Photo: Sarah Paris

When is a free lunch not free? A well-attended symposium Oct. 19 grappled with the question of how the pharmaceutical industry's influence extends to medical education and what guidelines should be adopted to regulate such influence. Moderated by Dean Kessler, the symposium drew faculty, students, and outside experts into a spirited discussion about whether any gifts from drug companies are ever acceptable. As the School of Medicine is working on a set of guidelines to address the issue, the event served to spotlight the need for such discussion and encourage campus involvement in helping to shape a coherent, fair policy to replace the patchwork policies that currently exist and vary from department to department or from one clinical site to another.

Billions Spent On Medical Professionals

Introducing the topic were Seth Landefeld, head of the Division of Geriatrics, and his colleague Michael Steinman. Both have been involved in research on the marketing practices of the pharmaceutical industry. Dr. Steinman explained that pharmaceutical industry is heavily invested in developing and refining marketing that targets health professionals, but until recently, data on those practices have been largely preserved as company secrets. To shed light on these practices, Steinman and Landefeld helped establish the Drug Industry Document Archive (DIDA) at the UCSF library, which incorporates internal industry documents related to the marketing of the drugs gabapentin (Neurontin) and rofecoxib (Vioxx) that have been made public through litigation.

Two guest speakers headlined the symposium. Dr. Michael Wilkes, Professor of Medicine and Vice Dean for Medical Education at UC Davis, called on academic centers to set an example for the health community and serve as role models to stem the flood of unwanted gifts and gadgets from the drug companies. "The pharmaceutical industry spends around 21 billion dollars on marketing per year. and 90% of it is spent on medical professionals," he said.

Existing voluntary standards do not work, because doctors do not believe they can be influenced by gifts and therefore accept them, he said. Yet the influence of even small gifts, he continued with a nod to a famously disputed UCSF discovery, can be compared to prions: they may fly below our radar, but the consequences are far from trivial. Pharmaceutical sales representatives, known as "detailers", are well aware of the psychological workings of the so-called "expectation of reciprocity" (see JAMA article).

Wilkes pointed out that the pharmaceutical companies themselves have strict rules prohibiting their own employees from accepting even small gifts.

The second guest speaker was Dr. Robert Steinbrook, national correspondent for the New England Journal of Medicine. Dr. Steinbrook spoke about the need for a balanced approach to the issue. While it was important and appropriate to “just say no to pharmaceutical industry involvement in medical education", the reality is that medical schools still need to work with the industry, especially in the area of research. In Steinbrook's view, however, the situation is "out of control", and a healthier balance needs to be reset.

Lunch Buys Access

Following the presentations, a lively panel and audience discussion led by Dean Kessler touched upon a variety of perspectives and raised provocative questions. A number of vignettes presented real-life scenarios on which audience and panel were invited to weigh in with their "yes" or "no" votes.

"Why would a pharmaceutical company want to pay for residents' lunches," Dean Kessler asked the lone industry representative, Mike Ingram, senior district sales manager for GlaxoSmithKline. Ingram responded that donated lunches served to gain access and establish a relationship with physicians, "and yes, we do sell", he admitted. Acting as a caterer is not what he wanted to do or was trained to do, he said, and his preference would be to focus on an ongoing dialogue about pharmaceutical products that could benefit patients.

While it was true that the industry had created somewhat of a "monster", this didn't mean "you can't trust us," Ingram asserted. He personally would have no objection if the school banned all gifts from the drug industry. Turning the tables, he then claimed that he was "shocked that this is the first time such a symposium has been held on this campus", and that "you guys have yet to adapt practical guidelines", while the industry itself, he said, had already adopted their own voluntary restrictions.

The "free lunch" vignette was just one scenario debated by panel and audience; other examples included unrestricted educational grants; faculty accepting honoraria for speaking engagements; and large industry donations in exchange for naming rights of new buildings.

Draft of Guidelines for the School

While the audience tended to vote for prohibition of most of the scenarios, Vice Dean Neal Cohen, one of the authors working on draft guidelines for the school, explained that several of these situations would be acceptable, though regulated under the new policy. He pointed out that the school is not in a position to control people's personal behavior. Associate Dean for Student Affairs Maxine Papadakis concurred, saying that it would be impossible to enforce a strict ban on students or residents participating in "freebies" off-campus, no matter how much she was personally opposed to such activities.

Dr. Robert Baron, associate dean for graduate and continuing medical education, was questioned about alternative funding for CME, which is heavily sponsored by the pharmaceutical industry. He said that while he was personally in favor of banning such sponsorship, finding alternative funding might be difficult and would need to be done across the CME industry to be effective. He also explained current requirements for disclosure of conflict of interest and the need for speakers to resolve all conflicts prior to teaching. He stated that this process has effectively prevented commercial bias in UCSF CME activities and could serve as a model for medical school and residency teaching.

The issue of a hypothetical multi-million dollar gift in exchange for naming rights stirred up a vigorous debate among the panelists and audience, most of whom supported a ban. The response became less clear-cut when Dean Kessler posed another hypothetical question; would their response be different if the gift were an unrestricted grant to a UCSF organization to save potentially hundreds of lives. Addressing former Chancellor Haile Debas, who now directs UCSF Global Health Sciences, Kessler asked if Debas would accept such a gift. Debas countered amiably, "When?"

The event was organized by the Office of Student Affairs/Advisory Colleges, sponsored by the UCSF Center on Aging, the UCSF SOM Advisory Colleges, the UCSF Library, and the SF Cochrane Center.