Is It Ever Okay to Accept Gifts From 'Big Pharma'?

Sarah Averill, MD

Disclosures

February 25, 2011

Question

What's the big deal about accepting gifts from drug companies, especially if they are small? Does the medical profession's code of conduct apply to medical students?

Response from Sarah Averill, MD
Resident, St. Joseph's Hospital and SUNY Upstate Medical University, Syracuse, New York

When a new pain medication came out last year, the staff in the office where I was rotating discussed how many prescriptions they were writing for that drug and how much they liked the fruit smoothies and gelato that the drug company representatives were bringing. "I don't like gelato," one secretary quipped. "More for us," laughed the physician assistants.

It was weird for me to overhear their conversation, and it made me wonder, did a fruit smoothie actually motivate them to write those prescriptions?

Indeed, evidence suggests that gifts do influence prescribing habits. An article in JAMA, Physicians and the Pharmaceutical Industry: Is a Gift Ever Just a Gift?, illustrates the ways in which gifts appear to influence prescribing.[1] A recent radio broadcast, How to Win Doctors and Influence Prescriptions,[2] documented how the pharmaceutical industry promotes their products. Even under new rules, there is strong evidence that the pharmaceutical industry takes a sophisticated approach to "educating" physicians and their staff.

Physicians like to think they are immune to manipulation, but when you are working long hours and your friends and family are busy leading normal lives, a pharmaceutical representative -- who will arrange his or her career around your schedule, shower you with small gifts, identify and hire you as a "thought leader," and promote you on the lecture circuit -- may find that you can be won over without much trouble. (I began to realize this after working a 24-hour shift on a holiday, following another 100-hour work week.)

Strictly speaking, even with the new codes, it's not considered unethical to accept small gifts from reps, if they advance the so-called "educational purpose" they are meant to serve. In fact, many physicians feel that representatives are worth meeting for the education they provide. Even though doctors know the information is biased, they believe they can sort out the bias.

Pharmaceutical representatives generally are not interested in medical students because you can't prescribe. That said, it's never too early to think about how you want to engage with pharma and device representatives down the road when you are a full-fledged physician and might have a weak moment. Your job as a medical student is to observe what you see and figure out who your role models will be.

For starters, it's good to know the current code of conduct, as it has undergone significant changes in the past few years. Make no mistake: accepting fancy dinners, cruises, and just about anything that's not strictly educational is considered to be in violation of the code.

You might also want to reflect on what "rewards" you think you deserve for the time and money you're investing in medical training. Reminding yourself of personal sacrifices actually doubles the likelihood that you'll accept gifts, according to a recent study by Carnegie Mellon researchers.[2] You might be tempted to justify gifts and much more, sliding down the well-established ethical slope to a future you can't currently imagine. Doctors work hard, delay gratification, and sacrifice time with friends and family for their careers. It's not unusual to feel some degree of ambivalence about those sacrifices.

My medical school banned drug reps from conference lunches during our inpatient rotations, so I was initially surprised to see them on my first outpatient clinical rotation at a community family practice. Every day of that rotation, someone wearing a suit brought lunch and literature for the entire office staff. The nurses, doctors, and even the techs flocked to the lunch room at noon and listened to sales pitches that were thinly veiled as educational talks. Some doctors distanced themselves by asking sharp questions. But an equal number were friendly and grateful for the information and free samples. The office's supply of samples was plentiful, and almost every doctor dispensed samples to tide patients over when needed.

To avoid that whole scene, I sometimes brought by own lunch or went for a short walk. I was trying to be a purist. Then, on the last day of my rotation, my preceptor offered to take me to lunch. He led me to the lunch room and unveiled a cake that said, "Good luck, Sarah!" He explained that he always asked the pharmaceutical representatives to bring a cake for every student on his or her last day. My heart sank, but I forced a smile and cut myself a generous piece of the cake, as I could see no polite way to refuse.

There simply is no way to be a purist in this enterprise. Ultimately, it's not about whether you eat some of the food or accept some small gifts some of the time. It's about having the personal integrity to recognize your own human nature. The relationship between the pharmaceutical industry and physicians is here to stay, but you do have the power to shape it and use drugs that benefit your patients without sacrificing your personal integrity.

And when it's your turn to train the next generation of medical students, you can help celebrate their accomplishments with lunch and cake -- paid for with your own hard-earned cash.

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