March 6th, 2013
The Influence of Medical School Gift Restrictions on Doctors’ Prescription Decisions
A recent BMJ study by King et al shows that gift restrictions adopted in medical schools resulted in graduates writing fewer prescriptions of certain newly marketed drugs compared with older, less expensive alternatives. Focusing on the prescribing patterns of three expensive new psychiatric medicines (paliperidone, lisdexamfetamine, and desvenlafaxine), the authors found that those who attended medical schools that did not allow gifts were three-quarters less likely to prescribe paliperidone and more than 50% less likely to prescribe lisdexamfetamine than those who attended schools without restrictions. The difference found for desvenlafaxine was not significant.
Associate Editor John Ryan asks the study’s senior author, Joseph Ross, about this finding and whether it might translate to cardiovascular agents.
Ryan: What is classified as a gift to a medical student from a pharmaceutical company? Seeing as medical students are not practicing physicians, do they have to declare such gifts in the same way that physicians do?
Ross: The classic gift given to a medical student from a pharmaceutical company is a stethoscope. At some medical schools, the presentation of the stethoscope from a company as part of a larger ceremony on the first day is a long-standing tradition. But many other types of gifts are more common, including pens, notepads, textbooks, and meals – lots and lots of pizza.
To my knowledge, however, there is no requirement for students to declare these gifts. The recently passed and soon to be enacted Physician-Payment Sunshine Act is focused on the reporting of payments from industry to physicians and academic medical centers, not payments to medical students. Those are not required to be reported.
Ryan: How did the medical schools ban such gifts?
Ross: Medical schools have been making the decision to ban gifts on a case-by-case basis for more than 15 years. I cannot speak to how any individual school made the decision to ban gifts, but I suspect that an individual, or group of individuals (most likely students), at the school became concerned about the frequent interactions that were taking place between pharmaceutical companies and medical school faculty and students, and questioned the purpose and consequences of these interactions. Their concern led to advocacy against permission of gifts from companies to students and faculty, eventually leading the schools to enact a policy that banned gifts completely.
Ryan: Do you expect that your findings would extend to the newer cardiology medicines that have been introduced in the past few years, be it new lipid medicines, antiplatelets or anticoagulants?
Ross: This is a great question, one on which I can only speculate since we did not explicitly examine prescribing of cardiology medicines in our study. However, my expectation is that our findings would be consistent, in that we would find that medical students who graduated from schools with gift restriction policies (and other policies governing the interaction between medical students/faculty and pharmaceutical companies) would be less likely to prescribe newly marketed cardiology medicines, specifically medicines that are not first in class.
In our study, we examined psychoactive medications that were new to market within a therapeutic class that had many alternatives, medications that had been on the market for many years and were much cheaper. The same would be true of any new lipid or antiplatelet medication. What we do not know from our study is whether graduates from medical schools with these policies are also less likely to prescribe newly marketed medicines that are first in-class or represent true therapeutic advances within an existing class of therapies. This question deserves scrutiny.