- Email: [email protected]
Preserving objectivity in medical education
Correspondence
3
4
5
Heaton A, Webb DJ, Maxwell SRJ. Undergraduate preparation for prescribing: the views of 2413 UK medical students and recent graduates. Br J Clin Pharmacol 2008; 66: 128–34. Illing J, Peile E, Morrison J, et al. How prepared are medical graduates to begin practice? A comparison of three diverse UK medical schools. London: General Medical Council, 2008. http://www.gmc-uk.org/about/ research/REPORT%20-preparedness%20of%2 0medical%20grads.pdf (accessed June 8, 2009). The Prescribe Project. eLearning in clinical pharmacology and prescribing. http://www. cpt-prescribe.org.uk/ (accessed June 8, 2009).
We would like to express our concern about the partnership between Brighton and Sussex Medical School (BSMS) and Pfizer.1 The Royal College of Physicians (RCP) report on the interactions between the medical profession and the pharmaceutical industry2 quotes one of Pfizer’s objectives as “improving... our reputation with future prescribers”. We believe that this is tantamount to drug marketing. The BSMS–Pfizer partnership serves to blur the boundary between what is marketing and what is education. We do not believe that this model of education will lead to the development of attitudes required for “a rational approach to prescribing” as advocated by the RCP.2 Medical education should be based on sound evidence and not influenced by marketing practices of pharmaceutical companies. Numerous studies have led us to believe that interactions between medical students and the pharmaceutical industry could influence the future independence of the medical profession, making it detrimental to patients’ trust. For example, after finding 80% of students to believe they were entitled to industry-sponsored gifts, one US study concluded that students were “at risk for unrecognised influence by [pharmaceutical company] marketing efforts”.3 Therefore, a partnership that allows Pfizer to teach about “the broader discipline of pharmaceutical www.thelancet.com Vol 373 June 27, 2009
medicine”1 poses serious risks to the application of evidence-based practice and to patients’ safety. We call for the preservation of medical schools as centres of unbiased evidence-based education, intent on benefiting future patients and health-care practice in the most positive manner. JC is a member of Medsin; MK is a member of PharmAware and Healthy Skepticism; JC is Campaigns Director of Medsin-UK.
form” and “not about promotion or manipulation”,4 unintended promotional or manipulative effects might have resulted from exposure to the partnership. These adverse events, whether intended or unintended, deserve scrutiny. I am a member of No Free Lunch, an organisation whose mission is to encourage health-care providers to practise medicine on the basis of scientific evidence rather than pharmaceutical promotion.
*James Chan, Merav Kliner, Jonny Currie, on behalf of Medsin-UK
Alexander C Tsai
[email protected]
Langley Porter Psychiatric Institute, University of California at San Francisco, San Francisco, CA 94143, USA
University of Leeds, School of Medicine, Leeds LS2 9JT, UK (JC); Watford General Hospital, Watford, UK (MK); and Medsin-UK, Redland, Bristol, UK (JC) 1
2
3
Hahn J, Hargreaves R, Hinde A, et al. An academia–industry partnership in health care. Lancet 2009; 373: 1504–05. Royal College of Physicians. Innovating for health: patients, physicians, the pharmaceutical industry and the NHS. London: RCP, 2009. Sierles FS, Brodkey AC, Cleary LM, et al. Medical students’ exposure to and attitudes about drug company interactions. JAMA 2005; 294: 1034–42.
Joanna Hahn and colleagues1 describe an unique partnership between Pfizer and the Brighton and Sussex Medical School (BSMS) in which Pfizer has assisted the school in developing a teaching programme focused on pharmaceutical medicine. Among the positive outcomes described are consistently positive feedback from students and stimulation of discussion on access to medicines in resourcelimited settings. Omitted, however, is a balanced discussion about the potential negative effects of this partnership—which is akin to omission of adverse events in drug trial reports.2 Subtle exposure to small pharmaceutical brand items has been shown to have an unconscious influence on branding preferences among medical students.3 This evidence cannot be ignored as a potential side-effect of the exposure, given that the study subjects were in training to someday make primary prescribing decisions for their patients. Although the Pfizer– BSMS partnership is described as “not promotional in any way, shape, or
[email protected]
1
2
3
4
Hahn J, Hargreaves R, Hinde A, et al. An academia-industry partnership in health care. Lancet 2009; 373: 1504–05. Gartlehner G, Gaynes BN, Hansen RA, et al. Comparative benefits and harms of secondgeneration antidepressants: background paper for the American College of Physicians. Ann Intern Med 2008; 149: 734–50. Grande D, Frosch DL, Perkins AW, et al. Effect of exposure to small pharmaceutical promotional items on treatment preferences. Arch Intern Med 2009; 169: 887–93. Coombes R. The pharmaceutical industry is stepping in to fill the therapeutics void. BMJ 2009; 338: a3179.
Moxifloxacin versus ethambutol in initial tuberculosis treatment Marcus Conde and co-workers (April 4, p 1183)1 show, in a randomised, controlled phase II trial, that moxifloxacin substituted for ethambutol significantly improves the 8-week culture status in patients with newly diagnosed tuberculosis. This finding agrees with that of the OFLOTUB study,2 but differs from that of the Tuberculosis Consortium Study 27.3 Closer examination of the findings by Conde and colleagues raises some concerns that might require clarification. First, despite a higher proportion of patients with cavitation on the baseline radiograph in the moxifloxacin group than in the ethambutol group (80% vs 57%), the proportion of patients with at least one sputum acid-fast bacilli smear per high-power field (AFB/ 2197
3
4
5
Heaton A, Webb DJ, Maxwell SRJ. Undergraduate preparation for prescribing: the views of 2413 UK medical students and recent graduates. Br J Clin Pharmacol 2008; 66: 128–34. Illing J, Peile E, Morrison J, et al. How prepared are medical graduates to begin practice? A comparison of three diverse UK medical schools. London: General Medical Council, 2008. http://www.gmc-uk.org/about/ research/REPORT%20-preparedness%20of%2 0medical%20grads.pdf (accessed June 8, 2009). The Prescribe Project. eLearning in clinical pharmacology and prescribing. http://www. cpt-prescribe.org.uk/ (accessed June 8, 2009).
We would like to express our concern about the partnership between Brighton and Sussex Medical School (BSMS) and Pfizer.1 The Royal College of Physicians (RCP) report on the interactions between the medical profession and the pharmaceutical industry2 quotes one of Pfizer’s objectives as “improving... our reputation with future prescribers”. We believe that this is tantamount to drug marketing. The BSMS–Pfizer partnership serves to blur the boundary between what is marketing and what is education. We do not believe that this model of education will lead to the development of attitudes required for “a rational approach to prescribing” as advocated by the RCP.2 Medical education should be based on sound evidence and not influenced by marketing practices of pharmaceutical companies. Numerous studies have led us to believe that interactions between medical students and the pharmaceutical industry could influence the future independence of the medical profession, making it detrimental to patients’ trust. For example, after finding 80% of students to believe they were entitled to industry-sponsored gifts, one US study concluded that students were “at risk for unrecognised influence by [pharmaceutical company] marketing efforts”.3 Therefore, a partnership that allows Pfizer to teach about “the broader discipline of pharmaceutical www.thelancet.com Vol 373 June 27, 2009
medicine”1 poses serious risks to the application of evidence-based practice and to patients’ safety. We call for the preservation of medical schools as centres of unbiased evidence-based education, intent on benefiting future patients and health-care practice in the most positive manner. JC is a member of Medsin; MK is a member of PharmAware and Healthy Skepticism; JC is Campaigns Director of Medsin-UK.
form” and “not about promotion or manipulation”,4 unintended promotional or manipulative effects might have resulted from exposure to the partnership. These adverse events, whether intended or unintended, deserve scrutiny. I am a member of No Free Lunch, an organisation whose mission is to encourage health-care providers to practise medicine on the basis of scientific evidence rather than pharmaceutical promotion.
*James Chan, Merav Kliner, Jonny Currie, on behalf of Medsin-UK
Alexander C Tsai
[email protected]
Langley Porter Psychiatric Institute, University of California at San Francisco, San Francisco, CA 94143, USA
University of Leeds, School of Medicine, Leeds LS2 9JT, UK (JC); Watford General Hospital, Watford, UK (MK); and Medsin-UK, Redland, Bristol, UK (JC) 1
2
3
Hahn J, Hargreaves R, Hinde A, et al. An academia–industry partnership in health care. Lancet 2009; 373: 1504–05. Royal College of Physicians. Innovating for health: patients, physicians, the pharmaceutical industry and the NHS. London: RCP, 2009. Sierles FS, Brodkey AC, Cleary LM, et al. Medical students’ exposure to and attitudes about drug company interactions. JAMA 2005; 294: 1034–42.
Joanna Hahn and colleagues1 describe an unique partnership between Pfizer and the Brighton and Sussex Medical School (BSMS) in which Pfizer has assisted the school in developing a teaching programme focused on pharmaceutical medicine. Among the positive outcomes described are consistently positive feedback from students and stimulation of discussion on access to medicines in resourcelimited settings. Omitted, however, is a balanced discussion about the potential negative effects of this partnership—which is akin to omission of adverse events in drug trial reports.2 Subtle exposure to small pharmaceutical brand items has been shown to have an unconscious influence on branding preferences among medical students.3 This evidence cannot be ignored as a potential side-effect of the exposure, given that the study subjects were in training to someday make primary prescribing decisions for their patients. Although the Pfizer– BSMS partnership is described as “not promotional in any way, shape, or
[email protected]
1
2
3
4
Hahn J, Hargreaves R, Hinde A, et al. An academia-industry partnership in health care. Lancet 2009; 373: 1504–05. Gartlehner G, Gaynes BN, Hansen RA, et al. Comparative benefits and harms of secondgeneration antidepressants: background paper for the American College of Physicians. Ann Intern Med 2008; 149: 734–50. Grande D, Frosch DL, Perkins AW, et al. Effect of exposure to small pharmaceutical promotional items on treatment preferences. Arch Intern Med 2009; 169: 887–93. Coombes R. The pharmaceutical industry is stepping in to fill the therapeutics void. BMJ 2009; 338: a3179.
Moxifloxacin versus ethambutol in initial tuberculosis treatment Marcus Conde and co-workers (April 4, p 1183)1 show, in a randomised, controlled phase II trial, that moxifloxacin substituted for ethambutol significantly improves the 8-week culture status in patients with newly diagnosed tuberculosis. This finding agrees with that of the OFLOTUB study,2 but differs from that of the Tuberculosis Consortium Study 27.3 Closer examination of the findings by Conde and colleagues raises some concerns that might require clarification. First, despite a higher proportion of patients with cavitation on the baseline radiograph in the moxifloxacin group than in the ethambutol group (80% vs 57%), the proportion of patients with at least one sputum acid-fast bacilli smear per high-power field (AFB/ 2197