Threats to Professionalism in Medicine: An Expert Interview With Shahram Ahari, BA, MPH

Laurie Barclay, MD

March 29, 2010

March 29, 2010 — Editor's note: There are many threats to professionalism in medicine that should be addressed, even at the medical student level, according to a panel discussion at the American Medical Student Association (AMSA) 60th Annual Convention, held from March 11 to 14, 2010 in Anaheim, California.

Threats to professionalism can range from discrimination and health disparities to substance abuse and the impact of social media on a physician's professional image. To learn more about how to improve awareness about threats to professionalism in medicine and how to overcome them, Medscape Med Students interviewed panelist Shahram Ahari, BA, MPH, a former drug representative who is now an antipharmaceutical industry activist; a first-year medical student at University of California, Davis; and an AMSA member.

Medscape: What are the main threats to professionalism in medicine encountered during medical training?

Mr. Ahari: Medical training is undeniably stressful, sometimes cruel, and tends to cultivate attitudes far different than those that inspired many to become physicians in the first place. From my perspective in drug sales, marketing exploits vulnerabilities created by such experiences that begin in medical school. For example, despite the best of intentions, some doctors (and students in the clinical years) tend to rationalize accepting gifts or engaging in business relationships that less jaded students earlier in their training would clearly identify as a conflict of interest.

Medscape: How can medical students best counteract these threats to professionalism?

Mr. Ahari: I would advise physicians and students to fight hard to stay true to their values. They should remember the noble aspirations that they wrote about in their application essays, what inspired them to commit themselves to this lifelong profession, and their vow to safeguard their patients' health above other concerns. After all, while there are many problems that need to be addressed, [we only have] control over our self.

Medscape: What do you regard as the greatest challenges facing medical students today?

Mr. Ahari: Medical school applicants are partially selected for their devotion to service and their compassion, yet once school begins, little of their training cultivates these values. In fact, modern training drives us towards paternalism and a general dehumanization of our patients. This is so common that some medical educators have formally renamed the student preclinical and clinical years as the "precynical" and "cynical" years. Ultimately, this forces students to struggle to preserve their altruistic beliefs in the face of a culture that increasingly values commodification (viewing healthcare services and skills as commodities) and efficiency.

Medscape: What role do the value systems underlying medical training play, and what shifts are needed to reduce threats to professionalism in medicine?

Mr. Ahari: A significant part of the problem stems from an imbalance in medical cultural philosophies. Some believe that health should be considered a commodity, that health has a calculated value that can be bartered, traded, and sold. Others believe that health is fundamental and intrinsic and that all people are entitled to care by virtue of simply being human, that health is a human right.

Given that such severe health disparities run along socioeconomic lines, medicine seems overly reliant on the former. The trick is to find a mutually acceptable reconciliation of these 2 philosophies to create a financially stable and efficient healthcare system that nurtures all patients and preserves the idealism of physicians in training.

Medscape: What do you believe should be the future directions of medical education?

Mr. Ahari: Medical education must make greater efforts to sustain student attitudes of compassion and service. Furthermore, it must somehow incorporate broader training in what is already a dense curriculum. After all, success in medicine today relies on much more than just the mastery of science. Beyond traditional curricula, modern medical practice requires an adequate understanding of economics, health policy, public health, and ethics. Medical training is already an intense experience, yet the current state of affairs seems to demand well-rounded doctors.

Medscape: Given your former experience in drug marketing, what role do you believe the pharmaceutical industry has in medical education?

Mr. Ahari: While it might seem to be common sense that pharmaceutical education should come from an objective source, amazingly, a significant portion of our education comes from private companies. For example, about 80% of CME funding comes from the drug industry. Studies have shown that the industry is quite adept at incorporating their marketing messages in a variety of methods mistakenly identified as "education" by the medical community — sponsored speakers, detailing, conferences, etc. Current evidence suggests that this education not only influences your typical private physician's prescribing habits, but also the even more "protected" decision makers, such as the formulary committees of major hospitals.

The most frightening evidence of the pervasiveness of industry education comes from Dr. Erick Turner and his colleagues in an article published in the New England Journal of Medicine (2008;358:252-260). The article describes how the availability of data for doctors prescribing selective serotonin reuptake inhibitors (SSRIs) was largely influenced by whether or not it reflected positively on the drug. In other words, information about SSRIs that had little benefit to a drug's sales potential barely saw the light of day, preventing doctors from having a balanced understanding of the drug's effectiveness.

In light of such practices, I believe that we need strong firewalls to prevent undue physician influence while making sure the evidence on which they rely isn't a parallax; drug companies contribute to society in many ways, but objectively educating our doctors isn't one of them.

Mr. Ahari reports having been hired as an expert witness and consultant for the State Attorneys General of Vermont and New Hampshire, and having served as an expert witness and consultant for several plaintiff law firms in cases related to drug marketing.


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