Financial IndigestionFinancial Indigestion

Over the past decade, I have had the fun and good fortune of being a visiting professor at more than two dozen teaching hospitals. One noon conference during a recent visit, however, stands out.

The chief resident had asked me ahead of time to discuss financial conflict of interest, but he neglected to inform me that a major pharmaceutical company would be hosting lunch before the conference. When I arrived, one of the two well-dressed drug reps asked politely who I was, then invited me to have lunch. I demurred when I learned his company was the sponsor.

One by one, house officers and medical students arrived to join the buffet line and were greeted warmly by the drug rep with "How was your weekend?" and "How're you doing?" The line moved slowly because it took some time to scoop up the salad, the pasta, and the chicken marsala onto paper plates. The two reps took advantage of this opportunity to pitch their company's products, one stationed strategically at the beginning of the line, the other at its end. I was nearly out of earshot, but I heard them describe two of the company's popular products as well as recommendations for dosages. Many attendees in line seemed to be listening less out of interest in the pitch but out of courtesy toward those who had spared them the expense and bother of getting fed. I learned later that it was uncommon to have two reps present, but that the chummy encounters, the free food, and the buffet setup, which virtually force attendees to listen to these persuasive emissaries of industry, were commonplace at this institution.

When the conference began, about 35 people were finishing their lunch and the chief resident, at my suggestion, asked the drug reps to leave the room. (He stated that most reps do not stay for the conference anyway.) I then began my talk by inviting the students and house officers to comment on a paragraph from a recently published opinion piece by a distinguished medical historian.¹ The resident read the paragraph aloud:

[M]edical schools should adopt formal rules that prohibit all gifts from drug companies to students, whether books, stethoscopes, or meals. Medical training should not include acquiring a sense of entitlement to the largesse of drug companies. Finally, teaching hospitals should enforce these same restrictions, proscibing drug-company sponsorship of lunches, conferences, and travel for house staff, and should also make it clear that accepting birthday presents, Christmas gifts, or food and drink off the premises from drug-company representatives violates the ethical norms of the profession.

The response? Stunned silence. Admittedly, it was an unfortunate "sting," nonetheless an inadvertent one, because I hadn't been aware that a drug company–sponsored lunch would antedate our discussion. I could have switched the subject to medical publishing, health care delivery, hyponatremia, or some other subject, but the chief resident and I agreed to go ahead with the announced topic.

I won't identify the institution or embarrass the trainees and students. In fact, there is no need to do so because the practice of pharmaceutical company sponsorship of food for house staff and students at teaching hospitals is widespread. During my visits to academic hospitals, I have encountered many departments that not only allow the companies to bring food in, but actually encourage them to do so when funding of conference lunches was cut back by their institutions. I should not neglect to emphasize, however, that some holdouts still exist: some departments refuse drug company support of any house staff or medical student functions. (Please stand up and identify yourselves!)

Eventually a few in the audience responded to my invitation. One said he saw nothing wrong with a free lunch because he couldn't remember which products were made by the various companies, and even if he did, he believed that because the house staff receive lunches from so many companies, he couldn't possibly favor one over another. One argued that she had no effect on the hospital's formulary, so what was the worry? I reminded her that the companies surely know this, but that they might be buying house officers' future influence on formularies or even their personal prescribing habits. The response of another house officer was a bit contentious. He saw nothing wrong with accepting gifts, he said, especially expensive textbooks that he could not afford. I asked what his salary was, and he replied he wasn't sure (it is between $35,000 and $40,000). Was it really true, I asked, that he couldn't afford his books? No response. One participant wanted to know why I singled out only money as having an excessive influence: weren't there many other factors that could potentially prejudice someone? I pointed out that in contrast to other factors that might promote bias, financial arrangements are optional. One need not accept them, including free food. Another said he was not worried about possible bias based on a financial conflict of interest because he believed he could identify it. I replied that I doubted it.

The discussion went on to include other financial conflicts of interest in medicine: investigators who own stock in companies whose products they are testing clinically, experts who tout products in which they have a hidden financial interest, and the benefits and problems of disclosure as a possible remedy for conflict of interest. By the end of the hour-long session, many in the audience seemed to "get it," which became apparent by the questions they asked, and later I learned that some had asked for more discussion on the issue. Notably, I was treated kindly by the house staff during the remainder of my visit.

It is reasonable to presume that nearly all of those present at this conference went into medicine with high-minded motives and that financial gain was only a secondary consideration. I am also quite certain that nearly all had been exposed in medical school to lectures and small group discussions about appropriate professional behavior. Yet the culture in academic medical centers becomes a major determinant of professional behavior once students enter the clinical years and later when they become house officers. Some of this acculturation is promoted by faculty members who themselves are exploiting their academic status for financial gain. But much of it, I suspect, is a consequence simply of inattention to the issue. Most students and house officers have not been challenged to consider that their relations with pharmaceutical companies might compromise their judgment.

Students and residents first acquire a taste for the largesse of the pharmaceutical industry in the halls and conference rooms of academic medical centers and later at lavish dinners at company-sponsored symposia. Some resist, but others develop a sense of entitlement. Their friendliness toward one company or another can be long lasting. A colleague who graduated medical school almost 30 years ago once told me he never forgot that a certain company had given him his very first medical bag. These early cordial relationships with pharmaceutical companies undoubtedly have a substantial effect on subsequent medical judgments and professional behavior.

Deans of medical schools and training program directors must do a better job of addressing conflict of interest. Where professionalism is concerned, they must teach that there is no free lunch. No free dinner. Or textbooks. Or even a ballpoint pen.