Adam Hofmann, a Montreal physician and pharmaceutical industry watchdog, says most doctors are oblivious to the extent to which their decisions on patient health care are influenced by drug companies.
Hofmann, a recent graduate now working as an internal medicine specialist at Montreal’s Sacre Coeur hospital, founded the McGill University chapter of the U.S. not-for-profit group No Free Lunch while still a medical student.
The group’s aim is to try to end the practice of accepting "freebies" from drug firms in the name of continuing medical education.
Hofmann figures it’s possible to eat free nearly every day of the week in a teaching hospital like the McGill University Health Centre — and some medical residents, saddled with debt, take full advantage of that.
But he brown-bagged it on principle, from the moment he realized how hard it was to stay at arm’s-length from people with something to sell him.
Hofmann estimates as much as 70 per cent of continuing medical education activities in Canada — from hospital rounds to conferences — are sponsored by the pharmaceutical industry, which he says has a vested interest in promoting its products.
"When the only thing you have going through your head is the purple pill, the purple pill, the purple pill, when there are half a dozen other reasonable, less expensive choices that can be used for treating your patients — are you actually making the right choice?" Hofmann asks.
Few would deny that pharmaceutical firms have a role to play, to share research findings and help doctors keep abreast of the latest developments in treatments and drug therapies.
"We’re entering into new areas of personalized medicine, areas involving genetic treatments, areas involving biologics," says Declan Hamill, the vice-president of legal affairs for RX&D, the association representing Canada’s research-based pharmaceutical companies.
"Companies (that) manufacture and create these medicines know an awful lot about them."
Hamill acknowledges the financial role played by the industry in subsidizing continuing education activities leaves a potential for conflict of interest.
"That being said … it is the doctor who controls the content, not the industry," Hamill stresses.
RX&D members must adhere to a strict code of ethical practices that covers everything from dispensing samples to when doctors can be paid honorariums to speak at industry-sponsored events.
Professional orders and medical faculties have adopted codes of ethics governing continuing medical education, too. But none bar the "free lunch" that is standard fare at hospital rounds and other educational activities.
"It’s a matter of judgment," says Dr. Yves Robert, the secretary of Quebec’s Collège des Médecins, or College of Physicians.
"If you think that a sandwich can have an effect on your professional independence — it’s probably not true. Even if it’s the best sandwich, it’s still just a sandwich."
Robert says doctors are trained from the moment they enter medical school to be critical and to evaluate everything they’re told based on evidence, not influence.
But a growing number of studies show doctors may not even be conscious of their biases and where they originate.
The Association of American Medical Colleges devoted a symposium to the Scientific Basis of Influence and Reciprocity in Washington, D.C., in 2007. It drew on a wealth of research, including studies using magnetic resonance imaging to show the "level of covert subtlety" at which the brain is working when a person is offered favours.
But studies don’t have to be that sophisticated.
"There was a study in 2001 that asked med students, residents and doctors, ‘Raise your hand if you think you are influenced by pharmaceutical funding?’" recalls Hofmann.
"Sixteen per cent raised their hand. The next question was, ‘Raise your hand if you think the guy sitting next to you is influenced' — and 61 per cent raised their hand!
"None of us are immune from the thought that we are critical thinkers — or better, smarter, faster, or whatever it is," concludes Hofmann. "The guy sitting next to you actually knows the truth."