Med Students And Their Pharma-Free Guide

Bravo to the Med Students!!

They are definitely on the right track.

While it may be too late to take the pharma candy away from some doctors, at least the "KIDS ARE ALRIGHT"

I used to sponsor journal clubs for residents and not surprisingly I was the only one who didn't restrict the articles discussed to those studies sponsored by my company. Funny, how my competitors couldn't get to sponsor the journal club....I never mentioned the company name or the products I represented.

The un-marketing marketer....

Great tip sheet and you may consider letting health care advocates become aware of this sheet as well. Thank you for posting it.

Let me rain a little on one part of the crazy kids' parade: "...or ask local restaurants and caterers to donate one or two meals a year for pharma-free rounds". Doesn't that perpetuate the freeby culture, the notion that MDs are somehow entitled to free lunch when others buy their own? Aren't the restaurants/caterers giving free meals to these students hoping to get their business? How does that differ from pharma buying them meals?

In the near past I lectured to the med students organization at an Ivy League medical school (yes, a sample of one). The students were cordial, interested in a full and open debate and determined to impose a ban not only on free gifts but sales' reps access to the medical center.

What I found interesting was the position of the chiefs of various departments: while they didn't like excess, they really wanted the industry underwriting rounds, CME, etc. because 1) they (the staff) was too busy to make the presentations interesting and 2) yes, even in a prestigious medical school, an inducement is needed to draw students, residents and attending staff. That is the reality of life in a major teachning hospital and med school.

From my one visit with this institution, I came away with 2 things: 1) rotten apples in the industry and their excesses can potentially ruin it for the others and 2) I came away with a very nice (and expensive) gift from the students (a coffee table book of the history of the med school and its teaching hospital).

Health Care Advocacy is not as popular as it should be, in my opinion. I applaud those organizations that facilitate such advocacy groups. Thier progress is slow, but thier efforts are more than what most do.

In every industry in the U.S. the producers of a product are allowed to speak with those that will use it. Why is it that we're so worried that med students simply can't discern for themselves what information is helpful and what isn't. Aren't they the best and brightest and yet we want to seperate them from every other market in the U.S. economy. Maybe we should get together and decide which books they shouldn't read or which churches they're allowed to attend. All of these can certainly influence how these young physicians will treat patients. If you are a student... I emplore you...stand up for yourself. The thought police (especially in academia)are always there "looking out FOR you".

I teach in one of those academic medical centers that has "divested" from pharma. There has been no loss; only gain.

As for "thought police," no one is preventing anyone from speaking with anyone. Obviously.

I am a rep at a large university medical center. We have little interest in talking to students: they can't prescribe and they know very little, so it is hard to carry on a conversation with them. What we want, of course, is access to the attendings and the residents.

I know the arguments about pharma-free med centers. I would encourage those who argue for pharma-free to make a trip to our VA, where the pharma-free neurologists are still using primarily Dilantin and Tegretol...fortunately, the pharma-friendly neurology department is teaching their residents about the new AEDs.

A few bad apples have ruined it for the rest of us.

I work in one of those systems, and we don't target medical students. In fact, they bug me, because they mooch on my lunches. They can't prescribe, and they know almost nothing about the medications. I am perfectly fine with drug reps having NO interactions with med students. OK, it would still be ok if they ate lunch, I guess...no skin off my nose.

We just want access to the residents and the attendings. And if you think they know everything they need to know...go to our VA, where the neurologists are still using Dilantin and Tegretol, despite complete access to the new AEDs. The fact is, doctors use the drugs they learn in residency, until they are persuaded to try something new. My residents tell me they appreciate all the access to information they can get--and they know when a rep is B.S.ing them.

The med students' activities are really a stalking horse for those who manage the formulary process and inventory.

Re the VA comment, if the older AEDs are working for the neurologists, what's wrong with that?

Bob, The problem with the older AEDs is that they have a very narrow therapeutic index...they are toxic at barely more than therapeutic dose. They have more morbidity and mortality associated with them...weird blood stuff and liver toxicity. They also have some really nuisance side effects, like gum hyperplasia and hirsutism. They are extremely sedating. Why put your patients through that if you have access to meds with fewer side effects? The VA doesn't discourage the docs from using the newer AEDs at all...these are just old docs (foreign medical school graduates, too)...did you know that docs at the VA don't have to have licenses to practice? So they get a lot of foreign medical graduates who prob couldn't cut it out in the real world.

[...] Feroz Ali wrote an interesting post today onHere’s a quick excerptCreate a pharma-free speaker’s fund for out-of-town speaker expenses; - Decrease the amount of honoraria offered to speakers; - Invite Federal employees. Many wonderful scientists and physicians are employed by Federal agencies or state … Tags: Pharma, Night [...]

I encourage you all to check out the websites of the groups sponsoring the tip sheet, and read the evidence for yourself. It's not a few bad apples, and med students most certainly are vulnerable. The evidence is clear. The industry-physician relationship is different and potentially conflicted. Every good physician, no matter how smart he or she is, can be influenced, so why not teach medical students early about the probable conflict of interest? It's the right thing to do, and I applaud the work of brave activists across the country that are bringing everyone's attention to the issue.

HorusCat, Did you know that you don't have to be a licensed MD to do Lipitor adds for Pfizer? You just have to appear to be a licensed Doc and a rower as well. Not all older AEDs cause hirsuitism and gingival hyperplasia and many of them work quite well. One of them, carbamazepine, worked well for seizures and many non-approved indications until pregabalin came along. Then for some curious reason, carbamazepine stopped working. Go figure. Skeptical in New England

Eric, Do you want conversation, or do you want to be snarky, because I guarantee you I can out-snark you.

I have no opinion on Dr. Jarvik. It seems like the man who developed an artificial heart might have something to say about cardiovascular disease. And all that is ancillary to whether or not Lipitor works, which it does. Now whether the widespread use of statins is worth the money, that is a conversation society may need to have. With my family history of cardiovascular disease, my high cholesterol and homocystein, I am doing everything I can to hedge my bets, and that includes Lipitor 10mg.

Carbamazepine, or Tegretol, does indeed have liver toxicity and blood dyscrasia issues. It is also very sedating. If I were an epileptic, I'd want to take lamotrigine or levitiracetam; if I needed adjunct therapy, pregaba might be my first choice. Feel free to take or prescribe what you want. Carbamazepine would probably be my drug of choice if I had trigeminal neuralgia.

Your sarcasm about pregabalin misses the mark, you know. Pregabalin is not indicated for monotherapy, so while it could be added onto carbamazepine, it would not be the cause of Tegretol's sudden inefficacy. Most neurologists I know really like Keppra. They like that it has an IV and they like the lack of side effects. I see no reason why a patient should have to suffer through the side effects associated with carbamazepine when they can have the same efficacy with the newer AEDs. Surely, the improved quality of life is worth the money--at least to the one suffering from the side effects, it is. Perhaps not to you, who doesn't have to live through it, eh?

And by the way, Eric, I don't work for Big Blue anymore. But I would still take pregaba as adjunct therapy for partial seizures.

In defense of the VA, its system is light-years ahead of the private sector in terms of e-prescribing and electronic medical records. At one point, VA hospitals affiliated with academic medical centers provided residency training for about 40% of the country's physicians. I think snipes at the VA are unwarranted. It is a closed system and because of that the pharma industry considers it second-rate.

Bob, I don't think that is entirely fair about only pharma seeing the VA as second-rate. Ask yourself, given the choice, would you go to a VA first?

They ARE well-advanced with their EMR and prescribing. And as far as their formulary goes, they are doing the best they can with limited money. My point about the AEDs is that they HAVE access to the newer drugs. The neurologists there who keep up with things are using the newer drugs. The neurologists who are just putting in their time until retirement aren't.

HC, if you've ever been an inpatient at any hospital you're at risk for any of a number of medical errors (far beyond medication errors). To continue to assail the VA is not appropriate.

You are absolutely correct; I am sorry, I wasn't intending to engage in gratuitous sniping at the VA.

It's an easy target, HC, and has been since I was in pharmacy school then grad school back in the 1970s. Sorry to have appeared to have been curt with you. Veterans' care overall is a disgrace. (Disclaimer: I'm not a vet, nor is any family member, nor have I worked for or with the system).

Keep up the posting: you bring both knowledge and on-hands experience into the mix.

Bob, Thanks. You are right; veterans' care is a disgrace. I see a mixed bag at our VA. For instance, there is a psych there who I think is wonderful; he ended up in the VA because he is kind of socially phobic, and private practice and productivity were too much for him. Two of the four neuros are great. They use a lot of residents, of course; and I am biased, but I think the quality of residents at our med school is pretty high.

What kills me is the cost-cutting mentality...the chief pharmacist at the VA has openly said that his only concern is not being on the upper half of the list for VA expenditures on pharmacy.

It's not just pharmacy, though. I think the congress ought to be forced to use VAs for their medical care. Steve Buyer, who is a vet and a congressman from Indiana, is very vocal in his push for better care for our veterans. I am afraid he is facing an uphill battle.

Thanks to you, HC, for a very thoughtful post. I was being a bit curt and unfortunately directed it to you because I don't see any collective will to remedy the problems with the VA. It's one of those societal problems where we can point out deficiencies but are unwilling to do any meaningful reform.

I worked for The Upjohn Company when Ted Cooper was the CEO. I recall he was very active in pushing for ambulatory clinic development but, regrettably, he died before his time.

The entire system is corrupt, reps and pharma should be denied access to students, residents, fellows and attendings. After all, doesn't big pharma say their dollar donations for research have no link to influence or sales? If they are speaking the truth, then get them out of the teaching institutions. I prefer doctors learn from other doctors, not industry reps.

Bob, I think the best idea would be to give vets an insurance voucher to go wherever they want, the way Tri-Care works for active servicemen and women.

I will say that the psychiatry department at the VA offers a dazzling array of services for the vets, services that they might not take advantage of were they just out in the medical world at large. Having everything in one place at the VA means they can see their doc, go to group, see a counselor, socialize and mingle, all in one place, which has to be good for them. And the formulary is not too restricted.

I'd be interested in your perception of where there is a real fall-off in care.

It's difficult to say, HC, whether the problem is as widespread as perceived. The VA system has a lot of unrelalistic (and unfunded) expectations: as you know, it was intended to provide care for service-related conditions and gradually evolved away from that mission. This part of TX is underserved for its veterans' population and access to care is an issue. I'm not up-to-date on the literature re VA inpatient quality, I'm afraid.

I'm glad you pointed out the strenghts of the psychiatric inpatient and outpatient services. This is, and will continue to be, a major medical need.

Bob, There was an interesting blurb in the paper about how responsive the VA CAN be--despite its titanic size. A woman experienced a medical error as a result of the way the computer system works...she went to officials and made a suggestion to fix the problem. They are looking at it and coming up with a way to solve the problem and prevent future errors. The difficulty lies in the fact that the computer system is used at every VA, and so any fix will be widespread in nature, but they are on it and taking steps. I found that impressive.

Agree, HC.

My identity is fully disclosed, by the way, so I'll add another point. Our PharmD students start their experiential learning very early--the San Antonio VA is probably the most sought-after site for externships because of the opportunities to be engaged in patient care at an advanced level and to become familiar with the e-health records/e-prescribing.

Bob,

What do you think of the concept of the portable EMR that contains an individual's entire medical history...accessible to any health care provider that a patient encounters...

I am hearing a lot of privacy fears...

HC, from what I understand that's the long-term goal of the EMR. Seems as though a number of steps have to occur first: standardization of the medical record (a universal record), adequate funding to insure dissemination and adoption of hardware and software, training platforms and, as you note, privacy safeguards. (Disclaimer: I have been a long-term skeptic about the quality of integrated medical records.)

Bob, Yeah, I don't know what to think. If our intelligence agencies can't get a uniform platform from which to work, what makes us think we can devise one for 300 million medical records? It's a nice fantasy, though--you could have your total EMR on a thumb drive and carry it with you wherever you went. One of my docs says that someday, we will all have our DNA coded on a card and carry it with us...

Off the subject--went to see "21." It was ok; Kevin Spacey plays a good bad guy, but the real-life book was better.

Haven't read the book--saw a program either on The History Channel or similar network on the MIT prof. Several of the students were interviewed with their voices distorted and a blacked out face. Fascinating.

I spent a lot of time and the company's money from the 80s onward to integrate managed care organizations' data bases for pharmaco-epi and outcomes research. Frankly, I'm glad those days are behind me. I know analyses can be done with at the patient level but it requires an extraordinary amount of quality audits. I have respected friends and colleagues working in HIT but I remain somewhat skeptical about the quality of the initiatives.

Another off-topic; my wife wanted to go to Mexico today so we made the short drive. I visited several farmacias and noted the long lines of Americans buying chronic meds. Given that about 40% of the Rx drug supply in Mexico is counterfeit, I'm not willing to take the risk.

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