Thomas Frank, MD
OB/GYN, MHMC
email Dr. Frank
phone: 778-7856

ABSTRACT

The impact of industry on medical education and medicine in general is a subject that has traditionally been given little attention in the curriculum of most medical schools and residencies. Medical education must incorporate a process of critical examination of the relationship of industry to research, practice and the educational process. As part of the Scholars Collaboration in Teaching and Learning Excellence in Medical Education Program, the faculty scholar will collaborate with a second and fourth year medical student in designing a study which will measure the impact of contact by representatives of industry on the prescribing practices of residents at CWRU-sponsored postgraduate programs. In addition, this group will work to design a structured curriculum in Physician-Industry Relations, which would begin in the preclinical years and would continue into the postgraduate programs sponsored by CWRU School of Medicine. This curriculum will be designed in conjunction with ethicists, educators and graduate medical education committees of the teaching hospitals affiliated with CWRU. It is anticipated that at the end of the project a set of guidelines on relationship to industry will be submitted to the Board of the Medical School for approval.

PROJECT OUTLINE

The importance of assessing outcomes of undergraduate and graduate education has only recently been appreciated. In 1999, the American College of Graduate Education endorsed a proposal mandating measurement of six general competencies by accredited residency programs. These include patient care, medical knowledge, practice-based learning and improvement, interpersonal communication skills, systems-based practice and professionalism. Similarly, educators and society at large are increasingly realizing a need to develop methods of insuring medical students' competence in areas other than the traditionally measured "book" knowledge.

In an era where research and educational activities are routinely sponsored by for-profit pharmaceutical companies and manufacturers of medical devices, groups such as Public Citizen and A.A.R.P. have questioned the impact of such practices on the exploding cost of prescription medicines. Several studies have demonstrated that physicians' prescribing practices are frequently influenced by subtle and more blatant marketing practices. The ethics of medicine dictate that a physician's first responsibility is to look after the well being of his or her patients. The ethics of industry dictate that the paramount responsibility of a corporation is to its shareholders. This conflict of interest is most glaring when one looks at promotional activities such as industry-sponsored social events and giveaways, yet it is probably more insidiously dangerous when one considers the marketing value of underwriting educational rounds where the speaker is chosen by the representative of a pharmaceutical company.

One option to this dilemma would be to completely eliminate industry from the process of medical education. While this would undoubtedly provide a learning environment free of outside pressures or influences, it would not prepare the young student or resident for the realities of life in the real world of practice or clinical research. Furthermore, it is not unreasonable to expect that an industry so dependent on well educated physicians to further its end, be expected to funnel some of its profits back by investing in the process of education.

Medical education must incorporate a process of critical examination of the relationship of industry to research, practice and education itself. A curriculum which includes evaluation of a student's professionalism should therefore provide formal ethics lectures on topics such as receiving gifts from industry and disclosure of conflicts of interest in research and education. As advertising is ubiquitous, young physicians must be taught how to differentiate between educational and marketing messages.

Competency in systems-based practice entails understanding consideration of cost-benefit analysis as a component of prescribing practice, advocacy for patient benefit with respect to pharmaceutical costs, and understanding the difference between education and promotion.

Competency in interpersonal and communication skills includes both learning to handle patient requests for specific medications, particularly ones promoted in direct-to-consumer marketing, and student/resident instruction in managing encounters with industry representatives.

In my role of Program Director for the CWRU Residency in Obstetrics and Gynecology at MetroHealth and the Cleveland Clinic, I have begun to address these issues, not by banning industry entirely from the process, but by separating the advertising message from the educational. While unrestricted educational grants and occasional clear-cut marketing lunches are still permitted, direct industry sponsorship of core educational material is not.

My goal for the Scholars Collaboration in Teaching and Learning Excellence in Medical Education Program is to help design a structured curriculum in Physician - Industry Relations which would begin in the preclinical years and would carry on into the postgraduate programs sponsored by CWRU. I would expect that my working group would interact with ethicists, residency program directors, hospital graduate medical education committees and educators throughout the Medical School. I would hope that by the completion of the project we would have designed not only a teaching curriculum, but also a set of guidelines for relationship to industry, which would be proposed to the Medical School for system-wide ratification.