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If you are an educator or administrator in this era of shrinking budgets and reduced government funding, it is "unethical" to neglect pursuing pharmaceutical-industry support for graduate and undergraduate medical education. Doing so with effective checks and balances in place will all but eliminate opportunities for bias or corruption to enter the system, according to psychiatrist Michael Schwartz, M.D., of Case Western Reserve School of Medicine.
Willingly following this common practice of accepting drug-company money could, however, easily put physicians' ethical obligations in direct conflict with pharmaceutical companies' fiduciary duty to maximize profits for stockholders, maintained University of Pennsylvania psychiatrist Amy Brodkey, M.D. The sophistication and persistence of drug-marketing promotions supply fertile ground for improper influence of the content of medical education to take root, she suggested.
The two participated in a passionate debate at APA's annual meeting last month about whether pharmaceutical industry support for undergraduate, graduate, and postgraduate medical education should be encouraged.
Joining Schwartz in endorsing the use of such money for medical education, Paul Mohl, M.D., residency training director at the University of Texas Southwestern Medical School, pointed out that if a drug company controls the content of educational programs it supports, it could rightly be accused of delivering a sales pitch in the guise of education. When a program's content is controlled by the educational institution, however, which is usually the case, it is clearly education and not sales that guides the endeavor.
Mohl emphasized as well that without such funding available, his trainees would have been deprived of hearing valuable speakers, and far fewer residents would have been able to attend APA annual meetings. Six of his residents had their annual meeting costs paid by pharmaceutical companies. When educators bestow plaques and monetary awards to students, drug firms make those possible, but he has never heard of industry officials interfering with whom program staff and administrators choose to honor, he noted.
Being asked just to listen to presentations is a "fair return" for accepting substantial funds from pharmaceutical firms. Anything more in the way of quid pro quo should be returned, Mohl stated.
Brodkey's debate partner, Irwin Hassen-feld, M.D., agreed that the practice does not equate with direct sales techniques, but attached a far less benign cast to accepting drug company money for education.
"Pharmaceutical representatives are more like lobbyists than salespersons," he said. "Their influence is in using gifts to win over a target. These gifts could be called a bribe."
There is a not very subtle message, he added, in the fact that "there is almost no pharmaceutical support for departments of pathology."
Brodkey agreed, insisting that there is no way to separate sales from education. She cited the attempt of McMaster University's medical school to impose strict regulations on the input contributing drug companies could have over education programs. The result was that half of the companies said they would be withdrawing all their support once the rules took effect.
Schwartz maintained that Brodkey was putting far too much emphasis on examples such as McMaster's, however, because marketing regulations and oversight to prevent abuses are already used by APA, the American Medical Association, American Hospital Association, and American Association of Directors of Psychiatric Residency Training, among others. Pharmaceutical companies also have governmental and their own regulatory rules with which they must comply, he said.
"The process will expose excesses, just as it has been designed to do," Schwarz commented. Though he acknowledged that the system of checks and balances is not perfect, it does, he said, "save our autonomy."
In fact, Mohl added, drug company representatives are "running scared. . . . They are very aware that they are prone to being audited by their own company and the FDA."
Challenging her opponent's viewpoints, Brodkey asserted that the existence of checks and balances does nothing to decrease the growing cynicism the public voices when asked their opinion of physicians and their claim of prescribing objectivity. It is the public that ultimately pays for all this marketing in the guise of educational support when they pay for their prescriptions. The pharmaceutical industry is the most profitable in the U.S., having earned $15 billion in 1996, more than is spent on all graduate medical education in this country, she added.
"Many physicians are offended by the idea that we can be bought off or influenced," Brodkey stated, but studies show that physicians do prescribe drugs manufactured by companies to whose presentations or gifts they are exposed. Trainees, at whom much of the money is aimed, "lack the ability to evaluate critically" the messages they receive from drug-company representatives about particular medications, she added.
A critical concept educators must convey to students and residents, Hassenfeld stressed, is that "literally, there is no free lunch."
Schwartz and Mohl challenged their opposing team to explain, then, what alternative funding sources they would propose to compensate for the withdrawal of drug company support they are advocating. Noted Schwartz, "I would love to see the managed care industry give us even one-tenth of the educational support of the pharmaceutical industry."
Hassenfeld responded by identifying one potential source of new money-the federal government. He pointed out that there is adequate funding for medical education circulating within the system, but it is routinely siphoned off for purposes other than direct education and training. Schwartz countered that government funding does not confer independence on medical schools. Citing one example, he noted that government entities regularly dictate the type, number, and site of clerkships.
Hassenfeld also suggested that medical school tuition levels should be structured so that they are adequate to fund medical school education. Brodkey added that a comprehensive review of ways to make medical education more efficient, such as through better use of technological advances, is long overdue. And if residents need to be provided with lunches, "let the faculty chip in and buy them," Has-sen--feld suggested to titters from the audience.
As for continuing medical education (CME) support, he observed that physicians are in the top 1 percent of earners in the U.S. and can afford to pay for their own CME without much hardship.