Ethics Forum: Teach Rheumatology Fellows to Use Good Judgment in Pharmaceutical Company Interactions

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We teach medical students, residents and fellows evidence-based medicine to lay the groundwork for rational prescribing and good clinical judgment. But should we stop our rheumatology fellows from interacting with pharmaceutical companies as part of this foundation?

It is not surprising that pharma­ceutical companies can influence physician pre­scribing through gifts. At least, it should not be: We know that pharmaceutical companies spend millions of dollars each year on physicians and that gifts to providers can influence prescribing.¹ The fact that companies continue to spend money on physicians supports this theory as well. Studies show, however, that we physicians are skeptical about the impact of receiving gifts and other incentives on our prescribing practices.²

Whatever our attitudes toward physician relationships with pharmaceutical com­panies, as educators, we must carefully monitor our fellows’—as well as students’ and residents’—training. Their education should not be driven by the agenda of pharmaceutical companies, nor should our lectures follow canned slide decks. But what does this mean in practice?

Is it disingenuous to forbid our fellows to meet with pharmaceutical representatives when we do so ourselves, even “just for samples”? What about when they see their mentors listed as speakers for a “drug dinner” that they are not allowed to attend? Fellowship program directors, of whom I am one, have the heavy responsibility for determining the curriculum. But all rheumatologists share this responsibility, and we should act accordingly as models for our fellows.

The ACR’s policy of restricting fellows’ interaction with pharmaceutical representatives aims to protect their education with the goal of best serving our patients.³ The ACR emphasizes the primacy of patients’ interests as the center of professionalism, itself a tenet fundamental to a fellowship training program. Although it is true that we should protect our trainees (and our patients) from undue influences, we cannot dispute that pharmaceutical companies and their representatives can sometimes provide helpful services to our patients. How, then, should we balance these principles of professionalism and what relationship, if any, is appropriate between pharmaceutical com­panies and our fellows?

Should we expect our trainees to know how to behave in meetings with pharmaceutical representatives without any explicit discussion? A restrictive stance neglects an important resource available to help trainees in these instances—ourselves.

Shields Up

Our impulse to shield our trainees is understandable, well intentioned and, in some ways, successful. Less contact between trainees and industry is associated with evidence-based prescribing choices, at least during training.^4,5 Yet explicitly discouraging trainees from contact with pharmaceutical companies may lead to an implied approval of less obvious sources of bias, such as industry-supported continuing medical education (CME) activities. Trainees, unfortunately, may lack the knowledge to adequately assess bias here.