Casey KirkHart was in many ways a typical medical student, which is to say he was usually hungry, always pressed for time and keenly aware of his mounting loan debt.
Unlike many of his peers, however, he routinely passed up the lunch that accompanied a weekly lecture, even though the food was everything a student could want: tasty, convenient and, thanks to the pharmaceutical company that catered it, free.
After getting “weird looks” from peers and instructors alike, KirkHart, then at the New York College of Osteopathic Medicine, put together a PowerPoint presentation to explain why. Using charts and graphs, he cited studies showing that about 90% of the drug industry’s $21-billion marketing budget went to physicians and that all those mugs, meals, drug samples and speakers’ fees influenced doctors’ prescription decisions.
He slipped in a photo of himself dressed in a white doctor’s coat plastered with enough drug-company logos to rival a NASCAR race driver. The caption read: “The White Coat of the Future?”
KirkHart is now a second-year resident at Harbor-UCLA Medical Center, and the future is starting to look a little different.
The “pharm-free” movement he championed is spreading around the country in the wake of an article in the Journal of the American Medical Assn. challenging academic medical centers to ban drug industry freebies.
In October, Stanford University Medical Center, following Yale University and the University of Pennsylvania hospitals, barred students, faculty and medical staff from accepting even small gifts. UC Davis passed a similar policy late last year that is to take effect July 1.
UCLA’s David Geffen School of Medicine approved one in November and sent it to its affiliated hospitals and clinics for a final review. The guidelines, expected to take effect by the end of the school year, will be among the toughest in the country, stripping all clinics and hospital buildings of pens, pads, clipboards and calendars bearing any signs of drug promotions.
And the UC Office of the President is working on systemwide rules for its five medical schools.
“It’s not fringe people,” KirkHart said. “These are reputable, world-class universities. There’s a real culture change happening. We’re going to wean ourselves off drug money.”
But Scott Lassman, senior assistant general counsel to the Pharmaceutical Research and Manufacturers of America, a marketing and lobbying group based in Washington, D.C., called such restrictive policies “unnecessary and an overreaction.”
“They’re going to be cutting themselves off from a lot of useful information,” he said, referring to bans on meals with sales representatives.
“I can tell you that the sales reps would just as soon not bring in the pizza and the meals,” Lassman said. “But often the physicians are extremely busy, and the only time they can get access is over a working lunch or dinner. We thought it was appropriate to pay for that.”
In 2002, the industry group and the American Medical Assn. responded to rising criticism by issuing voluntary ethics guidelines. Such lavish gifts as fishing trips, expensive football tickets and greens fees at swanky golf resorts were out. Gifts had to be relatively small -- pens, pads, stethoscopes -- and related to patient care. Drug reps, all 90,000 of them, were urged to deliver educational programs over modestly priced lunches or dinners.
Last month, the International Federation of Pharmaceutical Manufacturers & Assns., which represents drug companies worldwide, issued similar rules.
Doctors in private practice have been courted by “drug reps” for years and, with the exception of Kaiser Permanente, the California-based managed-care group, few private hospitals or physician groups have enacted restrictions. Many doctors, for instance, have drug samples to give to patients.
But academic institutions need to set an example, according to the AMA magazine’s article last year. “Academic medical centers, which include medical schools and their affiliated hospitals, should provide leadership for medicine in the United States,” said the article, signed by doctors from Harvard Medical School, Columbia University and other schools, including two UC campuses. “Research reveals that the habits learned or acquired during training persist into practice.”
The article called on academic centers to ban every free offering, even inexpensive note pads.
The article was notable, given the prominence of the magazine, but it was just the latest in a string of journal articles decrying drug marketing’s influence on medicine.
For years, many doctors shrugged off such studies. Some were insulted that anyone would think a few free doodads and dinners could affect their judgment. Others defended interactions with sales reps as a way to stay up to date on the latest drugs or as a source of free samples for low-income patients.
And some physicians liked the gifts, the meals and the company of affable and often attractive salesmen and women, especially after a day spent dealing with difficult patients and cost-wary insurers.
“Doctors in practice say, ‘I’m overworked. I’m underpaid. I’m besieged on all sides by insurance companies. The only solace I get all day is a sales rep taking me to dinner and not complaining about anything,’ ” said Dr. Jerry Avorn, professor of medicine at Harvard Medical School and author of “Powerful Medicines: The Benefits, Risks and Costs of Prescription Drugs.”
But in recent years, Avorn said, drug recalls and rising prices have undermined consumer confidence in pharmaceutical companies. Doctors began to fear getting caught up in the backlash.
Even small gifts and modest meals open doors and promote friendly relations between sales reps and physicians, according to a roundup of research published in the American Journal of Bioethics in 2003. The studies suggested that the more doctors interacted with drug marketers, the more likely they were to prescribe expensive new drugs when less costly generics would do.
“It was indisputable that small gifts had tremendous power in influencing favorable attitudes toward products,” said Arthur Caplan, director of the University of Pennsylvania’s Center for Bioethics and an author of the research paper.
In fact, he said, frequent small gifts, especially when combined with regular treats like doughnuts or pizza, carried as much sway as the occasional extravagant trip or hefty consultant fee.
“With a big gift, you’re on guard right away,” he said. “The very act of giving a small gift creates a cultural sense of obligation. Yet it’s subtle. Your guard isn’t up.”
Most of the medical centers that have announced new rules began the process before the AMA magazine’s article appeared, but some consider it to have been a tipping point.
“It gave us the green light,” KirkHart said. “If you want to make changes happen in your institution, go for it.”
At UCLA’s medical school, Dr. Andrew Leuchter, professor of psychiatry and chairman of the faculty executive committee, has already emptied his desk drawers of drug-logo pens and instructed his researchers and students to do the same.
“It’s quite remarkable the things you find,” he said, listing refrigerator magnets, penlights, computer memory sticks and, because he’s a psychiatrist, models of the brain. “Anything they can put a brand on, they’ll give to you.”
Leuchter, who wrote the new policy, said medical students have been especially supportive.
“They come in very sensitized to the idea of industry influence,” he said. “Some of us who have been doing this for years had become desensitized to it.”
Some student activists became aware of the cause through an undergraduate ethics class or by reading some of the many recent books about drug company marketing. Many, including KirkHart, drew inspiration from the American Medical Student Assn., an independent, nationwide group of physicians in training.
The group launched an ongoing pharm-free campaign in 2002. Members signed a pledge to accept no money, gifts or hospitality from the pharmaceutical industry and to seek unbiased sources of information. The group invited medical students to turn in their drug-logo pens for ones bearing the slogan “No Free Lunch.”
The debate has been vigorous even on campuses that have adopted new rules. At Stanford, for example, some students and instructors opposed the ban on drug samples, which had been used to treat low-income patients. The AMA magazine’s article argued that such samples drive up healthcare costs by inducing physicians and patients to “rely on medications that are more expensive but not more effective.”
Often the biggest controversy is the ban on free meals.
Dr. Tim Albertson, director of clinical care at UC Davis, said he has received many e-mails about food. “But for every one of those, I’ve gotten one that said, ‘It’s about time we did something. It’s about time we make a stand.’ ”
At UC Irvine, which has not yet issued a policy, about 20 of 100 third-year students signed a voluntary pharm-free pledge.
“The typical reaction I get from my peers,” said Boback Ziaeian, a pharm-free backer who helped circulate the pledge, “is, as medical students, we work long hours and are the lowest on the hospital totem pole. We should enjoy whatever we can.”
Still, Ziaeian, who takes a big bag of granola to munch on during lectures, said he believes that the young idealists will prevail.
He recently shared a hospital elevator with a distinguished oncologist. The older physician noticed that Ziaeian was wearing a pharm-free pin and called him a modern-day Don Quixote.
“I hope that when the UC system institutes an extensive pharm-free policy like Stanford, Yale and the University of Pennsylvania, he’ll realize that other, more influential people saw windmills too,” Ziaeian said.