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.

Another potential weakness of forbidding trainee contact with pharmaceutical representatives is that it ignores the reality of life after training, when contact with pharmaceutical representatives is not strictly prohibited and may in fact be a regular occurrence. Should we expect our trainees to know how to behave in these encounters without any explicit discussion? A restrictive stance neglects an important resource available to help trainees in these instances—ourselves.

We educate our trainees about other forms of bias (in themselves, about their patients and their conditions) and follow this with deliberate practice. Similarly, we should honestly discuss our perspectives on interactions with the pharmaceutical industry and help our fellows navigate them.

A Balanced Approach

What course of action should we take to improve our fellows’ education and promote better care for our patients? In my opinion, an abstinence-only policy will not work. Fellows should be prepared for their future interactions with the pharmaceutical industry, whether at meetings, in the office or at sponsored talks. The easiest step, of course, is to provide explicit education to our fellows on bias and conflicts of interest with regard to relationships with industry.

We should follow this instruction with practice—something that will require more careful scrutiny of educational material, as well as informed discussion. We cannot boil this topic down to one question on the presence of bias, but instead must look at specific manifestations of bias: For example, does information about a new medication include a discussion about established therapies, a literature review or a discussion of limitations of the clinical trial?

We must teach our fellows to be conscientious learners at all times, whether the talk is sponsored or not. Practicing this critical analysis may require us to chaperone their interaction with pharmaceutical companies rather than forbidding it, ignoring it or pretending it doesn’t exist.

Allowing our fellows to interact with industry while maintaining an objective, up-to-date curriculum requires a careful balancing act. But it is one that is intellectually honest: We can show that we trust our fellows to meet with people with a connection to industry while also critiquing sources of bias, just as we trust them to manage patients. Before we know it, they will be doing both independently, free from our oversight.

Arundathi Jayatilleke, MD, MS, is an assistant professor and director of the Rheumatology Fellowship Program at Drexel University College of Medicine in Philadelphia.

References

1. Fleischman W, Agrawal S, King M, et al. Association between payments from manufacturers of pharmaceuticals to physicians and regional prescribing: Cross sectional ecological study. BMJ. 2016 Aug 18;354:i4189.
2. Brett AS, Burr W, Moloo J. Are Gifts from pharmaceutical companies ethically problematic? A survey of physicians. Arch Intern Med. 2003 Oct 13;163(18):2213–2218.
3. American College of Rheumatology principles regarding external entity support for rheumatology fellowship training. American College of Rheumatology. 2015 Jan.
4. Yeh JS, Austad KE, Franklin JM, et al. Association of medical students’ reports of interactions with the pharmaceutical and medical device industries and medical school policies and characteristics: A cross-sectional study. PLoS Med. 2014 Oct 14;11(10):e1001743.
5. Austad KE, Avorn J, Franklin JM, et al. Association of marketing interactions with medical trainees’ knowledge about evidence-based prescribing: Results from a national survey. JAMA Intern Med. 2014;174(8):1283–1290.

Editor’s note: This article was written for The Rheumatologist on behalf of the ACR Committee on Ethics & Conflict of Interest. Comments or questions? Contact us at klosavio@wiley.com.