5pmm.
Here is the policy of one of these top five spenders about its employees receiving gifts:
Pfizer
The Blue Book: Summary of Pfizer Policies on Business Conduct (http://tinyurl.com/25ufurl), p. 27
Giving and Accepting Gifts, Entertainment, Loans, or Other Favors
The Company prohibits you…from giving and receiving gifts, services, perks, entertainment, or other items of more than token or nominal monetary value to or from the Company’s suppliers, customers, or other third parties. Moreover, gifts of nominal value are permitted only if they are not given or received on a regular or frequent basis.
The policies of the other four top spenders are similar.
The unblinking hypocrisy is galling.
industry insider
Dr. Altus, my sample size is about n=50, which represents the clinical residents that I’ve taught and mentored, who work 2-3X the usual humane work week and may sometimes be sleep-deprived. By the end of their shift they sometimes have trouble remembering their locker combination or where they parked their car. Furthermore, with industry mergers and consolidations, there is a good possibility that the company whose rep donated a slice of pizza to a sleep-deprived food deprived resident will have a different name by the time he/she is in practice.
I admit this was a biased sample. None of my residents belonged to AMSA, which pushes the “No Free Lunch” agenda. They were too busy as med students gunning for the top residencies, which also included no time for reps.
Personal disclaimer. As a second year medical student I received a Lilly bag and a Welch-Allyn ophthalmoscope/otoscope. I never used their company’s products any more than others. The reality is that today’s hospital resident prescribes whatever the formulary allows, and grabs whatever stethoscope he/she can find, sometimes out of the med student’s or nurse’s pocket, whichever is handy, and also usually without knowledge of who made the instrument.
I’d really like to know why so many people think that these doctors in training, who spent years holed up in libraries and laboring over cadavers, microscopes and pulling 3X/week overnight call suddenly wake up one day and decide that they will become shiils for big pharma.
As the shrinks say, analyze that.
harpy
“suddenly wake up one day and decide that they will become shiils for big pharma”
good question. I think the answer is money, flattery, and a sense of entitlement. as you say, they’ve put in all of this hard work for very little reward, why shouldn’t they be paid big bucks by the companies that fed them and loved them while they were in school, gave them the (branded) tools of their trade as they were starting out, and will tell them how brilliant and deserving they are, these key opinion leaders. I mean, you’d have to be some kind of saint to resist that. what’s the harm? pharma is all about what’s best for the patient, right? and what’s good for the the doctor, is good for the patient.
industry insider
Harpy I think we agree that what’s best for the patient is for the doctor to “do no harm”. In this definition I also include harm to the healthcare system, such as when a more expensive drug suggested by a rep is no better than a cheaper generic alternative, no matter whether the drug is Rx’ed by a resident, attending MD or an NP.
outcomes guru®
ii: why does the reverse of that get no attention? what about when the clinical pharmD, who is paid a bonus based upon resource allocation, ensures that every decubitus ulcer patient gets vancomycin regardless of renal sufficiency, regardless of MICs and regardless of past antibiotic exposure instead of in select cases considering 5 branded alternatives?
Surely you realize that in the very near future the acquisition cost alone that you speak of is not nearly as important to how we allocate scarce resources as is total cost of care.
the pharmD is just as guilty as the rep. both get paid a bonus, just from different masters.
pharma gal
This very passionate discussion shows how effective the propaganda against pharma has been and how poor the job PhRMA has done to defend the industry who has brought a lot of progress. I have been part of many an ad board with pharmacists, PBMs, Hospital Network etc. They all admit that price is the only criterion they are held accountable for and bonus incentives to the pharm Ds, pharmacy directors, and doctors are a fact of life. Doctors are sometimes reprimanded for prescribing branded drugs and certain side effect yes, may occur but the end justifies the means. When asked about system wide better outcomes we were told that “as long as my bonus is based on the pharmacy budget line item I will make the decisions based on my bonus criteria”. I am sure no one will acknowledge this comment eiher because it does not fit propaganda about how mercenary pharma is. Just remember when you all are patients, these teaching institutions will very frequently make the drug choices based on costs.
industry insider
Since every decubitus ulcer patient presents the ultimate possibllity of sepsis and death(read Chris Reeve bio), I have no problem ordering vancomycin on all of these patients. By the time the MIC’s come back the patient could be dead. You’ll need a better example, guru.
outcomes guru®
disappointing insider. I had higher hopes for you. Of course vancomycin might work. It also costs about $22 bucks a day to acquire.
Alternatives where you know you will get drug to the site of the infection regardless of renal sufficiency include daptomcyin, tigecycline, linezolid, televancin and perhaps even know, the new cephlasporin (not sure if it is stocked yet but the FDA did approve).
certainly those drugs are expensive and should be reserved for special cases, but the reality is that vancomycin will be given first line all the time.
renal capacity. MICs. previous ABx exposure. Cell wall thickness. Lots of other variable, but the only one our pharmacy looks at is cost. Unless the patient is a relative.
Yigel Bander, M.D., Ph.D.
Some of the comments here are rather disappointing.
Ethics in the medical field has deteriorated substantially over the past 10-15 years, with pharmaceutical sales reps even resorting to sexual tactics to get physicians to ally with a particular company.
Where has the integrity in the field of medicine gone?
We must have a “separation of church and state” mentality when it comes to medical students very open to suggestion by the ubiquitous money of big pharma. This article reveals a step in the right direction.
It’s time for our doctors to do something they have not done in a long time, i.e. think for themselves when it comes to administration of prescription medications. I believe, as do several in my circle, that standards for entry into medical school must be raised to exclude those who favor rote memorization in lieu of critical thinking.
We would all be much better off.
Y. Bander, M.D., Ph.D.