The Lancet 2000; 356:781


Drug-company influence on medical education in USA

It begins on the first day of medical school and lasts through to retirement, and it is the only reliable “cradle to grave” benefit that doctors can truly count on any more. Even in this era of medical-ledger watching world wide, there is little evidence to expect it will ever end. In fact, it may even be growing. It starts slowly and insidiously, like an addiction, and can end up influencing the very nature of medical decision-making and practice. It first appears harmless enough: a textbook here, a penlight there, and progresses to stethoscopes and black bags, until eventually come nights “on the town” at academic conventions and all-expenses paid “educational symposia” in lovely locales.

Attempts to influence the judgment of doctors by commercial interests serving the medical-industrial complex are nothing if not thorough. Unfortunately, they seem to work. Studies have shown that prescribing patterns are influenced by advertising and other marketing activities. If this were not the case, why would industry spend hundreds of millions of dollars on promotion? Advertising sustains industry, and no industry, not even the medical one, can avoid its reach. So it is not the fact of marketing that is in question here. It is the form in which it comes. Surely, no one would mistake a pen with a corporate logo as anything but promotion. Nor would anyone suggest that a stuffed animal with a brand-named drug stitched to its fur is of great medical value. But when the line between medical education and advertising or marketing is blurred, there is a problem.

A recent study completed by the US watchdog Public Citizen documents the relation between medical education activities, the pharmaceutical industry, and medical education services suppliers (MESS), which are private businesses that provide medical education. The study stems from survey data published in the December, 1999, issue of Medical Marketing & Media, an industry periodical. MM & M surveyed 123 MESS about their 1998 and 1999 operations. 80 returned questionnaires. In summary, the data suggest that supplying medical education can, in this form, be a very lucrative exercise, whose most consistent client is the pharmaceutical industry.

Of the 43 companies that answered questions on finances, total revenue amounted to $643 million in 1999 alone, a 19% increase from 1998. Extrapolating this to the entire industry, Public Citizen predicts that the MESS industry is worth at least $1 billion annually. An astounding $115 million was billed by MESS to their clients on grand rounds alone; $114 million on symposia, $64 million on advisory boards, and another $60 million on publications. 68 (85%) of MESSs provided data on their client mix. On average 76% of respondents' clients were drug manufacturers. 26% of the MESS reported that at least 90% of their clients were pharmaceutical companies.

It cannot be said that the quality of any of these educational activities was compromised by the ultimate patronage of the pharmaceutical industry. Indeed, 43% of the 80 MESS respondents reported being accredited by the Accreditation Council of Continuing Medical Education (ACCME) and an additional 5% said their accreditation was pending. Of course, that also means that over half of the MESS surveyed do not have ACCME accreditation. While one cannot be certain that lack of accreditation necessarily connotes poor educational quality, it does at least suggest the possibility that industry may be able in these situations to exert even greater influence over what material is presented and what is left out.

What is of most concern here is the fact that so much continuing medical education comes through the filter of industry. To ensure the integrity, and the appearance of integrity, of the process of learning in medicine, physicians should do more to pay for CME themselves, just as many other professionals have to do.

The Lancet