Print version ISSN 1414-3283
Interface (Botucatu) vol.4 no.se Botucatu 2008
Medical education: university business, not that of the pharmaceutical industry
Educação médica: negócio da universidade, não da indústria farmacêutica
Educación médica: negocio de la universidad, no de la industria farmacéutica
Elma Lourdes Campos Pavone Zobolii
Professor, Doctor of the Nursing School of the University of São Paulo <firstname.lastname@example.org>
Translated by Philip Sidney Pacheco Badiz
Translation from Interface - Comunicação, Saúde, Educação, Botucatu, v.12, n.27, p. 906 - 908, Out./Dez. 2008.
The link between medical schools and the pharmaceutical industry is intricate and controversial, as the article "Medication/Drug promotion and advertizing in teaching environments: elements of the debate" clearly shows. Medical students are a vulnerable group to the predatory marketing action of pharmaceutical industry. They might believe that the only possible therapy is medication and this could contribute to increasing the value of medication. The continuing medical education supported by pharmaceutical industry can influence the routine of prescribing drugs. Thus, we agree with the argument for complete prohibition of this activity within teaching environments to preserve medical education of this hazard influence.
The link between medical schools and the pharmaceutical industry is intricate and controversial, as the article "Medication/Drug promotion and advertizing in teaching environments: elements of the debate" clearly shows. The forms vary, including financing for research projects, sponsorship of scientific and educational events; the distribution of gifts, trips and dinners, but the purpose is singular: promotion of their products. Even optional modules are offered within medicine courses. An article by Stanley, Jackson & Barnett (2005) analyzes a discipline offered to graduate students of a medical school in England, in conjunction with a local pharmaceutical company, aimed at informing those responsible for future prescriptions of the complexity and cost of developing new therapeutic drugs, facilitating understanding of the importance of assessing new therapies and encouraging future collaboration with the industry. It seems that under the guise of a discipline is hidden an aggressive marketing strategy targeting medical students, which besides perpetuating the relationship between the industry and research and inciting consumption, aims to justify the high prices of medications as if these, indeed, resulted from investments in research and development (R&D). They should be compared with the costs of marketing and administration, which are more than double that of R&D. This, without acknowledging that since it is unclear what constitutes R&D' in the accounting balance sheets, marketing activities could be involved. One clue to this is the fact that a significant proportion of clinical trials are composed of phase IV studies. Another is that the most creative, dangerous and prolonged part of the R&D process, learning about the disease, is conducted with public funding. Only one in every 5000 potential drug candidates arrives on the market, therefore, even if clinical trials are the most costly part, the majority of these candidates are discarded at the beginning of the process, before much money is invested in them. In the clinical phase, financed by the laboratories, the ratio of approval is one in every five candidates. According to the testimony of an executive of a large pharmaceutical company, reproduced by Angell (2008, p. 67), the price of a drug is not determined by research costs, but by its usefulness in the prevention and treatment of disease; i.e., the doctor, the patient and who actually pays for the drug determines its market value. Thus, for Angell (2008), it is patently clear that the sector charges as much as the market will bear, which has little to do with R&D costs. The insertion of the industry into medical education, with persistent advertizing from the first years of graduation onward, leading future doctors to believe that the only possible therapy is medication-related, could contribute to increasing the value of medication use and result in a market forced to bear ever higher prices.
It should also be highlighted that maybe the pharmaceutical industry is not as innovative as it would have us believe. Of the 78 medications approved by the U.S Food and Drug Administration (FDA) in 2002, only 17 contained new active principles and only seven were classified as improvements over older medications, leaving 71 that were considered variations that were no better than drugs already on sale (Angell, 2008, p 64). Is this a marketing strategy? Making the public believe that they are more innovative than they are in reality as a more noble justification of their high prices and profits?
Although it has not been directly proven, it is not unreasonable to assume that medical students and residents, given their relative inexperience, could represent a particularly vulnerable group to this predatory marketing action by the pharmaceutical industry (Montague, Fortin-VI, Rosenbaum, 2008). Thus, we agree with the argument for complete prohibition of this activity within teaching environments, as defended by Marisa Palácios, Sergio Rego and Maria Helena Lino.
In 2001, in the USA, pharmaceutical laboratories paid more than 60% of the costs of continuing medical education, hiring companies who announced their services to the laboratories, advertizing: "medical education is a powerful tool that can deliver your message to key audiences and get those audiences to take action that benefits your product" (Angell p. 155). If continuing medical education constitutes an opportunity to influence the routine of prescribing drugs without equal, how much more so the application of this strategy among students of medicine? As doctors develop their professional and prescription skills during graduation and residency, this period is fertile for educational interventions (Montague, Fortin-VI, Rosenbaum, 2008). It is true that the students do not respond for their prescriptions alone, but what is important is how contact with the pharmaceutical industry and its representatives end up molding the values and attitudes of the future doctor, made vulnerable both by their inexperience and their false belief that they are immune to the industry's influence (Wofford & Ohl, 2005). The form of involvement is seductive. Laboratory representatives, young dynamic and charming, invite interns and residents to lunch, during which they stand close by chatting about their medications. This strategy of "food, flattery and friendship" creates within these young future doctors, with a long life of prescriptions awaiting them, a feeling of reciprocity, of gratitude to these pleasant people who are always offering them gifts (Angell, 2008, p. 142).
The pharmaceutical industry exist to sell medications, it is difficult to believe that their entrance into medical education is not surrounded by tendentiousness, hyperboles and misinformation (Angell, 2008). Fortunately, it appears that a consensus is slowly growing regarding the influence of the industry on medical prescriptions and the practice of doctors, residents and medical students of receiving presents, sponsorship and gifts is being questioned. The Judicial and Ethics Commission of the American Medical Association has recommended that both doctors, individually, and teaching hospitals do not accept financing from the pharmaceutical laboratories for educational activities directed at students and doctors, limiting as far as possible, by means of internal policies, the activities of the industry with this audience (Relman, 2008). This appears minimal and insufficient to contain such predatory action. We agree with Palácios, Rego and Lino that "it is necessary to establish rigorous criteria for the ethical advertizing of these products" among professionals, with society in general demanding transparency in the relationship of doctors and medical schools with the pharmaceutical industry.
The university is responsible for medical education and not the laboratory. There is a difference between professional education and information about new medications, distributed to doctors and students for the purposes of advertizing and promotion. Promoting new products is part of the work of the industry. They can even call this promotion education, but it isn't; it's marketing (Relman, 2008).
When universities allow themselves to be influenced by the offers of the industry to the point that it compromises their primary interests, that is, providing a good education for future professionals, then clearly a conflict of interests is at work. This configures a situation in which secondary interests unduly influence the professional judgment of a person or entity with respect to their primary interests, determined by professional obligations. In the health area, this includes: the health and well-being of the patient; research integrity; and good education of professionals (Thompson, 1993).
Education is an intervention in the world, which, besides knowledge transmission, implies the dialectical struggle of the reproduction of the dominant ideology and its unmasking (Freire, 1996). Teaching responsibility, ensuring that people have a responsible vision of the world and life is the greatest challenge of our societies. The formation of mature, reasonable, prudent and responsible adults is a necessity, which is not possible without paying special attention to the sphere of values (Gracia, 2006). This necessity is even more urgent when it involves the formation of professionals who will deal with people's lives. When we recognize our capacity to observe, compare, evaluate, deliberate, choose, decide, intervene, rupture, transform, opt for, that is, to attribute meaning, we become ethical beings, moral citizens. It is true that this opens the way for the transgression of ethics, which must be seen as a possibility, but never as a right. A possibility, in the face of which we cannot simply cross our arms in paralyzed fatalism. We cannot absorb transgressions, making them seem natural, this would be an irresponsible attitude reiterative of the perversity that leads to the superposition of the market over that which is human and generates unacceptable injustices. Rather we should condemn them. It remains to be decided what we want: education to maintain the present situation of societies or to transform them? And in regard to health, do we want to maintain the present state of attendance and education or transform it?
ANGELL, M. A verdade sobre os laboratórios farmacêuticos: como somos enganados e o que podemos fazer a respeito. 3.ed. São Paulo: Record, 2008.
FREIRE, P. A pedagogia da autonomia. Rio de Janeiro: Paz e Terra ,1996.
GRACIA, D. Como arqueros al blanco: estudios de bioética. Madrid: Triacastela, 2006.
MONTAGUE, B.T.; FORTIN-VI, A.H.; ROSENBAUM, J. A systematic review of curricula on relationships between residents and the pharmaceutical industry. Medical Education. v. 42, p. 301-8, 2008.
RELMAN, A.S. Industry Support of Medical Education. JAMA. v. 300, n. 9, p. 1071-73, 2008. DOI: 10.1001/jama.300.9.1071.
STANLEY, A.G.; JACKSON, D.; BARNETT, D.B. The teaching of drug development to medical students: collaboration between the pharmaceutical industry and medical school. Br. J. Clin. Pharmacol. v. 59, n. 4, p. 464-74, 2005
THOMPSON, D.F. Understanding Financial Conflicts Of Interest. New England Journal of Medicine. v. 329, n. 8, p. 573-6, 1993.
WOFFORD, J.L.; OHL, C.A. Teaching appropriate interactions with pharmaceutical company representatives: The impact of an innovative workshop on student attitudes. BMC Medical Education. v. 5, n. 5, 2005. DOI: 10.1186/1472-6920-5-5.
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