Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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A tragic development
- Evan Begg, Les Toop (7 January 2009)
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Sinister infiltration at Brighton and Sussex Medical School
- Joe Collier (9 January 2009)
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Pharmaceutical Drug Companies being bashed
- Celine M Aranjo (9 January 2009)
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Involve the Pharmacists
- Robert Lord (9 January 2009)
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Degradation of student teaching
- Amy L Blake (11 January 2009)
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Sublime to the Ridiculous
- Charles W Dixon (11 January 2009)
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Generic teaching or trade names only?
- David G Samuel (12 January 2009)
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Welcome to Castle Dracula
- Hugh Mann (12 January 2009)
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New news?
- Michael Schachter (13 January 2009)
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Time for drug company apologists to get real.
- Rich Braithwaite (13 January 2009)
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Re: Generic teaching or trade names only?
- Shiv Kumar (13 January 2009)
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A worrying development for the students concerned.
- Alexandra J Obee (13 January 2009)
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A Lesson in Objectivity
- Patrick James Howlett (15 January 2009)
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Altruism or Promotion?
- Matthew P Doogue (16 January 2009)
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re pharma outsourcing
- nasir hannan (17 January 2009)
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Striking the balance.
- David A Biles (21 January 2009)
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Medical School Precedent
- Merav S Kliner (21 January 2009)
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Let us protest loudly
- Tom Yates, Gordon Stewart (Professor of Experimental Medicine, UCL), John S Yudkin (Emeritus Professor of Medicine, UCL), John Yates (Emeritus Professor of Medical Genetics, University of Cambridge), Sir Alexander Macara (Chairman of Council, BMA, 1993-1998) (22 January 2009)
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A different perspective from BSMS - some clarification.
- Raphael Rogans-Watson (22 January 2009)
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Pharmacology and Therapeutics Teaching at BSMS
- Martin Llewelyn, BN1 9PS (30 January 2009)
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Evan Begg, Head of Clincal Pharmacology University of Otago, Christchurch, New Zealand, Les Toop
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Using Pharmaceutical Industry staff to teach clinical pharmacology to undergraduates is a tragedy on several counts: Firstly, because medical schools continue to undervalue this discipline which is the backbone of medical practice; secondly, because academic medicine has allowed this void to develop; thirdly, because the drug industry has been meekly allowed to fill the void; fourthly, because the drug industry is apparently seen as trustworthy - when their record in providing complete and balanced information to prescribers has been and remains consistently appalling (remembering also their primary goal is maximising shareholder value); and fifthly, perhaps saddest of all, no one seems to care. There is a growing worldwide movement to minimise the commercially driven, vested influence of the pharmaceutical industry on medical students. To allow their staff to give them lectures and run their tutorials is dangerously naive. It is time for the medical profession to re-establish the grounds upon which we operate. Competing interests: Professor of Clinical Pharmacology(EB), Professor of General Practice (LT) |
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Joe Collier, emeritus professor of medicines policy St George's, University of London, SW17 ORE
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The developments at Brighton and Sussex Medical School are abhorrent and must call into question the School's position as an academic institution vested with responsibility to teach our future doctors. If we are to have reliable (impartial) prescribers in the future, clinical pharmacology has to be taught (and delivered) in an intellectual atmosphere free from bias. If Brighton and Sussex does not have resident clinical pharmacologists to teach students about the proper use of medicines and, bye the bye to place the industry's bias in some perspective, the future for its students is bleak. I can well imagine that the ABPI and Pfizer are delighted with this development - I am simply appalled. The Dean of the medical has some answering to do. Joe Collier Competing interests: None declared |
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Celine M Aranjo, Retired G.P. Sydney, NSW, 2208,Australia
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This on-going issue seems to blame those who do not deserve to be blamed. Were it not for the research done by the clinical pharmacology scientists, we would not have ANY drugs for treatments that require pharmacological interventions, and if it is no longer financially viable for medical schools to maintain such a department, someone else must be found, and who can be better than the companies that stand by their products. Some/many confuse the role of the reps. employed to market the drugs with the actual research scientists and their detailing of their years of research after the drug has passed the safety tests, etc. Are we returning to the 'pills and potions' eras? Will we humans be the new generation of guinea pigs in the name of 'research'? Competing interests: None declared |
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Robert Lord, Associate Director of Teaching Rotherham S60 2UD
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The involvement of a drug company in this kind of way is not ideal. I note that the teaching is carried out as an SSC and hence is not viewed as 'core' as not all students will participate. I am told on a regular basis how little prescribing knowledge the new doctors have who come to us from the Medical School. Students may be taught about pharmacology and the molecular basis of diuretic action in the nephron but not be able to prescribe using the wide variety of prescription charts that must exist across the country. We now have an agreed prescription chart in the region which might make life a bit easier but we need to teach the students how to prescribe. There are e learning packages out there... but how do we teach students to prescribe when they are not allowed to actually do so until they are qualified? In attempt to try and get the students 'prescribing' I am hoping to involve our ward based pharmacists to have regular times with our students so that the students can learn on the wards as well as in small group tutorials from experts who are dealing with medication all the time. I do not think this will be the full answer and that part of the answer must also come from lessening the amount of time that students now have to spend doing SSC work and instead increase the core work to involve such key areas as prescribing and enable more time to be spent in the course in dermatology (see another BMJ letter) ophthalmology, ENT etc. Competing interests: I teach student doctors |
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Amy L Blake, Foundation Year 2 Public Health Warwick Medical School, Gibbet Hill Campus, Coventry CV4 7AL
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As a recent graduate, it saddens me that a medical school would be willing to outsource such a fundamental aspect of medical education as clinical pharmacology to any external body. Prescribing medicines is an elementary role of even the most junior doctor. The consequences of a wrong decision can be life threatening for patients. Surely the most suitable people to train medical students in this task are those with direct experience of it: other doctors and clinical pharmacists. Although Ms Hahn claims that the course offered by Pfizer is “not promotional” it is almost impossible for it to be free from bias. The very fact that it is delivered away from the medical school, at Pfizer's headquarters will influence students. Those delivering the teaching all have vested interests in promoting the company's products and are unlikely to give equal “air time” to drugs produced by other companies which perform the same function. There are clear benefits to the company, and few for the students, who are taken even further from the patient's bedside than the medical school lecture theatre, further separating theory and practise. The question we should be asking is not whether or not pharmaceutical companies should be teaching clinical pharmacology to medical students, but why medical schools find themselves ill-equipped to do this. If there is a diminishing presence of clinical pharmacology in medical schools this needs to be reversed, not replaced with something else, as a matter of patient safety. Competing interests: None declared |
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Charles W Dixon, Consultant Psychiatrist Wonford House Hospital, Exeter, EX2 5AF
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I was lucky enough to be taught therapeutics by Professor Kendall as a medical student and remember him advising us on how to respond when meeting drug reps as qualified doctors. He counselled that we accept the pen, return the smile and ignore the information. I, like the previous correspondent, am horrified that medical students are missing out on independent, high quality information on medications. I feel that if medical schools legitimise drug companies as a source of information then students are more likely to be influenced by drug company marketing dressed up as education when they are qualified doctors. This approach seems a regressive step when many hospitals are now starting to end drug company sponsorship of educational meetings. I hope correct funding will be put in place to ensure that Brighton and Sussex Medical School students get the opportunity to be taught by inspirational teachers such as Professor Kendall and don’t have to rely on drug companies who bring their own agendas. Competing interests: None declared |
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David G Samuel, F1 doctor in Gastroenterology Prince Charles Hospital, Merthyr Tydfil. CF47 9TD
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While the generous scheme initiated by Pfizer in educating future doctors about therapeutics may at first be applauded I have grave concerns about the close involvement of drugs companies with undergraduate education. As an F1 doctor I recognise the need for high quality teaching in therapeutics and the first months of life as a doctor are sometimes scary when prescribing drugs. However, I question how generic their teaching will prove to be? Will the brand name be used in teaching session or the generic name? Will certain trials used for discussion and teaching be sourced from their own drug trials or competitors? In addition, the claim that they withdrew their offers of refreshments to prevent criticism is a nice touch but I feel merely a smoke screen. How many times have doctors and students been in teaching sessions sponsored by drug firms? I can count on my one hand the number of times I have been taught anything useful about a particular drug. More often the not the free sarnies are delicious following a hard morning of work, the pen is lapped up ready for the afternoon round and the added freebees are bonuses. The same must be said about this teaching programme. A clever way of influencing s students’ perceptions and future prescribing patterns. I was fortunate to experience good quality teaching at Medical school relating to therapeutics. As an F1 the pharmacists on the ward are invaluable in offering advice. Senior colleagues also quiz me and provide on the job teaching. Surely this is how to learn. Medical teaching must remain independent from drug companies. Where will this end? Will Private hospitals start providing "days out" out of the goodness of their heart to improve medical education? Will major publishers start providing expensive textbooks free of charge? I only hope that the medical profession takes this as a wake up call and that leading pharmacologists and senior clinicians ensure that the teaching at every medical school is up to the prescribed standard. Competing interests: None declared |
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Hugh Mann, Physician Eagle Rock, MO 65641 USA
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"Enter freely and of your own free will." With this ominous greeting, Count Dracula bid welcome to his victims. Apparently, Dracula needed his victims’ consent. At the risk of making an invidious comparison, I would suggest that all medical students who are taught clinical pharmacology by pharmaceutical companies, should receive Dracula’s greeting. The veil has been lifted, the pretense of objectivity has been removed, and doctors are merely pharmaceutical representatives. Competing interests: None declared |
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Michael Schachter, Senior lecturer in clinical pharmacology, Imperial College London St Mary's Hospital London W2 1NY
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It is worth making a few observations about this rather surprising report. It is surprising because there is increasing awareness in the country and world-wide that safe prescribing is a crucial aspect of patient safety and therefore of the training of doctors.This is a rather belated realisation,reversing to some extent the thinking of the early 1990s when many clinical pharmacology departments disappeared largely in response to then- fashionable educational theory. Consequently in many schools there was minimal teaching in this area and some of us had the impression that some were reinstituting therapeutics in their curriculum- something which the new edition of "Tomorrow's Doctors" is likely to reinforce.But it should be noted that some schools, like ours, have never stopped teaching both basic and clinical pharmacology as separate subjects, and we still have a separate finals exam in therapeutics.I have no specific comment on the involvement of pharmaceutical companies in teaching,and would not immediately infer underhand motives. But the concept that therapeutics is anything other than a core element of medical training is indefensible and a major threat to the safety of our patients. Competing interests: Teaching clinical pharmacology |
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Rich Braithwaite, Specialist Registrar in Psychiatry Orion Centre, Dunsbury Way, Havant, Hants, PO9 5BG
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If Pfizer's sessions were "not promotional", they would not be wasting their time and money. Competing interests: None declared |
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Shiv Kumar, Senior House Officer Avondale Unit, Royal Preston Hospital, Preston, PR2 9HT
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This is indeed a sad development in medical teaching when one of the core subjects in medicine is trivialised to the extent of it being "out sourced" to the pharma industry. "There is nothing called a free lunch" has been quoted often. I wonder what the pharmaceutical companies expect to get out of it? let us be real they are not doing this out out of the goodness of their heart. At the end of the day they have a business to run.I graduated in India where pharmacology is still taught as a subject through lectures & by the end of it one does have better understanding of the mechanism of action & is able to coorelate the whole thing in a clinical setting I am quite worried about the quality of such teaching & will be quite sceptical about it being unbiased I agree with Dr R Lord that all the hospitals have well qualified pharmacists, what stops the medical schools from inviting them to provide didactic teaching to students? I am concerned that with the plan of reducing the "burden" of learning subjects like pharmacology microbiology would go the same way of anatomy & biochemistry Competing interests: None declared |
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Alexandra J Obee, FY1 in Colorectal Surgery University of Birmingham NHS Foundation Trust. B29 6JD
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As a recent graduate who received excellent therapeutics teaching in my final year, I am alarmed and concerned about this recent development in medical education. However, I hope that the students involved are intelligent enough to take the information given by the pharmaceutical companies with the proverbial pinch of salt. Unfortunately, this may leave them lacking in basic knowledge, and unclear about what information is impartial and which has a bias. Such ambiguity can only serve to make their first few months at work even more frightening and confusing than they already are. Competing interests: None declared |
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Patrick James Howlett, Medical Student University of Bristol
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The news that some medical schools are struggling to continue teaching medical undergraduate pharmacology is worrying and needs a response. However, for Brighton and Hove Medical school to use pharmaceutical companies to plug this gap is a poorly thought-out reaction(1). The use of any pharmaceutical company to provide medical teaching to students or junior doctors – in whom a relative lack of knowledge increases vulnerability to marketing – provides a clear conflict of interests(2); while pharmaceutical companies aim sell their stock to practitioners satisfy shareholders, future doctors have a duty to prescribe what is best for their patients. The interactions between doctors and pharmaceutical companies are an essential part of medicine, however this recent development clearly highlights the need for UK medical schools to evaluate how they propose to interact with pharmaceutical companies. In the US, 8 universities have chosen to ban any interaction between pharmaceutical companies and their students(3). This comes in response to this obvious conflict and the evidence questioning the validity of pharmaceutical marketing information(4). Why is it then that we in the UK have chosen an entirely opposite direction? Personally, I am grateful to have received a good standard to teaching from what I am confident is a high quality, objective source. If the use of pharmaceutical representatives as undergraduate teachers continues, my experience, along with those of countless other students will be jeopardised, and the objectivity of future doctors thrown into question. -------- 1. Coombes R BMJ 2009;338:a3179 2. McCormick BB, Tomlinson G, Brill-Edwards P, Detsky AS. Effect of restricting contact between pharmaceutical company representatives and internal medicine residents on posttraining attitudes and behavior. JAMA. 2001 Oct 24-31;286(16):1994-9.Click here to read 3. http://www.amsascorecard.org/ accessed 14/01/09 4. A Wazana Physicians and the Pharmaceutical Industry Is a Gift Ever Just a Gift? JAMA 2000 Jan 19;283(3):373-80.Click here to read Competing interests: None declared |
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Matthew P Doogue, Clinical Pharmacologist Flinders University, School of Medicine, SA5042, Australia
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The generosity of the pharmaceutical industry to medical opinion leaders, prescribers and researchers has been extended to consumer groups and now to students. At this news, some appear sad, some angry and some confused, but few appear surprised. I've gone to a dictionary to help me understand. Here are definitions of five important words.(1) Altruism - Unselfish concern for the welfare of others; selflessness. Promotion - Encouragement of the progress, growth, or acceptance of something; furtherance. Duty - An act or a course of action that is required of one by position, social custom, law, or religion. Fiduciary - A person bound to act for someone else's benefit, as a trustee. And for the fifth word, Learning, here are two definitions. The act, process, or experience of gaining knowledge or skill. Behavioral modification especially through experience or conditioning. In carrying out our work we all have fiduciary duties, I believe it is important to know where they lie. ----- 1) TheFreeDictionary.com Farlex, Inc. Huntingdon Valley, PA 19006 USA http://www.thefreedictionary.com accessed 16 Jan 2008. Competing interests: I teach clinical pharmacology to medical students and others |
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nasir hannan, GP registrar bassetlaw
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how is this allowed to happen. if a course could not for example teach cardiology, then it would simply have to stop teaching medicine as it is no longer providing adequate medical education. patients would be concerned with all the current scandals that are taking place in the drug industry. commercial companies are not philanthropic organisations. I think that we can work in partnership because they are the industry providers, but we each need to define our limits. on the bigger picture, I remember going to school in order to be taught by teachers certain subjects that i required in order to progress and grow as a person. #somehow medical schools have lost their way in that respect and they need to get back to where they once were. Competing interests: None declared |
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David A Biles, Final year medical student University of Bristol Medical School, Bristol BS2 8DZ
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Coombs informs us that Brighton and Sussex Medical School have contracted Pfizer to fill their ‘therapeutics void’. However the new course is as much about therapeutics as it is about the interactions of the pharmaceutical industry with society and the medical profession: drug development, industry contact with patient groups and drug marketing. An assertion confirmed when a colleague at Brighton and Sussex sent me a copy of the timetable. Martin Kendall, senior advisor to the BNF, was worried about maintaining objectivity in teaching delivered by industry on therapeutics. However, it is industry being the sole voice in educating students on this second set of hotly debated issues that is most concerning. Each issue is separate but legitimately contested. Drug development currently does not reflect the global burden of disease [1]. Industry’s links with patient groups can have their questionable side [2]. And drug marketing can negatively influence prescribing [3]. Industry and the medical profession share the blame for such problems and industry’s current contribution to improving health and saving lives should not be undervalued. However, on drug development, we would be doing future doctors and their patients a disservice if Universities do not uphold their proud tradition as catalysts for exchange and generation of ideas, instead of unashamedly promoting a single agenda. On marketing, we risk leaving future doctors unarmed with the evidence that heeds caution in interactions [4]. Balanced, objective teaching on marketing is vital if we want students to uphold critical, evidence based practise and maintain their patient’s trust. Better models of how to deliver such teaching exist: they should be used [5]. [1] O’Neale Roach J. Research does not reflect global disease burden. BMJ 2000;320;1228 [2] Moynihan R, Heath I, Henry D. Selling sickness: the pharmaceutical industry and disease mongering. BMJ 2002;324:886–91 [3] Wazana A. Physicians and the pharmaceutical industry: is a gift ever just a gift? JAMA. 2000;283,373-380 [4] Brennan TA et al. Health Industry Practices That Create Conflicts of Interest. A Policy Proposal for Academic Medical Centers. JAMA 2006;295, 429-433 [5] Black H. Dealing with drugs. The Lancet 2006; 364,1655-1656 Competing interests: None declared |
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Merav S Kliner, FY2, public health West Hertfordshire NHS Trust, HP2 4AD
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In 1996, Dr Lee, the then Director-General of the World Health Organisation, stated to the 49th World Health Assembly, “There continues to be an imbalance between commercially produced drug information and independent, comparative, scientifically validated and up-to-date information on drugs for prescribers, dispensers and consumers”.
The involvement of drug companies in teaching medical school pharmacology is a worrying initiative. Practicing evidence-based medicine is one the most effective ways of providing patients with optimal care. Medical schools provide a model for how students will practice medicine in their future career. The close interaction between medical students and the pharmaceutical industry encouraged at medical school is therefore likely to persist through practice as a junior doctor. As relationships develop, good clinical practice is jeopardised as these doctors fail to develop their critical analysis skills and practice evidence-based medicine and therefore put patients’ health at risk. Brighton and Sussex Medical School are currently encouraging this dangerous practice and I hope they soon reconsider this method of teaching, putting a safe distance between the pharmaceutical industry and the UK’s future doctors. Competing interests: I founded and am an active member of PharmAware. I am a member of Healthy Skepticism |
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Tom Yates, Final Year Medical Student UCL Medical School, Gower Street, London WC1E 6BT, Gordon Stewart (Professor of Experimental Medicine, UCL), John S Yudkin (Emeritus Professor of Medicine, UCL), John Yates (Emeritus Professor of Medical Genetics, University of Cambridge), Sir Alexander Macara (Chairman of Council, BMA, 1993-1998)
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We write to express our concerns about any outsourcing of medical education to pharmaceutical companies (1). Common sense tells us this could only be harmful and a growing literature suggests contact between healthcare providers and pharmaceutical companies leads to irrational prescribing (2, 3) and to the provision of biased or inaccurate information (4, 5), with inaccuracies favouring the products of the company (4, 5). If we know that most doctors fail to spot misinformation provided by pharmaceutical company employees (4, 5), can we expect medical students to fare any better? Recognising this, American medical schools have commendably started to limit contact between medical students and pharmaceutical companies (6). If budgets do not allow the provision of comprehensive teaching in pharmacology to medical students given by independent academics and clinicians then let us protest loudly rather than resorting to unacceptable alternatives. 1. Coombes R. Stepping into the therapeutics void. BMJ 2009; 338: a3179. 2. Lexchin J. Interactions between physicians and the pharmaceutical industry: what does the literature say? CAMJ 1993; 149: 1401-1407. 3. Wazana A. Physicians and the Pharmaceutical Industry. Is a Gift Ever Just a Gift? JAMA 2000; 283: 373-380. 4. Lexchin J. What information do physicians receive from pharmaceutical representatives? Can Fam Physician 1997; 43: 941–945. 5. Ziegler MG, Lew P, Singer BC. The accuracy of drug information from pharmaceutical sales representatives. JAMA 1995; 273(16): 1296-8. 6. See http://www.amsascorecard.org/ (accessed 21 January 2009). Competing interests: All of the authors are or have been medical students. Some teach or have taught medical students. |
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Raphael Rogans-Watson, 4th year medical student Brighton and Sussex Medical School (BSMS)
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I am a student at Brighton and Sussex Medical School (BSMS) and I was interested to read the article "Stepping into the therapeutics void" about my medical school. I would like to echo many of the concerns raised in the Rapid Responses to this article about the dangers of interactions between medical students and the pharmaceutical industry and big business. I will not repeat the points already mentioned, but I feel it is vital that we are aware of the role and scope of pharma advertising (in whatever form it may take) and its affect on prescribing. I myself have campaigned on such issues and originally raised my concerns about the module here at BSMS. However, I must clarify a few points. - As far as I am aware, it is unlikely that BSMS is 'filling the therapeutics void' with this module. For one thing, only a maximum of 10 students per year can undertake the module as it is one of approximately 60 Student Selected Components that we are allocated for one afternoon a week over a period of 8 weeks in the 3rd year. - The author is correct in saying that BSMS does not have its own clinical pharmacology department, and although some students feel that this aspect of teaching could be increased, all our pharmacology teaching is currently provided by the School of Pharmacy at Brighton University, as part of a series of lectures given in the 3rd year. I am concerned that medical students are getting this kind of exposure every year at my university, but I don't feel that it is to the extent that is suggested in the article. However, I am grateful that the article has raised the issue because I think it is one that needs to be monitored closely. Guidelines exist with regards to interactions between doctors and large pharamaceutical companies in this country, but too often medical students (who may often be more impressionable) are overlooked in this area. Competing interests: I am a 4th year student at Brighton and Sussex Medical School. I have not taken the Student Selected Component in question. |
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Martin Llewelyn, Senior Lecturer, Infectious Diseases and Therapeutics Brighton and Sussex Medical School, BN1 9PS
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I thought that it might be helpful if I corrected some of the misunderstandings that have arisen in relation to this discussion, and set the record straight in regarding the BSMS undergraduate curriculum. The student selected project on drug development is precisely that: student selected. It is not core material and in fact a relatively small number of students have chosen to take it. It is not concerned with the teaching of clinical pharmacology or therapeutics, but with understanding the complexities involved in pharmaceutical research & development. Core teaching of clinical pharmacology and therapeutics is undertaken throughout the BSMS undergraduate programme, and those of your correspondents who believe that this student selected component contributes to this have misunderstood the situation. The BSMS course has very recently been assessed and approved by the GMC, and indeed as part of the recent quality assurance process an external examiner (himself in fact a clinical pharmacologist) commented that he “was particularly pleased to see a distinct emphasis on therapeutics in one of the papers, and in the extent of topics covered in the OSCE”. Colleagues and students can be reassured that at BSMS we take the teaching of therapeutics extremely seriously and that the external quality assurance process has demonstrated that the curriculum is delivered appropriately and to a high standard. Competing interests: Senior Lecturer in Therpeutics, Brighton and Sussex Medical School |
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