Student Doctors Start to RebelJun 24, 2002 | Wall Street Journal Jaya Agrawal carries her revolt against the world's drug industry in a yellow lunchbox.
Ms. Agrawal used to join her fellow students at Brown Medical School in scarfing up the free lunches, pens, notepads and other gifts dished out by pharmaceutical makers at Providence, R.I., teaching hospitals. Then, two years ago, she decided to stop.
She started bringing her own sandwiches to lectures where drug companies provided lunch. She went through her lab coats and threw out all the pens and notepads emblazoned with drug-company logos. She even tossed the fun freebie from a Viagra sales rep a Viagra calculator that stood up on a base when the "on" button was pressed.
The fourth-year student is part of a growing movement among students and some teachers trying to curtail the drug industry's efforts to woo young doctors as future customers. "We need to find some way to reclaim the moral high ground," she says.
Just as drug salespeople court full-fledged doctors with fancy meals, ballgame tickets and other niceties, they strive to persuade aspiring physicians to prescribe their products. For example, a drug company might spring for pizza at a lecture on uses of a newly approved class of drug, hoping to get in a plug for its own product.
"The reps know it's one thing to reach a doctor in practice, but another thing altogether to reach somebody who has a whole career ahead of him," says Jerry Avorn, a Harvard Medical School associate professor who for years has studied the interactions between drug representatives and doctors.
Ms. Agrawal helped launch a national campaign calling on students to sign pledges swearing off all drug-industry gifts. She is also urging them to ditch their drug-company pens, or at least put tape over company logos. And she plans to push officials at Brown University's medical school this fall to limit interaction between drug-company salespeople and students.
Medical students on other campuses are organizing seminars and lectures on the issue. At a recent luncheon at Washington University in St. Louis, leaders of the local chapter of the American Medical Student Association handed out cans of soft drinks affixed with labels taking digs at drug-industry marketing.
"In 2000, Merck [& Co.] spent $161 million on advertising for Vioxx," one label read. "That is more than PepsiCo spent advertising Pepsi ($125 million), and more than Anheuser-Busch spent advertising Budweiser ($146 million)."
Research has shown that industry largess influences doctors to the point that some improperly prescribe or overprescribe certain drugs. It also may affect how much consumers pay. A study in the Journal of the American Medical Association in January 2000 said doctors who were more inclined to interact with drug reps were less likely to prescribe cheaper generic drugs.
The industry disputes many of these findings, arguing that its salespeople provide physicians with useful product information, and that doctors are too smart to let free tickets affect prescription decisions.
Jeff Trewhitt, a spokesman for the Pharmaceutical Research and Manufacturers of America, the industry's main Washington trade group, says: "It is an insult to assume new young doctors don't have the ability to exercise independent judgment about the information disseminated at lectures."
But there is little dispute that drug makers spend big money more than $16 billion in 2001, according to one estimate cultivating physicians and medical students. Critics say these ever-rising costs contribute to rising drug prices.
Drug makers have grown more sensitive about these issues as Congress, insurers and some big employers have increased their scrutiny of drug prices. In April, the industry issued voluntary guidelines aimed at curbing the most egregious types of direct-to-doctor marketing, including "dine 'n' dash" events at which physicians show up for a brief drug pitch before leaving with a fancy to-go meal.
But drug companies say they will continue to market to residents and students as long as teaching hospitals continue to let them do so which may be for some time to come. Despite the recent opposition, drug salespeople are welcome at most medical schools and teaching hospitals, and many students and faculty members like the perks.
Last month, two Harvard Medical School students proposed that a statewide Massachusetts physicians' association adopt a resolution that doctors, residents and medical students would refuse to accept any industry gifts. Doctor after doctor stood up at a public hearing to defend the industry. The physicians' group voted to study the issue further.
Doctors who oppose drug companies' wining-and-dining policies can meet with stiff counterresistance. Such was the case when Edward Wing, chairman of the department of medicine at Brown Medical School and chief of medicine at two affiliated teaching hospitals, blocked drug reps two years ago from sponsoring lunches for residents and students. Since then, reps have stuffed residents' mailboxes with invitations to off-campus events and complained to Dr. Wing's superiors, thus far to no avail.
"Drug-company salespeople don't like me," Dr. Wing says. His department now spends more than $70,000 a year of its own funds supplying lunches for medicine residents at Rhode Island Hospital and a sister institution.
Harvard's Dr. Avorn says he has been fending off drug reps for almost 30 years, ever since he was a medical resident. In the early 1980s, he conducted a pivotal study showing how strongly physicians were influenced by company sales pitches. Doctors said they were swayed by scientific literature, not drug reps. But Dr. Avorn and his researchers showed that the information doctors had about certain drugs could have come only from salespeople or ads, not medical literature.
Today, at Brigham and Women's Hospital in Boston, Dr. Avorn runs the Division of Pharmacoepidemiology and Pharmacoeconomics, which seeks to provide "Data on Prescribing Effectively." (The acronym DOPE was a pure accident, Dr. Avorn says.)
Dr. Avorn's 18 researchers and support staff assemble facts designed to counter-spin the drug reps by questioning, for example, whether a particular drug is as necessary as a company says.
The issue picked up steam when Bob Goodman of Columbia University's College of Physicians and Surgeons started the national No Free Lunch organization in 1999. The organization has become a clearinghouse of information about doctors and drug reps used by Ms. Agrawal and other students.
Ms. Agrawal says she didn't notice much drug-company presence in her first two years at Brown. The next year, when instruction moved from the classroom to the hospital, drug reps started appearing. "You walk into a lunch, and there is somebody dressed in a suit, and they approach you and are very nice to you," she says. "It's kind of confusing, because generally when you're a medical student, people don't come up and ask your opinion on anything."
The confusion cleared up when she got involved with AMSA, the national medical-student group based in Reston, Va. She heard about Dr. Goodman's "no free lunch" idea and skipped some lunches sponsored by drug reps. But because she was expected to attend such events, she began to bring her own lunch in the yellow box. "It's hard to sit there and not eat," she says.
After her third year, Ms. Agrawal was elected president of AMSA. At the group's annual meeting in Houston in March, she pushed a resolution urging all physicians, residents and medical students to refuse "any promotional gifts from the pharmaceutical industry." The resolution also called on hospitals and residency programs to eliminate drug-company lunches and lectures. It passed in a voice vote.
Mr. Trewhitt, the PHRMA spokesman, says the students are "irresponsibly suggesting that doctors should automatically walk away from lectures that could convey important technical information about diseases and medicines that treat them."
Now that her one-year term as AMSA president is up, Ms. Agrawal is back on the Brown campus. Among other things, she's arranging to meet with school officials about limiting interaction between drug companies and students.
Recently, Ms. Agrawal got a reminder of how tough her challenge will be. When she moved into the apartment she shares with two other students, the first thing she saw was a big purple Zithromax clock in the common room. There was another in the kitchen, and yet another in a roommate's room.