Casey KirkHart was in many ways a typical medical student, which is to say he was usually hungry, always pressed for time and keenly aware of his mounting loan debt.
Unlike many of his peers, however, he routinely passed up the lunch that accompanied a weekly lecture, even though the food was everything a student could want: tasty, convenient and, thanks to the pharmaceutical company that catered it, free.
After getting "weird looks" from peers and instructors alike, KirkHart, then at the New York College of Osteopathic Medicine, put together a PowerPoint presentation to explain why. Using charts and graphs, he cited studies showing that about 90% of the drug industry's $21-billion marketing budget went to physicians and that all those mugs, meals, drug samples and speakers' fees influenced doctors' prescription decisions.
He slipped in a photo of himself dressed in a white doctor's coat plastered with enough drug-company logos to rival a NASCAR race driver. The caption read: "The White Coat of the Future?"
KirkHart is now a second-year resident at Harbor-UCLA Medical Center, and the future is starting to look a little different.
The "pharm-free" movement he championed is spreading around the country in the wake of an article in the Journal of the American Medical Assn. challenging academic medical centers to ban drug industry freebies.
In October, Stanford University Medical Center, following Yale University and the University of Pennsylvania hospitals, barred students, faculty and medical staff from accepting even small gifts. UC Davis passed a similar policy late last year that is to take effect July 1.
UCLA's David Geffen School of Medicine approved one in November and sent it to its affiliated hospitals and clinics for a final review. The guidelines, expected to take effect by the end of the school year, will be among the toughest in the country, stripping all clinics and hospital buildings of pens, pads, clipboards and calendars bearing any signs of drug promotions.
And the UC Office of the President is working on systemwide rules for its five medical schools.
"It's not fringe people," KirkHart said. "These are reputable, world-class universities. There's a real culture change happening. We're going to wean ourselves off drug money."
But Scott Lassman, senior assistant general counsel to the Pharmaceutical Research and Manufacturers of America, a marketing and lobbying group based in Washington, D.C., called such restrictive policies "unnecessary and an overreaction."
"They're going to be cutting themselves off from a lot of useful information," he said, referring to bans on meals with sales representatives.
"I can tell you that the sales reps would just as soon not bring in the pizza and the meals," Lassman said. "But often the physicians are extremely busy, and the only time they can get access is over a working lunch or dinner. We thought it was appropriate to pay for that."
In 2002, the industry group and the American Medical Assn. responded to rising criticism by issuing voluntary ethics guidelines. Such lavish gifts as fishing trips, expensive football tickets and greens fees at swanky golf resorts were out. Gifts had to be relatively small -- pens, pads, stethoscopes -- and related to patient care. Drug reps, all 90,000 of them, were urged to deliver educational programs over modestly priced lunches or dinners.
Last month, the International Federation of Pharmaceutical Manufacturers & Assns., which represents drug companies worldwide, issued similar rules.
Doctors in private practice have been courted by "drug reps" for years and, with the exception of Kaiser Permanente, the California-based managed-care group, few private hospitals or physician groups have enacted restrictions. Many doctors, for instance, have drug samples to give to patients.
But academic institutions need to set an example, according to the AMA magazine's article last year. "Academic medical centers, which include medical schools and their affiliated hospitals, should provide leadership for medicine in the United States," said the article, signed by doctors from Harvard Medical School, Columbia University and other schools, including two UC campuses. "Research reveals that the habits learned or acquired during training persist into practice."
The article called on academic centers to ban every free offering, even inexpensive note pads.
The article was notable, given the prominence of the magazine, but it was just the latest in a string of journal articles decrying drug marketing's influence on medicine.
For years, many doctors shrugged off such studies. Some were insulted that anyone would think a few free doodads and dinners could affect their judgment. Others defended interactions with sales reps as a way to stay up to date on the latest drugs or as a source of free samples for low-income patients.