Commentary

ACADEMIC PSYCHIATRY 135

Pharmaceutical Companies andAcademic Departments of Psychiatry

A Call for Ethics Education

Richard C. Christensen, M.D.Michael J. Tueth, M.D.

Pharmaceutical companies contribute over $13,000 per physician for promotion and ad-vertisement of products. Psychiatrists and psychiatric residents are influenced by theseinteractions. Two recommendations to psychiatric residency training programs are of-fered: Incorporation of ethics education into teaching forums and the establishment ofspecific ground rules that would govern the interaction of pharmaceutical companieswith psychiatric residents. (Academic Psychiatry 1998; 22:135–137)

Pharmaceutical companies mean busi-ness. In the United States alone, phar-

maceutical manufacturers spend in excessof $10 billion dollars per year on promotionand advertising (1). In 1988 they spent anestimated $5,000 per physician, and in 1993this amount swelled to more than $13,000(2). Coffee mugs, pens, and free lunches areonly some examples of the largess bestowedon physicians. In academic psychiatry, forinstance, drug companies underwrite edu-cational symposia, provide stipends forspeakers at Grand Rounds presentations,sponsor continuing medical education sem-inars and teleconferences, and fund univer-sity-affiliated researchers to undertake com-pany-sponsored clinical trials.

Make no mistake about it: psychiatrists,like other physicians, are influenced bythese interactions. A number of studieshave shown that contacts with pharmaceu-tical promotions have resulted in the adop-tion of commercial views of drugs, requestsfor additions to hospital formularies, andchanges in prescribing practices that favora particular drug company’s product (3,4).

Psychiatry residents may be particu-larly susceptible to the influences of phar-

maceutical marketing practices because theresidents have assumed the dual roles oflearners and practicing physicians. As aconsequence, their prescribing preferenceshave yet to be established and their fund ofknowledge, though developing, is limited.

Although industry-supported educa-tional trips, free gifts, and expensive din-ners may be particularly irresistible to phy-sicians in training, it should not beoverlooked that these marketing practicesare commonly linked to the promotion ofnew and expensive psychotropic medica-tions. However, as in other medical special-ties, the one who writes the prescription isnot the one who pays for it. As a conse-quence, when industry is inserted into thephysician–patient relationship the potentialfor inherent conflicts of interest is arguablyhigh.

Dr. Christiansen is assistant professor of psychi-atry, University of Florida College of Medicine; and Dr.Tueth is associate professor of psychiatry, University ofFlorida College of Medicine, Gainesville. Address re-print requests to Dr. Tueth, University of Florida Col-lege of Medicine, Geriatric Psychiatry Residency Pro-gram, P.O. Box 100256, Gainesville, FL 32610.

Copyright � 1998 Academic Psychiatry.

PHARMACEUTICAL COMPANIES

136 VOLUME 22 • NUMBER 2 • SUMMER 1998

Obviously, interactions between resi-dents and drug companies should not beuniversally prohibited. However, we do be-lieve they warrant increased ethical exami-nation and monitoring. The focus of thiscommentary, therefore, is to neither to pil-lory pharmaceutical companies nor chastisedepartments of academic psychiatry. Ratherthe aim is to propose that ethics educationin academic departments of psychiatry for-mally address the issue of pharmaceuticalcompany interactions with house staff.

Although ethical guidelines regardingthis issue currently exist (5), there remainsa serious question about how familiar psy-chiatry residents are with these specific di-rectives. Moreover, ethical guidelines meanlittle if they are either irrelevant to an indi-vidual’s situation, inadequately dissemi-nated, or generally ignored, as evidencedby the practices of the resident’s depart-ment.

To address the issue of pharmaceuticalcompany interactions with residents, we of-fer two recommendations to directors ofresidency training. First, we propose thateach department make an attempt to for-mally incorporate this topic into the coursecontent of the teaching forums usually at-tended by psychiatry residents. Educatinghouse staff about the established profes-sional guidelines is the necessary first stepto enhancing an awareness about potentialmoral conflicts in medical–industry inter-actions. Didactic seminars in psychiatricethics are the logical settings for introduc-ing this important, but frequently unartic-ulated, ethical issue.

By using selected readings on the topic,as well as case studies, encourage residentsto carefully reflect upon the relevance ofprofessional codes of ethics in their day-to-day interactions with pharmaceutical com-panies. However, other forums for ethicseducation could also be pursued that wouldinvolve all members of the academic de-

partment. For example, a Grand Roundspresentation could be an exceptional op-portunity to highlight the issue for medicalstudents, residents, and faculty alike. Ad-ditionally, a department-sponsored paneldiscussion, involving representatives fromthe pharmaceutical industry, faculty, andresidents, has the potential of creating alively and highly interactive examination ofthe pertinent ethical dimensions of thiscomplex issue. Finally, department-basedjournal clubs, which are usually organizedby senior residents but open to faculty,could be tapped as a forum for reviewingthe current ethical literature on this topic.

Second, we recommend that each de-partment consider the establishment of spe-cific ground rules that would govern the in-teractions of pharmaceutical companieswith residents. Department-specific guide-lines have been successfully developed in anumber of different specialties and have theadvantage of being specifically tailored tomeet the needs of particular resident pop-ulations (6,7). Obviously, this approachwould involve an ethical examination of adepartment’s relationship with the drug in-dustry and would entail a dialogue that hasbeen instigated by the aforementioned edu-cational forums. The endeavor to developsuch guidelines would have to be rooted ina departmental-wide ethical analysis on atopic that has received scant formal atten-tion in most academic departments of psy-chiatry.

Pharmaceutical companies do, indeed,mean business. However, as has becomeabundantly obvious in recent years, the mo-rality of the marketplace is not always con-sistent with the internal goals of medicaleducation and the provision of patient care.Academic departments of psychiatry oughtto be especially mindful of this critical issuewhen developing their programs in ethicseducation and assessing their relationshipwith the pharmaceutical industry.

CHRISTENSEN AND TUETH

ACADEMIC PSYCHIATRY 137

References

1. Heber A: Drug companies and doctors: a troublingalliance. Psychiatric Residency Newsletter 1993;17:1–2

2. Hodges B: Interactions with the pharmaceutical in-dustry: experiences and attitudes of psychiatryresidents, interns and clerks. Can Med Assoc J1995; 153:553–559

3. Lexchin J: Interactions between physicians and thepharmaceutical industry: what does the literaturesay? Can Med Assoc J 1993; 149:1401–1407

4. Lurie N, Rich EC, Simpson DE, et al: Pharmaceu-tical representatives in academic medical centers:interactions with faculty and housestaff. J Gen In-tern Med 1990; 5:240–243

5. American Medical Association, Council on Ethicaland Judicial Affairs of the American Medical As-sociation: Gifts to Physicians From Industry. Chi-cago, IL, American Medical Association, 1997, pp117–119

6. Johnstone RE, Valenzuela RC, Sullivan D: Man-aging pharmaceutical sales activities in an aca-demic anesthesiology department. J Clin Anesthe-sia 1995; 7:544–548

7. Lichstein PR, Turner RC, O’Brien KO: Impact ofpharmaceutical company representaives on inter-nal medicine residency programs: a survey of res-idency program directors. Arch Intern Med 1992;152:1009–1013