THERE ARE SIGNIFICANT problems in the relationship between the pharmaceutical industry and academic medical centers, as highlighted by Iowa Sen. Charles Grassley’s ongoing investigation and the recent accusations of impropriety involving several child psychiatrists at the Massachusetts General Hospital. To be sure, things have improved measurably in the past two to four years in response to revelations about some of the most excessive industry practices to influence physicians. Once common offers of all-expense-paid junkets with fat “consulting fees” to fancy resorts are now not so common; I haven’t received such an offer in several years. The practice of burying the results of an unfavorable drug trial, and forcing researchers to give up their rights to report their data without industry approval and editing, is harder to accomplish now that all clinical trials must be publicly registered at their outset if they are ever to be published in a reputable scientific journal. Disclosure of potential conflicts of interest is now de rigueur before most academic presentations and publications.

But one need only attend a major medical meeting, such as the American Psychiatric Association’s this past May, to see that the high-priced efforts of the pharmaceutical industry to influence psychiatrists are very much alive. The exhibit hall is usually a monument to the wiles of successful advertising, with hundreds of highly trained, socially adept representatives focused on one-to-one soft sales pitches, bags and trinkets labeled with drug names seemingly everywhere, and enough glitz stimulation to rival a casino.

The most insidious influence of the industry comes from the symposia they organize and market heavily before the meeting. These are usually very well done. They feature excellent speakers, little redundancy, current data, professionally made slides and handouts and terrific free food. Those seminars contrast sharply with the non-pharmacologic seminars. Those dealing with such topics as family therapy or health-services research or group interventions don’t have access to big honoraria for speakers, media consultants to hone the presentations, etc., and therefore often seem dowdy by comparison. The insidious aspect is that a newcomer to the field would easily conclude that the excitement and future of psychiatry is only in psychopharmacology.This imbalance in prestige and financial rewards between the pharmacologic and psychosocial components constitutes a major factor behind the trend for many psychiatrists to become only prescription writers.

A physician’s attitudes about appropriate relations with industry are shaped during training. Four out of five clinical departments in U.S. medical schools have some relationship with the pharmaceutical industry. Research has shown that medical students encounter on average one industry-sponsored activity or gift a week, and over 90 percent are asked or required to attend at least one lunch hosted by drug representatives during medical school. Recognizing the impact of such contact during students’ formative years, some medical schools have adopted policies to make their campuses completely free of industry influence, banning all gifts, food, representatives and activities sponsored by pharmaceutical companies. Other schools believe that such blanket protections do not adequately prepare medical students for the pressures they’ll encounter in the real world after graduation.

Even many progressive physicians argue that they can’t be bought by small gifts and that full disclosure of conflicts solves the major problem. Data do not support either contention. Small gifts aren’t intended as bribes; rather, they engender a feeling of friendly reciprocity and are clearly associated with industry-favoring attitudes and practices in the physicians who receive them. It is naïve to think that the $21 billion that the pharmaceutical industry spends on marketing (90 percent of which is directed at physicians) is misguided and ineffective; profit margins prove the opposite.

Disclosure is far from a panacea. The litany of disclosures of possible conflicts of interest that precede a medical article or presentation can be mind-numbing, desensitizing the reader or listener while serving to “sanitize” real issues of conflict. Disclosing the actual amount of money a company pays to an individual “thought leader” in honoraria, consulting fees, etc., would certainly make the process more informative and interesting, but that is almost universally resisted by those involved. There is a real difference in impact between a $500 honorarium and $50,000 in consulting fees, but our current disclosure system does not make that distinction.

Children with psychiatric disorders are at ground zero regarding all these issues. Most psychoactive medications children take are prescribed off label, with less research available to support their efficacy than one would wish. Nowhere is the potential for pharmaceutical industry influence greater. There really is no free lunch; ultimately our patients pay for the medications we provide and for the marketing costs to sell them. We owe it to the children to maintain our medical integrity and avoid conflicts of interest.

Gregory K. Fritz, M.D., is academic director at Bradley Hospital and editor of the Brown University Child and Adolescent Behavior Letter.