While physician certification is being tied to quality efforts, one source of physician education funding is coming under increasing scrutiny.
Spurred by Congressional and nonprofit attention to close relationships between professors and pharmaceutical companies and by the American Medical Student Association (AMSA)'s PharmFree campaign, academic medical centers are backing away from any overt relationships with drug companies, sometimes incurring substantial costs.
Meanwhile, doctors in training are pushing them to move faster.
“It's getting to the point now that, if people carry a drug company pen, they put tape over the logo to hide it,” said Gabriel Palley, a third-year medical student at University of New Mexico School of Medicine and current national chair of the AMSA PharmFree campaign. “Whereas you used to get laughed at if you carried a Bic, because everyone knew they were not as good as the ones the drug company representatives bring.”
The new view of conflicts of interest was stated in a January 2006 article in the Journal of the American Medical Association that proposed that disclosure of potential conflicts is not sufficient to defuse the conflicts' influence. The authors—faculty from 6 major medical schools and representatives of the Association of American Medical Colleges (AAMC)—wrote: “More stringent regulation is necessary, including the elimination or modification of common practices related to small gifts, pharmaceutical samples, continuing medical education, funds for physician travel, speakers bureaus, ghostwriting, and consulting and research contracts.”1
The article spurred sharp reaction—8 letters in JAMA and almost 200 cites in 3 years—and led to examination as well of pharma funding for residencies and fellowships.2, 3 At the same time, Sen. Chuck Grassley (R-Iowa), ranking Republican on the Senate Finance Committee, began interrogating universities over undisclosed ties to pharmaceutical companies, leading to a series of embarrassing disclosures of millions of dollars in professors' outside income.4
A Sea Change
The result has been a spate of reports and reassessments so numerous and rapid that they appear to represent at least a trend if not actual culture change. In May 2008, the American Medical Association's Council on Ethical and Judicial Affairs issued a draft report, “Industry Support of Professional Education in Medicine,” that concluded in part: “Medical schools and teaching hospitals
…have special responsibilities to create and foster learning and work environments that instill professional values, norms, and expectations. They must limit, to the greatest extent possible, industry marketing and promotional activities on their campuses.”5
A month later, the AAMC issued a report urging academic medical centers to prohibit any drug industry gifts and services.6 And a month after that, PhRMA (the Pharmaceutical Research and Manufacturers of America), revised its “Code on Interactions with Healthcare Professionals.” Among other measures, the revisions prohibited distribution of branded “reminder” merchandise such as pens and mugs and banned sales representatives from buying restaurant meals for health care workers (though it continued to allow informal in-office meals “in conjunction with informational presentations”).7
Meanwhile, in spring 2009, the Institute of Medicine also weighed in with a wide-ranging report that recommended both voluntary measures and increased regulation to reduce conflicts of interest across medicine and medical education.8 And by this summer, the AMA had issued a second report aimed specifically at funding for continuing medical education (CME), which concludes: “It is ethically preferable that CME providers accept funding only from sources that have no direct financial interest in a physician's clinical recommendations and that those involved in CME have no current, recent or potential direct financial interest in the subject matter.”9
And in the midst of the unfolding examination, AMSA began issuing its PharmFree Scorecard, ranking the United States' medical schools on receiving gifts and meals, allowing paid promotional speaking, accepting free drug samples, and allowing industry to fund education. In 2008, the group (assisted by the Prescription Project of the Pew Charitable Trusts) gave only 29 of the country's 149 schools an A or B grade; it raised that to 45 in 2009, but handed an F to 23 more because they declined to disclose their policies.10
The combined pressure from regulators, nonprofits and medical students is prompting change at many academic medical centers. Faculties and administrators say their students and residents are calling for change, and the schools are willing. But the cost of making the changes can be substantial: at the University of New Mexico School of Medicine (a B school, according to AMSA), merely canceling pharma-funded lunches and didactic conferences has cost about $1 million in foregone support per year.
“The medical students were very supportive of this and actually pushed it very hard,” said David P. Sklar, MD, associate dean for graduate medical education. “The residents were somewhat more split, though I think their concern was mainly that they wanted lunch at their conferences; they didn't care who was providing it.”
The University of New Mexico had previously attempted to finesse any potential conflict by following any lunchtime chat by a pharma rep with a contrary comment from a faculty member, but found it too hard to organize consistently across departments. Now the school has made an institutional commitment to phase out any drug industry funding of education within 2 years.
“If departments can wean themselves from the funding sooner, that's fine,” Dr. Sklar said. “But the expense is relatively high and the change is a substantial one, so we are giving the most-enmeshed departments time to find alternatives.”
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