Reviews of undergraduate and graduate medical education often emphasize the “formal curriculum” (i.e., required courses and explicit educational objectives). That formal curriculum aims to help students develop the core competencies that are defined by accreditation agencies.
The learning environment also includes two other elements: the informal curriculum (i.e., ad hoc interactions among teachers and students) and the hidden curriculum (i.e., institutional practices and culture).
Members of the U.S. Congress have also expressed concern about commercial relationships in medical education, primarily continuing medical education.
In contrast to the requirements for recipients of U.S. Public Health Service research awards, the federal government does not require the recipients of direct or indirect funds for medical education to establish and administer conflict of interest policies.
The committee concluded that, in general, industry financial relationships do not benefit the educational missions of medical institutions in ways that offset the risks created.
Academic medical centers dominate the provision of undergraduate and graduate medical education. The institutions consist of two related enterprises: a medical school that trains physicians and conducts research and a system that provides health care services. The latter system may include teaching hospitals, satellite clinics, and physician office practices. Academic health centers include other health professions schools, such as a school of dentistry, nursing, or pharmacy.
In recent years, academic medical centers have struggled financially… At the same time, teaching hospitals have faced rising costs…
Physicians in training also face financial challenges. In 2006, the median levels of debt of medical students graduating from public and private medical schools were $120,000 and $160,000, respectively.
This level of indebtedness and the delayed gratification of a profession that requires years of training before independent practice is permitted can contribute to a sense of entitlement, which, in turn, may position medical students, residents, and fellows to be strongly influenced by gifts and attention from representatives of pharmaceutical and medical device companies.
Sierles and colleagues (2005) found that 80 percent of the medical students that they surveyed believed that they were entitled to gifts. In addition… once they are in practice, limits on reimbursements for physician services… make gifts and other financial relationships with industry more appealing.
During most of the 20th century, medical product companies were not major participants in medical education.
In the latter decades of the century, however, medical product companies became increasingly involved in sponsoring continuing medical education, including grand rounds and other academic-based programs.
In a 2008 report on industry funding of medical education, a task force of AAMC observed generally that:
Over recent decades, medical schools and teaching hospitals have become increasingly dependent on industry support of their core educational missions. This reliance raises concerns because such support, including gifts, can influence the objectivity and integrity of academic teaching, learning, and practice, thereby calling into question the commitment of academia and industry together to promote the public’s interest by fostering the most cost-effective, evidence-based medical care possible.
By 2003, about half of all funding for accredited continuing medical education programs came from commercial [industry] sources.
Interactions between medical students and industry are common. Almost all students had received an industry-provided lunch or other gift. More than one-third had attended a social event hosted by a drug company.
[A] 2002 survey of emergency medicine residency program directors found that approximately 40 percent allowed industry to fund social activities, and a similar percentage allowed pharmaceutical representatives to teach residents.
Medical students and residents reported that they received insufficient training in interacting with drug representatives. Studies also indicate that students and residents believe that their own prescribing behavior is not affected by drug company gifts, although they believe that the prescribing behavior of their colleagues is.
One review concluded that the “pharmaceutical industry has a significant presence during residency training, has gained the overall acceptance of trainees, and appears to influence prescribing behavior”.
Taken together with the information reviewed below on the role of drug samples and gifts (which typically accompany sales visits), the literature suggests that academic medicine and the public have reason to be concerned about the easy access of sales representatives to medical students, residents, and faculty.