Jaya is a political activist. I certainly agree with some of her concerns, but it appears she is more interested in publicity than making effective changes in the medical system. KL
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Student Doctors Start to Rebel Against Drug Makers' Influence
By CHRIS ADAMS
Ms. Agrawal used to join her fellow students at Brown Medical School in scarfing up the free lunches, pens, notepads and other gifts dished out by pharmaceutical makers at Providence, R.I., teaching hospitals. Then, two years ago, she decided to stop. She started bringing her own sandwiches to lectures where drug companies provided lunch. She went through her lab coats and threw out all the pens and notepads emblazoned with drug-company logos. She even tossed the fun freebie from a Viagra sales rep -- a Viagra calculator that stood up on a base when the "on" button was pressed. The fourth-year student is part of a growing movement among students and some teachers trying to curtail the drug industry's efforts to woo young doctors as future customers. "We need to find some way to reclaim the moral high ground," she says. Just as drug salespeople court full-fledged doctors with fancy meals, ballgame tickets and other niceties, they strive to persuade aspiring physicians to prescribe their products. For example, a drug company might spring for pizza at a lecture on uses of a newly approved class of drug, hoping to get in a plug for its own product. "The reps know it's one thing to reach a doctor in practice, but another thing altogether to reach somebody who has a whole career ahead of him," says Jerry Avorn, a Harvard Medical School associate professor who for years has studied the interactions between drug representatives and doctors. Ms. Agrawal helped launch a national campaign calling on students to sign pledges swearing off all drug-industry gifts. She is also urging them to ditch their drug-company pens, or at least put tape over company logos. And she plans to push officials at Brown University's medical school this fall to limit interaction between drug-company salespeople and students.
Medical students on other campuses are organizing seminars and lectures on the issue. At a recent luncheon at Washington University in St. Louis, leaders of the local chapter of the American Medical Student Association handed out cans of soft drinks affixed with labels taking digs at drug-industry marketing. "In 2000, Merck [& Co.] spent $161 million on advertising for Vioxx," one label read. "That is more than PepsiCo spent advertising Pepsi ($125 million), and more than Anheuser-Busch spent advertising Budweiser ($146 million)." Research has shown that industry largess influences doctors to the point that some improperly prescribe -- or overprescribe -- certain drugs. It also may affect how much consumers pay. A study in the Journal of the American Medical Association in January 2000 said doctors who were more inclined to interact with drug reps were less likely to prescribe cheaper generic drugs. The industry disputes many of these findings, arguing that its salespeople provide physicians with useful product information, and that doctors are too smart to let free tickets affect prescription decisions. Jeff Trewhitt, a spokesman for the Pharmaceutical Research and Manufacturers of America, the industry's main Washington trade group, says: "It is an insult to assume new young doctors don't have the ability to exercise independent judgment about the information disseminated at lectures." But there is little dispute that drug makers spend big money -- more than $16 billion in 2001, according to one estimate -- cultivating physicians and medical students. Critics say these ever-rising costs contribute to rising drug prices. Drug makers have grown more sensitive about these issues as Congress, insurers and some big employers have increased their scrutiny of drug prices. In April, the industry issued voluntary guidelines aimed at curbing the most egregious types of direct-to-doctor marketing, including "dine 'n' dash" events at which physicians show up for a brief drug pitch before leaving with a fancy to-go meal. But drug companies say they will continue to market to residents and students as long as teaching hospitals continue to let them do so -- which may be for some time to come. Despite the recent opposition, drug salespeople are welcome at most medical schools and teaching hospitals, and many students and faculty members like the perks. Last month, two Harvard Medical School students proposed that a statewide Massachusetts physicians' association adopt a resolution that doctors, residents and medical students would refuse to accept any industry gifts. Doctor after doctor stood up at a public hearing to defend the industry. The physicians' group voted to study the issue further. Doctors who oppose drug companies' wining-and-dining policies can meet with stiff counterresistance. Such was the case when Edward Wing, chairman of the department of medicine at Brown Medical School and chief of medicine at two affiliated teaching hospitals, blocked drug reps two years ago from sponsoring lunches for residents and students. Since then, reps have stuffed residents' mailboxes with invitations to off-campus events and complained to Dr. Wing's superiors, thus far to no avail. "Drug-company salespeople don't like me," Dr. Wing says. His department now spends more than $70,000 a year of its own funds supplying lunches for medicine residents at Rhode Island Hospital and a sister institution. Harvard's Dr. Avorn says he has been fending off drug reps for almost 30 years, ever since he was a medical resident. In the early 1980s, he conducted a pivotal study showing how strongly physicians were influenced by company sales pitches. Doctors said they were swayed by scientific literature, not drug reps. But Dr. Avorn and his researchers showed that the information doctors had about certain drugs could have come only from salespeople or ads, not medical literature. Today, at Brigham and Women's Hospital in Boston, Dr. Avorn runs the Division of Pharmacoepidemiology and Pharmacoeconomics, which seeks to provide "Data on Prescribing Effectively." (The acronym DOPE was a pure accident, Dr. Avorn says.) Dr. Avorn's 18 researchers and support staff assemble facts designed to counter-spin the drug reps by questioning, for example, whether a particular drug is as necessary as a company says. The issue picked up steam when Bob Goodman of Columbia University's College of Physicians and Surgeons started the national No Free Lunch organization in 1999. The organization has become a clearinghouse of information about doctors and drug reps used by Ms. Agrawal and other students. Ms. Agrawal says she didn't notice much drug-company presence in her first two years at Brown. The next year, when instruction moved from the classroom to the hospital, drug reps started appearing. "You walk into a lunch, and there is somebody dressed in a suit, and they approach you and are very nice to you," she says. "It's kind of confusing, because generally when you're a medical student, people don't come up and ask your opinion on anything." The confusion cleared up when she got involved with AMSA, the national medical-student group based in Reston, Va. She heard about Dr. Goodman's "no free lunch" idea and skipped some lunches sponsored by drug reps. But because she was expected to attend such events, she began to bring her own lunch in the yellow box. "It's hard to sit there and not eat," she says. After her third year, Ms. Agrawal was elected president of AMSA. At the group's annual meeting in Houston in March, she pushed a resolution urging all physicians, residents and medical students to refuse "any promotional gifts from the pharmaceutical industry." The resolution also called on hospitals and residency programs to eliminate drug-company lunches and lectures. It passed in a voice vote. Mr. Trewhitt, the PHRMA spokesman, says the students are "irresponsibly suggesting that doctors should automatically walk away from lectures that could convey important technical information about diseases and medicines that treat them." Now that her one-year term as AMSA president is up, Ms. Agrawal is back on the Brown campus. Among other things, she's arranging to meet with school officials about limiting interaction between drug companies and students. Recently, Ms. Agrawal got a reminder of how tough her challenge will be. When she moved into the apartment she shares with two other students, the first thing she saw was a big purple Zithromax clock in the common room. There was another in the kitchen, and yet another in a roommate's room. Write to Chris Adams at chris.adams@wsj.com 1
Updated June 24, 2002 |
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Jaya Agrawal, a fourth-year student in the Medical School, was elected national president of the American Medical Student Association (AMSA) for 2001-2002. She will devote the next year to AMSA and the medical student community. This past year, Agrawal completed training in public health at Harvard. After her term as AMSA president ends next June, she will return for her final year of medical school at Brown. Agrawal plans to graduate from both Brown, with a medical degree, and Harvard, with a master’s in public health, in 2003. Actively involved in issues of social justice, community organizing, primary care and fair access to quality health care, Agrawal is working with medical students, physicians, policymakers, patients and others on AMSA initiatives in universal health care, diversity in medicine and the well-being of medical students and residents. She is the third Brown medical student to serve as national AMSA president. Dedicated to improving medical training and the nation's health, AMSA is the nation’s oldest and largest independent association of physicians-in-training; it has more than 30,000 members.
March 4, 2002 Posted: 12:32 p.m. EST (1732 GMT)
Sleep is a funny thing. We're taught that we should get seven or eight hours a night, but a lot of us get by just fine on less, and some of us actually sleep too much. A study out of the University of Buffalo last month reported that people who routinely sleep more than eight hours a day and are still tired are nearly three times as likely to die of stroke--probably as a result of an underlying disorder that keeps them from snoozing soundly.
Doctors have their own special sleep problems. Residents are famously sleep deprived. When I was training to become a neurosurgeon, it was not unusual to work 40 hours in a row without rest. Most of us took it in stride, confident we could still deliver the highest quality of medical care.
Maybe we shouldn't have been so sure of ourselves. An article in the Journal of the American Medical Association points out that in the morning after 24 hours of sleeplessness, a person's motor performance is comparable to that of someone who is legally intoxicated. Curiously, surgeons who believe that operating under the influence is grounds for dismissal often don't think twice about operating without enough sleep.
"I could tell you horror stories," says Jaya Agrawal, president of the American Medical Student Association, which runs a website where residents can post anonymous anecdotes. Some are terrifying. "I was operating after being up for over 36 hours," one writes. "I literally fell asleep standing up and nearly face planted into the wound."
"Practically every surgical resident I know has fallen asleep at the wheel driving home from work," writes another. "I know of three who have hit parked cars. Another hit a 'Jersey barrier' on the New Jersey Turnpike, going 65 m.p.h."
"Your own patients have become the enemy," writes a third, because they are "the one thing that stands between you and a few hours of sleep."
Agrawal's organization is supporting the Patient and Physician Safety and Protection Act of 2001, introduced last November by Representative John Conyers Jr. of Michigan. Its key provisions, modeled on New York State's regulations, include an 80-hour workweek and a 24-hour work-shift limit.
Most doctors, however, resist such interference. Dr. Charles Binkley, a senior surgery resident at the University of Michigan, agrees that something needs to be done but believes "doctors should be bound by their conscience, not by the government."
The U.S. controls the hours of pilots and truck drivers. But until such a system is in place for doctors, patients are on their own. If you're worried about the people treating you or a loved one, you should feel free to ask how many hours of sleep they have had and if more-rested staffers are available. Doctors, for their part, have to give up their pose of infallibility and get the rest they need.
Dr. Gupta is a neurosurgeon and CNN medical correspondent
The Patient & Physician Safety and Protection Act of 2001 (PPSPA), H.R. 3236, which has been introduced in the House, would reduce excessive work hours for resident physicians -- who are often required to work 36-hour shifts and as much as 120-hour weeks. The bill would create regulations similar to those that limit working hours for truck drivers and airline pilots.
This, says a statement from the American Medical Student Association (AMSA), is the first time Congress has been asked to address the issue with legislation. PPSPA was introduced by Rep. John Conyers (D-Mich.) and is co-sponsored by 11 other members. It calls for resident work hours to be limited to 80 a week and no more than 24 at one time. In addition, it would limit emergency room shifts for residents to no more than 12 hours and address the issue of supervision for all residents.
The measure would also provide for annual surveys of resident working conditions, public disclosure of hospitals that violate the limits on hours and the imposition of civil penalties. "Nearly every practicing physician has a story about a mistake made while on his or her 30th hour of duty during internship," comments Jaya Agrawal, AMSA president and a fourth-year medical student at Brown University. "These abusive practices and the culture of silence surrounding them need to end."
Patients come to the hospital in their most desperate hour of need, Agrawal continues in the statement, "and they deserve to be seen by professionals who are at their best." AMSA is the nation's largest independent medical student organization, representing more than 30,000 physicians in training at more than 150 medical schools across the country.
Organizations supporting the PPSPA include Public Citizen, a consumer advocacy organization; the Committee of Interns and Residents/CIR (SEIU 1957), the nation's largest resident union; the Center for Patient Advocacy; the American Medical Women's Association; the American Society for Addiction Medicine; the Academy of Organizational and Occupational Psychiatry; the Physicians Committee for Responsible Medicine; and the Union of American Physicians and Dentists.
"Too many resident physicians are working 100, 120, even 130 hours a week," reports Ladi Haroona, M.D., CIR president. "The public demands safe, compassionate healthcare and an end to preventable medical errors. Residents demand an end to excessive work hours that prevent us from delivering compassionate and quality patient care, put our own health and safety at risk and diminish our medical training."
CIR is the country's oldest and largest union of resident physicians, representing 11,000 residents in five states, the District of Columbia and Puerto Rico.
Surveys show that between 30% and 40% of residents' time is spent on non-educational activities, the statement continues. "The continued use of residents as cheap labor in hospitals is unacceptable," Agrawal asserts. "Residency training should be focused on education and dedication to patients. The current system teaches residents that patients are what come between them and an extra hour of sleep."
AMSA, the statement goes on, believes that adequate support staff and responsible regulation are required steps toward producing a culture of safety in the nation's hospitals. The Accreditation Council for Graduate Medical Education accredits residency programs and develops rules for working conditions, the statement adds. Those rules have, resulted, so far, it says, in lax, unenforceable guidelines. "The time for federal intervention has come," says Rob Levy, AMSA's legislative affairs director and a fourth-year medical student at State University of New York/Upstate Medical University. "Congress must ensure public disclosure of the names of hospitals that violate reasonable work hour limits, provide residents with a mechanism to make anonymous complaints about their programs and ensure hospital compliance through the prospect of civil penalties."
Public Citizen's Peter Lurie, M.D., M.P.H., adds that "because organized medicine has proved itself incapable of remedying these exploitative working conditions, either the U.S. Congress or OSHA will have to step in to protect patients and residents." The effects of sleep deprivation on performance and safety are widely known, the statement continues, noting that being awake for 24 hours results in cognitive function -- such as hand-eye coordination -- at a level equivalent to having a 0.1% blood alcohol level. Residents would be considered too impaired to safely operate a motor vehicle yet can treat patients for 12 additional hours in some cases.
Emergency medicine residents are nearly seven times more likely to have a motor vehicle accident due to falling asleep at the wheel during their residency than before residency, the statement continues. And nearly 30% of first-year residents suffer from depression. Finally, it says, nearly 60% of obstetrics/gynecology residents fear the hours they work compromise the quality of care they provide.
AMSA, Public Citizen, CIR and others filed a petition with the Occupational Safety and Health Administration (OSHA) last April, seeking federal regulations of the work-hour system, the statement notes. The petition reviewed studies demonstrating that current working conditions have resulted in higher rates of motor vehicle accidents, depression and pregnancy complications for residents. It calls for work hour restrictions similar to those in PPSPA. The petition is still under review by OSHA.
Source - American Medical Student Association
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Jaya
Agrawal carries her revolt against the world's drug
industry in a yellow lunchbox. ![[Chart]](images/2f_school06232002233814.gif)