An expensive free lunch

I arrived late to the pediatrics conference and snuck in around the side to grab some food. "Wow! Chinese chicken salad with sesame dressing," I thought to myself. "Just what I need."

I was exhausted from my day in the neonatal intensive care unit, and the fresh food could not have looked tastier — especially in light of the dry cafeteria garden burgers I had been eating for weeks.


As we left, I commented to a friend how delicious the lunch had been.

"Thanks to the drug company," he said.

Because I'd arrived late, I had missed the introduction from the pharmaceutical rep. I had accepted the gift unknowingly, and felt guilty. These extravagant lunches were partly what made drugs unaffordable. Such wining and dining inflated costs for patients. So in a twist, I would have to blame myself for my patients' inability to pay for medications.

That introduction to pharmaceutical largesse came in my first month on the hospital wards, almost two years ago, and it wouldn't be the last. Drug companies are not just infiltrating doctors' offices and residency training programs but also medical student education. Despite my own resistance, I have gone from being aghast at their presence to being an acquiescent, if reluctant, participant in the drug advertising world. Here's how it happened. On my junior medicine rotation, pharmaceutical reps sponsored lunches nearly every week. I knew I was at such a lunch when I saw


plates or


napkins laid out before a delicious buffet of Thai or Chinese food. At the end of the lunchtime talk, given by a school professor, the moderator would say something like, "Thanks to Marc from Bayer for providing the food. If you have any questions about their drugs, please see him after the lecture."

The rationalizing began then — I call it the lemming phenomenon. I saw all of my residents, even some of my professors, whom I respected, lining up. In such good company, accepting food could not be such a bad thing. Also, if I silently boycotted, and no one else did, the drug rep would still bring lunches. So what's the point of denying myself a hot, tasty lunch? Plus I promised myself that I would avoid looking at the name on the plate — just quickly slap some food on it and throw out the plate as soon as I was near done.

These were silly excuses, but I convinced myself that I had more serious ones too. For example, because I was eating meals ready made, I did not have to pack a lunch the night before and therefore could spend more time at home studying, ultimately improving my future patients' lives. Also, I reasoned that the lunchtime lecture was planned only by the faculty member, not influenced by company representatives.

I was fast becoming indoctrinated but still felt uneasy.

Would my future prescribing judgment be clouded? Would the names of drug companies and their new drugs make their way into my mind despite my desperate attempts to ignore them? Very possibly. Studies indicate that doctors' prescribing habits are influenced by interactions with drug representatives. Even a brand-name emblazoned on a pen might subconsciously affect prescribing preferences.

The acculturation process I went through appears the norm at medical schools, though surprisingly the majority of medical students do not perceive this as a problem. In a national survey of medical students published in September in the Journal of the American Medical Assn., most trainees said pharmaceutical-sponsored meals and textbooks were appropriate. More than two-thirds said gifts would not influence their prescribing practices, and 80% said they were entitled to these gifts because of financial hardship.

These alarming findings are a wake-up call. Medical studies, not medical lunches, should determine our prescribing practices. I worry that the pharmaceutical industry will have undue influence on students — who, of all practitioners, have the most prescribing years ahead of them — if medical schools do not act quickly. In the JAMA study, 90% of student affairs deans reported having no school-wide policies.


There are small signs of turnaround. The medicine department at my former hospital no longer accepts pharm-sponsored lunches, though certain divisions, such as cardiology, do. In addition, student activists often put boxes in our lounge where we can exchange pharmaceutical pens for regular pens. And the American Medical Student Assn. has developed guidelines to weaken the drug companies' ties with the medical profession. It urges hospitals to end company-funded lunches and lectures and suggests that doctors and students refuse promotional gifts. But these are mere recommendations, and most students do not know they exist.

A few weeks ago, I had a dreary glimpse of the future, that is, if the current situation continues. A bunch of residents were heading out on a Friday night to dinner at Masa's. According to the Zagat Survey, the restaurant treats guests "like royalty," and the average price of dinner for one, including one drink and tip, is $92. A drug rep was footing the bill.

I hope that as I start my residency training that I can resist such temptations, but more than that, I hope I never am faced with that proposition.


Rachel Sobel is a fourth-year medical student at UC San Francisco.