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Drug Company-Clinician and Drug Company Health Professional Student Relationships Frederick S. Sierles, M.D.* Professor and Director of Medical Student.

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Presentation on theme: "Drug Company-Clinician and Drug Company Health Professional Student Relationships Frederick S. Sierles, M.D.* Professor and Director of Medical Student."— Presentation transcript:

1 Drug Company-Clinician and Drug Company Health Professional Student Relationships Frederick S. Sierles, M.D.* Professor and Director of Medical Student Education in Psychiatry and Behavioral Sciences Rosalind Franklin University of Medicine and Science RFUMS August 29, 2012 Pharmacology Course Amy C. Brodkey, M.D.* Associate Clinical Professor of Psychiatry University of Pennsylvania 1 * No financial ties with, or gifts accepted from, drug companies

2 This Presentation Will Cover Interactions between the pharmaceutical industry, physicians and medical students Characteristics of the pharmaceutical industry Characteristics of the information that industry provides to us Our denial of industry influence Our efforts to reduce industry influence RFUMS’ policies about industry-clinician and industry- student interaction Outcomes of our efforts to reduce industry influence. 2

3 Objectives of this Presentation Please read these. I will not discuss them in class. Define a conflict of interest. Discuss the characteristics of information that the pharmaceutical industry provides to us health professionals and health professional students. Using data about pharmaceutical industry-clinician or industry- student interactions, given a vignette of an interaction between a typical (modal) drug rep and a typical (modal) clinician or health professional student, summarize what is most likely to occur during and after the interaction. Summarize the factors contributing to pro-industry outcomes in research (published and un-published) and publications that are sponsored by drug companies. State the RFUMS policies concerning industry-clinician and industry- student interactions. 3

4 Main Theme: The Disappearing Boundary Between the Health Professions and Industry—Particularly the Pharmaceutical Industry— and its Consequences From , we health professionals interacted progressively more frequently with industry (particularly the pharmaceutical and medical device industries), with fewer boundaries between us and them. Between 2009 and today, this may have reached a “plateau.” In the past 13 years, enormous public and health professional attention has been given to these interactions and their consequences. This has taken the form of scientific journal articles, books, media coverage, governmental investigations and health profession policy statements. 4

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10 Health Professional Responses to the Decreasing Boundary As a consequence of this attention, influential national organizations like the Institute of Medicine and the Association of Medical Colleges, have urged that our health professions set boundaries between us and industry, and teach about our interactions with industry. Most US medical and health sciences schools— including RFUMS—have developed policies about industry-clinician and industry-student interactions. But industry—more powerful than ever—still tries to maximize its interactions with us. 10

11 Disappearing Boundary and Conflicts of Interest These ties between doctors and the drug industry often create conflicts of interest, defined as A set of conditions in which professional judgment concerning a primary interest, such as a patient’s health or the validity of research, tends to be unduly influenced by a secondary interest, such as financial gain. 11 Source: Thompson DF. NEJM 1993;329:

12 12 Source: Catherine de Angelis, MD, at UIC Pharmacy School, 10/27/07

13 Effects of the Disappearing Boundary and Conflicts of Interest The more that the boundary between the health professions and industry disappears (i.e., the more we interact with and receive gifts from industry), The more we are exposed to and influenced by information that favors the sponsor’s product. An extraordinary body of literature uniformly demonstrates that for virtually every type of drug industry-clinician interaction, including advertising, education and research, the outcome is the presentation of information that favors the sponsor’s drug. 13

14 Effects of Receiving Information that Favors the Sponsor’s Product This increases the likelihood of our prescribing the sponsor’s product and teaching that the product (i.e., the drug) is effective. This often occurs – Regardless of whether the drug is best for the patient, – Despite scientific evidence to the contrary – Against our better judgment 14

15 Compounding the Problem This problem is compounded by – Our proneness to deny that the influence exists – Our passivity 15

16 The increased likelihood of our prescribing the sponsored product, even when scientific evidence and our better judgment says otherwise, leads to… Poorer patient care Poorer health science education Scandalously high costs of drugs 16

17 The Pharmaceutical Industry From , and 2008-present, the highest return on sales, assets and equity of any industry, overall a 38-year-long pattern. From , the industry came in third, below mining/crude oil production and commercial banks. 17 Sources: Angell M. The Truth about the Drug Companies, 2004; IMS Health; Brody H: Hooked, 2007

18 Drug Companies’ Return on Revenues: The Highest Profit Margins of All Industries 18 Source: Time Magazine, February 2, 2004

19 Pharmaceutical Industry and Government There is more than one drug company lobbyist for every member of Congress. The pharmaceutical industry is taxed less than any other industry. 19 Source: Public Citizen 7/6/2000, NEJM 6/22/2000, Time Magazine 2/6/2000, Common Cause, 6/2001

20 20 Source: Catherine de Angelis, MD, at UIC Pharmacy School, 10/27/07

21 The Pharmaceutical Industry Lobby is so Powerful that, for Example… In the 2004 Medicare Part D law, Medicare is forbidden to negotiate prices with drug companies, which maintains the high costs of drugs. – Subsequently, Rep. Tauzin, pro-Pharma House leader in this Medicare Part D debate, retired from Congress and became CEO of the Pharmaceutical Manufacturers’ Association. In the health care reform debate, to obtain drug company support for the Affordable Health Care Act—and ward off company opposition to the bills—President Obama privately told them that, once again, the reform bill would not include government negotiation of drug company prices. 21 Sources: Public Citizen Congress Watch, July 2001; Angell M. The Truth about the Drug Companies, 2004

22 Costs of Marketing to Doctors In marketing and promotion to doctors, in the U.S., the pharmaceutical industry spends between $61,000/practicing physician/year. These costs are borne largely by patients and the public (as taxes) to whom the marketing costs are transferred in the huge costs of drugs. 22 Source: Gagnon M-A, Lexchin J, PLoS Medicine 2008;5:1-5

23 MD Profiling: An Ethically Troubling Marketing Technique Drug companies find out how often each doctor prescribes each drug. They obtain this information from a combination of – The American Medical Association, whom they pay ~$44,000,000/year – Pharmacy chains like Walgreens, CVS, OSCO They use this information to pitch their products to individual doctors. 23 Greene JA. Ann Int Med May 15;146:742-8; Steinbrook R. NEJM Jun 29;354(26):

24 24 Sources: Edwards J. Brandweek Feb 7; ;46(6):24-6; Public Citizen, 2001

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26 Drug Detailing In 2000, the pharmaceutical sales force was 88,000, and there was one drug rep for every 7-8 MDs and the number of details (visits by a drug rep to an MD) was 60,000,000. Currently it is 100,000 sales reps, and for high- prescribing doctors, the ratio is 1 rep per 2.5 MDs. 26 Sources: New York Times 1/11/99; Scott Levin Consulting, PhRMA Pharmaceutical Industry Profile Goldberg M et. al. (2001 appendix); Goldberg M et. al. Pharm Exec Jan 1;24:40-5. Source: Presentations by Amy C. Brodkey, MD, Adriane Fugh-Berman, MD

27 Types of Health Professional-Pharmaceutical Industry Interactions Gifts Meals Honoraria Clinician self-esteem Detailing Medication samples Continuing education (CE) events Fellowships Stage 3 and 4 drug trials Consultancies Speakers’ bureaus Ghostwriting Professional society and society meeting support Medical Education Companies (MECs) Investments Patient advocacy groups Contract research organizations Academic-industry partnerships Direct-to-consumer ads 27 Modified from 2003 presentation by Amy C. Brodkey, MD

28 Continuing Medical Education (CME) The pharmaceutical and medical device industries pay for over 50% of the $2.3 billion spent annually for continuing medical education (CME). CME programs are biased in favor of the sponsor’s products. 28 Sources: ACCME, 2006; Bowman & Pearle. J Contin Educ Heal Prof 1988; Relman A

29 Fees to MDs to Enroll Patients in Clinical Trials Drug companies pay an average of $7,000 to enroll one of their patients in a clinical trial, sometimes with bonuses for rapid enrollment. In one trial, MDs were paid $12,000 for each patient enrolled, plus another $30,000 for enrollment of the sixth patient. – “If it means an extra $30,000 to you to enroll a patient in an asthma study, you might very well be tempted to decide your next patient has asthma, whether he does or not. (‘Sounds like a little wheeze you have there’)” 29 Source: Angell M. The Truth about the Drug Companies, 2004, p. 31

30 Physicians Who Participated in Sponsored Clinical Trials Were More Likely to Prescribe Sponsored Drug in their Practices than Non- Participating Physicians (Chart review for 55,013 patients) 30 Source: Andersen M et al. JAMA 2006;295:

31 Consultancies to Drug Companies In the commonest type of “consultancy,” clinicians are invited to expensive restaurants or on trips to luxurious settings. “The doctors listen to speakers and provide some minimal response about how they like the company drugs or what they think of a new advertising campaign. This enables drug companies to pay doctors just for showing up.” 31 Source: Boston Globe, December 15, 2002

32 Speakers’ Bureaus and MECs Many clinicians are recruited to serve on speakers’ bureaus, typically run by for-profit medical education companies (MECs). MECs are – Typically supported by drug companies – Sometimes owned by advertising agencies – Accredited to provide CME programs MECs – Plan meetings – Suggest topics and speakers – Prepare slides – Coach speakers on how to use the slides and what to say 32 Source: Angell M. The Truth about the Drug Companies, 2004, p. 139

33 Ghostwriting Approximately 11% of medical journal articles are ghostwritten by professional writers working for medical education companies (MECs) largely funded by DCs. Sources: Moffatt B, Elliott C Perspect Biol Med 2007; Healy D, Cattell D. Brit J Psychiatry 2003; Flanigin et al., JAMA

34 Support of Professional Meetings “Many big professional meetings resemble bazaars, dominated by garish drug company exhibits and friendly salespeople eager to ply doctors with gifts while they pitch their companies’ drugs…Instead of sober professionalism, the atmosphere of these meetings is now trade-show hucksterism.” 34 Source: Boston Globe, May 28, 2002

35 35 American Psychiatric Association Convention, 2005 (photo by F. Sierles)

36 36 American Psychiatric Association Convention, 2005 (photo by F. Sierles)

37 37 American Psychiatric Association Convention, 2005 (photo by F. Sierles)

38 38 American Psychiatric Association Convention, 2005 (photo by F. Sierles)

39 Support of Professional Meetings (cont.) “Most professional societies support this because the drug companies support the meetings. At the American Psychiatric Association (APA) annual meeting in 2002, drug companies spent between $200,000 and $400,000—plus a $60,000 direct payment to the APA—for each of ~50 “industry- sponsored symposia.” APA officials state that drug companies provide one third of the APA’s budget. 39 Sources: Boston Globe, May 28, 2002; Brody H: Hooked, 2004, p. 215

40 Consultation to the Investment Industry Almost 1 in 10 physicians has a formal consultancy with the investment industry. Hourly rates range from $200-1,000. For example, New York’s Gerson Lehrman Group has contracts with over 60,000 physicians. 40 Source: Topol EJ, Blumenthal D JAMA 293:

41 Patient Advocacy Groups Many patient advocacy groups receive drug company support. In some instances, the drug company actually creates the advocacy group. For example, – The American Reye’s Syndrome Association was created by Bayer aspirin to oppose the FDA’s proposal of a warning label for use of aspirin for viral illnesses. 41 Source: Washington Post, September 12, 2000

42 Examples of Patient Advocacy Groups Created by Industry The majority of donations to the National Alliance for the Mentally Ill (NAMI) comes from drug companies. Consumer groups fully funded by Eli Lilly bombarded Kentucky state agencies when they proposed to remove olanzapine from its formulary. 42 Source: Brody H: Hooked, 2007; Harris G: Drug makers are advocacy group’s biggest Donors. NY Times, October 21, 2009.

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44 Criminal and Civil Penalties for Drug Companies’ Illegal Marketing of Drugs, or Kickbacks to Doctors Pfizer. $240 million for off-label marketing of gabapentin (Neurontin) TAP. $875 million for illegal kickbacks to doctors who prescribed leuprolide (Lupron) Pfizer. $2.3 billion for off-label marketing of valdecoxib (Bextra), ziprasidone (Geodon), linezolid (Zyvox) and pregabalin (Lyrica) Lilly. $800 million for off-label marketing of olanzapine (Zyprexa) Glaxo Smith Kline. $3 billion for off-label marketing of paroxetine (Paxil) and failing to report safety data about rosaglitazone (Avandia) 44 Sources: Steinman MA, Bero LA, et al. Ann Int Med 2006; Spielmans GI. Soc Sci Med 2009; Harris G. NY Times, October, 2009; Brody H. Hooked. Rowman & Littlefield, 2007; NY Times, July, 2012)

45 Profits and Laws “Managers do not have an ethical duty to obey economic regulatory laws just because the laws exist. They must determine the importance of these laws. The penalties Congress names for disobedience are a measure of how much it wants firms to sacrifice in order to adhere to the rules; the idea of optional sanctions is based on the supposition that managers not only may but also should violate the rules when it is profitable to do so.” 45 Source: Easterbrook FH, Fischel DR, “Chicago School”: Antitrust Suits by Targets of Tender Offers. Michigan Law Rev 1982;80: (p. 1157)

46 Visits per Month with Drug Reps in National Survey of Physician-Industry Relationships, 2003 Anonymous mail survey 3167 clinicians, 52% response rate 46 Source: Campbell EG et al. NEJM April 26, 2007 Visits/ Month

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48 48 New Yorker, September 2008

49 % of Medical Students Experiencing Various Types of DC Marketing (826 3 rd year students at 8 schools) 49 Source: Sierles et al., JAMA, 2005

50 NOT ME “I can see how other students and doctors could be influenced by gifts and sponsored presentations. But NOT ME. I’m objective and scientific and I know when what I hear is biased and I can’t be influenced.” 50 Attitude of most doctors and medical students

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52 52 Source: NoFreeLunch website

53 Denial of Influence: Proportions of Residents or Medical Students Who Perceive that They, or Doctors in General, Are Not Influenced by Gifts 53 Sources: Hodges, 1995; Reeder, 1993; Steinman, 2001; Wilkes, 2001; Sierles 2005; Austad, Avorn, Kesselheim 2011

54 Students’ Perceive that They Are 1) Minimally Influenced by and 2) Entitled to DC Gifts 54 Source: Sierles et al., JAMA, 2005

55 “I’m Not Biased: The Other Guy Is”: Resident Perceptions of Whether DC Gifts Can Influence Their Prescribing Practices 55 Source: Steinman et al. Am J Med 2001;110:551

56 56 BIAS IN INFORMATION PROVIDED BY DRUG COMPANIES TO DOCTORS

57 Other Data about DCs: Virtually All Information Presented by Industry to Physicians is Biased in Favor of the Sponsor’s Product. This Includes… Journal articles Journal supplements CME presentations Grand rounds Details by reps to doctors Journal advertisements National medical meetings Sources: Bekelman et al., JAMA Bero LA, Rennie D. Int J Technol Assess Health Care Lexchin J Bero L et al. BMJ Safer DJ. J Nerv Ment Dis Cho MK, Bero LA. Ann Int Med Bowman MA. Mobius 1986, Spingarn RW, et al. Acad Med Ziegler MG. JAMA Villanueva et al. Lancet Fries JF, Krishnan E. Arthritis Res Ther 2004;6:

58 Abstracts on Randomized Controlled Trials Presented at 2001 American College of Rheumatology Meetings 58 Source: Fries JF, Krishnan E. Arthritis Res Ther 2004;6:

59 Abstracts in Scientific Program at 2005 and 2006 American Psychiatric Association Annual Meetings: Industry- Sponsored Research or Author’s Ties Listed in Program 59 Source: Sierles FS, Gill T. Unpublished Manuscript, 2008.

60 Conflicts of Interest in Research: Sponsored Studies Tend to Have Pro-Drug Company Conclusions (11 articles that evaluated 1140 original studies) 60

61 61 Source: Bekelman et al., 2003

62 62 Copyright ©2003 BMJ Publishing Group Ltd. Bias in Research: Relationship between Industry Sponsorship and Study Outcome in 16 Additional Studies of Clinical Trials Source: Lexchin J Bero L et al. BMJ 2003;May 31, 2003

63 Sponsor’s Drug Beats Comparison Drug in 18/21 Head-to-Head Studies of Atypical Antipsychotics 63 Source: Heres et al. Am J Psychiatry, Feb, 2006

64 Factors Contributing towards Bias in Studies Selecting healthier (younger, fewer co-morbidities) patients “Enriching” randomized double-blind trials by including patients who previously responded to sponsored drug in open-label trials Withholding unfavorable data (about lack of effect, or bad outcomes) Comparing high dose of sponsored drug with low dose (or ineffective route of administration) of competitor’s product Comparing sponsored drug to a placebo 64 Sources: Bero L, Rennie D. Int J Technol Health 1996;12; ; Lexchin J, Bero LA. BMJ 2003;326:1167; Melander H et al. BMJ 2003;326:1171; Dubovsky S, Dubovsky A. Psychotropic Drug Prescriber’s Survival Guide, 2007

65 Factors Contributing towards Bias in Studies (cont.) Conflating statistical significance with clinical importance Emphasizing lab values over meaningful clinical effects Including the same data and patients in multiple publications Publishing in non-peer-reviewed symposium proceedings and journal supplements, not peer-reviewed journals Drawing conclusions not based on the data 65 Sources: Bero L, Rennie D. Int J Technol Health 1996;12; ; Lexchin J, Bero LA. BMJ 2003;326:1167; Melander H et al. BMJ 2003;326:1171; Dubovsky S, Dubovsky A. Psychotropic Drug Prescriber’s Survival Guide, 2007

66 Positive Studies of Antidepressant Efficacy are More Likely than Negative Studies to Be Published Review of 74 Studies involving 12,564 Patients Turner EH et al. NEJM, Jan. 17,

67 67 Positive Studies of Antidepressant Efficacy are More Likely than Negative Studies to Be Published (cont.) Review of 74 Studies involving 12,564 Patients. Turner EH et al. NEJM, Jan. 17, 2008

68 Direct-to-Consumer (DTC) Ads Depictions of Illness and the Company Drug (Peak TV viewing times x 1 mo.) 68 Source: Frosch et al. Ann Fam Med 2007;5:6-13

69 When a Behavioral (Lifestyle) Change is as Good as Medication for a Condition, How Do Direct-to-Consumer Drug Ads (DTCA) Address This? (Peak TV viewing times x 1 mo.) 69 Source: Frosch et al. Ann Fam Med 2007;5:6-13

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71 Characteristics of Direct to Consumer Ads (Peak TV viewing times x 1 mo.) 71 Source: Frosch et al. Ann Fam Med 2007;5:6-13

72 Statements by Drug Reps Tended to Favor the Promoted Drug Rather than the Competitor’s Drug (recordings of 106 statements by 12 reps speaking to 27 medicine residents at 8 lunch conferences) 72 Source: Ziegler et al. JAMA 1995;273:

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74 MD Passivity (cont.): ~7% of Patients Requested Specific Drugs, and 3/4 Received Them (1431 patients, pre-visit questionnaires; 78 MDs, post-visit questionnaires) 74

75 Too Often, Primary Care MDs Who Prescribed the Requested Drug Might Not Have Prescribed it for Another Patient. 75

76 Free Drug Samples Are More Likely to Be Given to Privileged than Underprivileged Persons 76 Source: Cutrona SL, Woolhandler S, et al. Am J Pub Health, 2008

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78 Conflicts of Interest in Patient Care: Authors of Clinical Practice Guidelines’ (CPGs) Relationships With Drug Companies (written survey of 100 authors of 44 CPGs) 78 Source: Choudary et al. JAMA 2002; 287:

79 However, Authors Declared Conflict of Interest in Only 1 of 44 Guideline Sets 79 Source: Choudhry et al. JAMA 2002; 287:

80 Percentage of DSM-IV Panel Members With and Without Ties to Pharmaceutical Industry—Yet No Ties Were Disclosed 80 Source: Cosgrove L, Krimsky S, et al. Psychother Psychosom 2006;75:

81 81 Proposed Solutions

82 82 The Association of American Medical Colleges (AAMC), which accredits all medical schools, expects/urges all medical schools and academic medical centers to have rules about drug company-physician and drug company-student interactions. Association of American Medical Colleges (AAMC). Industry Funding of Medical Education: Report of an AAMC Task Force. Washington, DC: AAMC, June 2008

83 Medical Students at U. of Miami (Gifts Permitted) Are More Apt than Students at Penn (No Gifts) to Perceive that They Are 1) Minimally Influenced by and 2) Entitled to DC Gifts. (Sources: Grande et al., 2009; Sierles et al., 2005) 83

84 84 RFUMS Rules about Drug Company-Physician and Drug Company-Student Interactions

85 Gifts to Individuals Gifts to an individual (e.g., doctor, student) from the health care industry are prohibited. A gift from the health care industry to the University is not a “gift to an individual” if – The gift is processed by the Office of Institutional Advancement. – Health care industry does not give the gift directly to an individual. – Health care industry does not select the recipient of the gift. 85

86 Food No food from industry UNLESS – The event is an approved Continuing Medical Education event. – The sponsor gives a grant to the college’s/school’s Office of Continuing Education. 86

87 Drug Samples Samples, which are gifts, may not be given directly to doctors or patients by drug company representatives. They may be given by drug reps to the university health system to centrally manage the giving of samples. 87

88 Ghostwriting Health care professionals and students may not accept credit for articles ghostwritten by others. 88

89 Meetings with, or Presentations by, Drug Reps Drug reps may not meet directly or make appointments with students or residents, and vice versa. A faculty member may invite a drug rep to discuss a topic with him or her, and may include a trainees in that meeting. 89

90 Pharmaceutical Manufacturers of America 2009 Code about Their Drug Reps’ Interactions with Healthcare Professionals Providing items for healthcare professionals’ use that do not advance disease or treatment education—even if they are practice-related items of minimal value (e.g., pens, note pads, mugs…) may foster misperceptions that company interactions are not based on informing them about medical and scientific issues. These (pens, notepads, mugs) should not be offered to healthcare professionals or members of their staff. Companies should provide – No entertainment or recreational items like theater or sporting event tickets – No golf balls or sports bags It is inappropriate to include a healthcare professional’s spouse or other guest in a meal accompanying an informational presentation made on behalf of a company. 90

91 Monthly Frequency of Drug Company Lunches Provided to Third Year Students at Three Medical Schools, 2003 vs (Source: Sierles FS, Kessler KH et al., 2012) 91 F=31.54 P <.001

92 Monthly Frequency of Drug Company-Sponsored Grand Rounds Attended by Third Year Students at Three Medical Schools, 2003 vs (Source: Sierles FS, Kessler KH et al., 2012) 92 F=57.1 P <.001

93 Monthly Frequency of Drug Company-Sponsored Grand Rounds Attended by Third Year Students at Three Medical Schools, 2003 vs (Source: Sierles FS, Kessler KH et al., 2012) 93 F=57.1 P <.001

94 Monthly Frequency of Small Gifts Provided by Drug Companies to Third Year Students at Three Medical Schools, 2003 vs (Source: Sierles FS, Kessler KH et al., 2012) 94 F=172.9 P <.001

95 Monthly Frequency of Snacks Provided by Drug Companies to Third Year Students at Three Medical Schools, 2003 vs (Source: Sierles FS, Kessler KH et al., 2012) 95 F=20.18 P <.001

96 Monthly Frequency of Reprints or Glossy Brochures Provided by Drug Companies to Third Year Students at Three Medical Schools, 2003 vs (Source: Sierles FS, Kessler KH et al., 2012) 96 F=25.5 P <.001

97 Monthly Frequency of Physicians Asking Third Year Students at Three Medical Schools to Attend a Drug Company Sponsored Lunch or Dinner, 2003 vs (Source: Sierles FS, Kessler KH et al., 2012) 97 F=4.02 P <.045

98 Changes in Physician-Industry Relationships from 2004 to 2009 (Random Sample of 2,938 Physicians) Source: Campbell E. et al. Arch Int Med 2010;170:

99 Change in Medical Students’ Attitudes about Drug Company Interactions in Response to a Teaching Intervention 99 Source: Kao AC, Braddock C. Academic Medicine, November 2011

100 List of Unbiased Drug Sources Medical Letter Prescriber’s Letter Therapeutics Letter (Canada) Drug and Therapeutics Bulletin (UK) Infopoems Cochrane Database Consumer Union Best Buy Drugs Carlat Report (psychotropic drugs) Prescrire (France) 100

101 Health Sciences Schools—Not Drug Companies—Are Responsible for Health Science Education “Medical education worthy of the name requires an impartial analysis of all the available evidence, led by experts who have no vested interest in the drugs they are discussing. It is the job of medical schools and their faculty, and of professional societies, to educate doctors in that way. To abdicate that responsibility is wrong, and it is doubly wrong to leave it to an industry with an obvious financial interest in the enterprise and then pretend it is otherwise. That a noble profession has been willing to do this is a testament to the power of ‘food, flattery and friendship’—and money, lots of it.” 101 Source: Relman A, Angell M. America’s other drug problem: New Republic, December 16, 2002


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