Medical student Clarence Lam marveled at the feast that a drug company sponsored this spring at the Inner Harbor's upscale Capital Grille.
The night's appetizer was seafood, the entree was filet mignon and dessert was cheesecake.
"They paid for everything," recalled Lam, 26, who attends the University of Maryland School of Medicine. "They even covered the wine."
Like other drugmakers, Novartis Pharmaceutical Co. sponsors such events to woo practicing doctors and to promote its products to future physicians such as Lam. It's a common marketing tactic that is raising concerns on medical school campuses nationwide. Medical scholars and student groups have called for tighter restrictions on industry access to the nation's medical students.
The Association of American Medical Colleges has a task force investigating the issue, and several medical schools have adopted policies that restrict such marketing. Officials at UM and the Johns Hopkins School of Medicine are considering similar rules.
Experts say drug companies spend about $19 billion a year marketing to doctors. How much of that goes to physicians in training isn't clear, but students say they often receive small gifts, free meals and invitations to events paid for by the pharmaceutical industry. Sometimes the invitations come from the doctors who teach them.
Critics say such early exposure to marketing perks produces doctors whose treatment decisions might be tainted by biased information and the doctors' financial interests. For evidence, they point to highly publicized cases in which the relationships between doctors and the industry put patients' lives in jeopardy.
Last month, Purdue Frederick Co., the parent company of the manufacturer of the painkiller OxyContin, admitted misleading doctors about the drug's addictive properties. A 2002 report by the Drug Enforcement Administration traced 146 deaths to OxyContin overdoses.
The New York Times has reported on doctors who received millions of dollars for prescribing anemia drugs, despite warnings that the drugs might shorten patients' lives.
Drugmakers say such cases are extreme and argue that most doctors and companies follow the rules. They say company representatives provide important guidance on drugs and are sufficiently restrained by industry and federal guidelines.
"Pharmaceutical marketing is one of several important ways for health care providers to receive the information they need to make sure medicines are used properly and patients are safely and effectively treated," Ken Johnson, senior vice president of the Pharmaceutical Research and Manufacturers of America, wrote last month in a statement responding to the OxyContin and anemia drug cases.
Experts also note that many medical breakthroughs are the result of research collaboration between physicians and drugmakers. Some argue that doctors can look past the hype to make unbiased decisions about treatments. Meanwhile, medical schools and professional organizations have begun efforts to limit industry access to students.
In a paper published in January in the Journal of the American Medical Association, a group of prominent scholars called for academic medical centers - medical schools and affiliated teaching hospitals - to take the lead in eliminating conflicts of interest between doctors and the pharmaceutical industry. They called for academic centers to adopt stringent guidelines, including a ban on accepting gifts and free meals from industry representatives.
Research suggests that "the impulse to reciprocate for even small gifts is a powerful influence on people's behavior," they wrote.
They also argued that medical schools should prohibit faculty members, students' role models, from accepting speaking fees as part of industry promotional campaigns. Doctors can be paid thousands of dollars for promoting a drug at such engagements.
Since the paper was published, at least seven medical schools have adopted stricter policies, including those at the University of Pennsylvania, Yale University and Stanford University. The policies vary by school but follow the suggestions of the JAMA paper to some degree.
Last summer, the Association of American Medical Colleges formed a task force to produce guidelines for its members.
"A lot of medical schools are actively deliberating," said Dr. David Korn, the AAMC's senior vice president for research policy.
Korn said the AAMC probably won't release those guidelines until summer 2008 because experts have not reached a consensus.
Also pushing for tighter restrictions is the American Medical Student Association, which sponsors a "PharmFree" campaign urging students to refuse free meals and gifts. "The drug companies have made institutions feel that they need them, but we think they don't," said Justin Sanders, a student at the University of Vermont College of Medicine and the campaign's coordinator.
Schools lack policies
Few medical schools have comprehensive policies that strictly limit industry access to students, said a report released by the student association last month.
The University of Maryland and Hopkins have policies that govern their hospitals and extend to medical school faculties and students in clinical training in their hospitals. The schools have no comprehensive policy, although officials at both said they are considering new rules.
Hopkins has several groups "looking at and evaluating potential issues related to conflict of interest," said Dr. Todd Dorman, a Hopkins anesthesiologist who led a policy task force that reported to the school's dean in March.
UM is also looking at possible changes, said Dr. Nancy R. Lowitt, associate dean for professional development. The school is "very interested" in developing a policy, she said, and awaits the AAMC recommendations. "The key," she said, "is to figure out what relationships [with the industry] are valuable ones and which compromise our decisions."
Meanwhile, the pharmaceutical industry continues to shower students with food and trinkets.
Sarah E. Sharfstein, 31, has been offered a variety of goodies, though she just finished her second year at UM and has spent most of her time in the classroom. In one class on diagnosing neurological problems, a doctor handed out free reflex hammers, courtesy of a drug company.
"Our professors don't need to disclose their financial relationships to us or their patients," she said. "So we don't know where they are coming from."
Sharfstein, president of the student association's local chapter and sister of Baltimore's health commissioner, Dr. Joshua M. Sharfstein, hired a speaker to talk to students about the issue in November. "The only lecture we've had in two years on pharmaceutical ethics was sponsored by me," she said.
In their third and fourth years, students shadow attending physicians and residents, recent graduates who are just beginning to practice medicine. Residents, meanwhile, are required to participate in continuing medical education seminars, which are often sponsored by drug companies that provide free food along with information on their products. Medical students often attend the seminars, or at least show up for the food. They also get free, industry-sponsored meals in doctors' offices and promotional events at off-campus restaurants.
Julia Skapik, 28, a fourth-year student at Hopkins, is skeptical of students' ability to resist such marketing. She said one professor regularly provided sushi lunches in his office. "You get like $100 of sushi, and the drug companies pay for it," she said.
The same doctor invited students to a dinner sponsored by Pfizer, which was promoting its schizophrenia medication Geodon. The professor was a speaker at the event.
"It was a lavish dinner, about three hours long," Skapik recalled. "I thought, 'I can't believe this is happening. Does no one else think this is weird?'"
She said she was uncomfortable accepting free food but feared insulting the professor if she refused to attend.
Ezana Azene, 30, who received his medical degree from Hopkins last month, said drug company representatives sometimes drop the names of well-known doctors.
"They will say [the doctor] uses this drug almost exclusively," said Azene, who is headed for an internal medicine residency at University of Maryland Medical Center.
"You can be duped," he said. "They are only going to present the positives for their products."
Even so, he said, his overall experience with industry representatives has been positive. "You can't treat them like ogres," he said.
It is hard to keep up with the new medicines coming onto the market, Azene said, so the representatives are an important source of information.
Well-trained doctors will not be swayed by marketing once they go into practice, he said, adding, "I don't care if the most prominent doctor in the country is prescribing a drug. I will only use it when I feel it's OK to go ahead. Show me the data."
Lam, 26, who is entering his fourth year at UM, also sees pitfalls and promise in industry relationships. He said doctors should accept the help but remain skeptical.
"The drug companies aren't stupid," he said. "They wouldn't be doing all of this marketing if there isn't some benefit. Why else would they spend so much money?"
Like Skapik, Lam said that the dinners are inappropriate but that he felt pressure from his mentors to attend. He remembers the name of the blood pressure medicine that Novartis was promoting at the Capital Grille in March.
"It was Diovan," he said. "That stuck in my head, so at some level it worked."