Results tagged “medical education” from Pathophilia

So who uses the web to find health information—or should I say, health misinformation?

According to a National Health Interview Survey...

• nearly one half of adults (46%);
• women (51%) more than men (40%); and
• younger adults.

Here's the age-sex breakdown:

Once again: I'll attempt to clarify the difference between participating in speakers' bureaus and delivering continuing medical education (CME).

The repeat effort to distinguish the two is prompted by today's newspaper and blog reports of physician Lawrence DuBuske, who decided to give up his academic gig at Harvard when the institution required him to make a choice between speaking for pharma and working at the Brigham and Women's Hospital.

Evidently DuBuske earned nearly $100,000 during April, May, and June of last year for giving Glaxo-paid talks to physicians and decided that the pharma gigs were just too lucrative.* In GSK's second-quarter report, "Fees Paid to US Based Healthcare Professionals for Consulting & Speaking Services," DuBuske's services are described as "speaker" and are apparently distinct from any CME honoraria that he might have received through GSK's educational grants (see, for example, "Grants & Charitable Contributions to US Based Healthcare Organizations").

A quick Google search shows that DuBuske did, in fact, also deliver certified CME programs last year (see here and here). Published disclosures through one of these CME programs reveal that DuBuske participated in the speakers' bureaus of 10 drug companies (including GSK) and received honoraria (assumed to be CME honoraria) through grants from 11 drug companies during the last 12 months (at least).

Distinction Between Speakers' Bureaus and CME

Participation in speakers' bureaus consists of giving talks that are based on slides and talking points created by the drug or medical-device company. The content of these talks must be reviewed by the company's medical-legal department and must adhere to FDA guidelines—for example, they must contain so-called fair-balance information. In essence, a healthcare professional who participates in speakers' bureaus becomes a glorified sales representative (like Daniel Carlat during his speakers' gigs for Wyeth).

Participation in CME requires either the development of educational content or its delivery to other healthcare professionals. In the case of industry-funded CME, funds are procured by an organization that is accredited to produce CME.** This organization—which can be a university-based CME department, a medical professional organization, or a for-profit medical education communications company (MECC)—then recruits faculty and assists them with the development of the educational content. The organization is also instrumental in deciding the format of the CME program (eg, Internet-based activity, dinner meeting) and enforcing recognized guidelines to ensure the independence of the program. Honoraria to faculty that develop or deliver content are paid by the accredited organization from the industry-supplied educational grant. Critics of industry-funded CME (eg, Daniel Carlat) argue that companies unduly influence the content of these CME programs through their indirect or direct pressure on grant recipients.

Policies of Partners Healthcare Regarding Speakers' Bureaus and CME

The newly enforced policies of Partners Healthcare, comprising Harvard's Mass General and Brigham and Women's Hospitals, "ban faculty participation in industry speakers bureaus." However, policies relating to industry funding for CME only address involvement at the institutional level; they do not explicitly prohibit Partners physicians from receiving honoraria for developing or presenting certified industry-funded CME programs.

Industry funding for "educational programs" (whether certified or not) may only be accepted after approval from Partners' newly created Educational Review Board, which requires that support for a specific CME program come from more than one company. Also Partners faculty who earn so much per year from a potential industry sponsor (eg, ≥$20,000) might be prohibited from participating in the creation or delivery of a Partners-produced CME program.

* Whether industry will still want to pay DuBuske to speak after his separation from Harvard is debated.

** In the United States, accreditation is most often bestowed by the Accreditation Council for CME.

In an apparent effort to suppress criticism of industry bias in continuing medical education (CME), Pfizer is giving Stanford $3 million to produce such programs without condition. Specifically the grant will not stipulate therapeutic areas of interest for the educational activities—a major departure from current, recognized standards for US-based CME. A full report, with soup-to-nuts opinions from physicians on Pfizer's new type of pooled CME grant to the university, is available in today's NYT.

However...however.

Decisions have apparently been made that Stanford's Pfizer-funded CME will concentrate on diabetes, cardiovascular disease, smoking cessation, and infections, reports the paper. All of these therapeutic areas are of potential interest to the monolithic company.* For example, Pfizer makes Chantix, a smoking-cessation drug; the blockbuster statin Lipitor; and Caduet, a combo calcium-channel blocker/statin.

Now whether bias is inherent in a CME grant that merely specifies a therapeutic area is up for debate. For instance, see the comments here.

And for the historical record:

1. Last year, Pfizer announced that it would no longer directly provide CME grants to medical education communications companies (MECCs), presumably because of the perception of bias in MECC-produced CME.
2. In 2004, Pfizer agreed to pay the government $430 million to settle allegations of promoting Neurontin (gabapentin) off-label. One alleged off-label outlet: Pfizer-funded CME.**

* Implying here that it might be hard to find a therapeutic area that is not of interest to Pfizer.

** Also 2 months ago, it was revealed that the protocol-defined primary endpoints in company-funded trials of Neurontin were often changed.

On Friday, the WSJ printed a story by Alicia Mundy, "Health-Bill Disclosure Rule Is Resisted," which revealed that a recently passed health-reform bill in the House would require drug companies to disclose payments made to physicians and third parties, such as medical education communications companies, or MECCs. But the idea is nothing new, and reports of such disclosures have been carried extensively by various news sources, including the WSJ and the related WSJ Health Blog.

Given the scrutiny that financial relationships between pharma and physicians have received of late (thanks largely to the Senate Special Committee on Aging and Senate Finance Committee), several drug companies (for example, Eli Lilly and GSK) have voluntarily offered readily accessible information about payments made to physicians for consultant, advisory, or speaking services, as well as educational grants given to MECCs to produce CME programs.

Resisting disclosure, Mundy reported, is John Kamp, executive director of the Coalition for Healthcare Communication. The Coalition, according to the organization's web site, "defends the right of health professionals and consumers to receive truthful information regarding pharmaceuticals and medical products, as safeguarded by the Constitution of the United States. Founded in 1991, the Coalition represents organizations, rather than individuals, dedicated to assuring the free exchange of scientific information without undue government interference." Among the member groups of the Coalition are the American Association of Advertising Agencies and the Association of Medical Media.

Kamp penned his objection to legislated CME disclosure in a July letter to Senator Herb "I'm Richer Than Croesus and God" Kohl (WI-D), who chairs the Special Committee on Aging. In response to an inquiry from the Committee, Kamp wrote, "Many leading drug and device companies have published all their grants for the world to see, and others are following quickly. Given this trend, the Committee should consider elimination of certified CME reporting in all versions of Health Care Reform bills because they are unneeded, redundant and needlessly expensive [boldface sic]." Mundy quoted Kamp, beginning at "should consider..."; she failed to clarify why Kamp resisted legislated disclosure—thereby misleading her readers to believe that Kamp resists disclosure altogether. 

Mundy then segued to Thomas Sullivan, president of a small Maryland-based MECC, Rockpointe, and sole blogger at Policy and Medicine. Although Sullivan reported to Mundy that he's not against legislated CME disclosure from drug companies, he has been openly critical of Senator Kohl's Committee, as well as Senator Chuck Gassley (IA-R), who is the ranking minority member of the Senate Finance Committee. In a September blog post, Sullivan described the efforts of Grassley's investigator, Paul Thacker, into physician-related conflicts of interest with pharma as "witch hunts." (It's a description that Sullivan should have heeded when considering any voluntary cooperation with Senator Kohl's Committee and its chief investigator, Jack Mitchell. But more on Mitchell in a follow-up post.) 

In a move that was off-point from her article's lede but apparently designed to shock or embarrass, Mundy then proceeded to report the amount of educational grant money that Sullivan's private company had received from drug firms during the last 3½ years. Evidently Mundy had obtained this proprietary company data through the UCSF's publicly accessible Drug Industry Document Archive, which had received the information from Kohl's Committee.

In July, the Committee had requested "an accounting of the funding received by Rockpointe Corporation from pharmaceutical, medical device and biologics companies." Why the Committee was spending taxpayer dollars investigating the 18-employee, privately owned MECC is anybody's guess.* In any event, Sullivan volunteered the information, writing, "We have discussed with your Chief of Investigations, Jack Mitchell, the business information provided is proprietary. We would appreciate your use of this information in the aggregate, and reasonable protection against this information becoming publicly available." So much for government courtesy. 

Mundy proceeded to report the cumulative amount of CME grant money that Rockpointe received from the beginning of 2006 to July 2009 (~$23 million), as well as a breakdown of funds the company received from Medtronic ($802,791 or about $100,350 per CME seminar). She added, "Rockpointe's classes typically addressed ailments that the sponsors' products treat"—an observation that should be news to, well, no one. A drug firm is not going to fund a CME program that is outside its therapeutic area of interest.

What Mundy (most egregiously) failed to do was examine (or ask an independent and knowledgeable physician to examine) Rockpointe's CME programs, to determine if any were biased toward the grantor's product. To do so would have required work, and the possible outcome (namely that Rockpointe's CME programs were not biased) would mean that Mundy wouldn't have much of a story. 

But as irresponsible as Mundy's reportage is here, it's nothing compared to the harsh writing of blogger and shrill critic of pharma-funded CME Daniel Carlat—who, curiously enough, posted his arguably libelous rant about Sullivan and his company's finances the day before Mundy's story was published. The timing suggests that Carlat is more than a mere fall-off-a-log quote source for lazy and/or agenda-driven reporters like Mundy.

* In his letter to Senator Kohl (which is available at the UCSF archive), Sullivan wrote, "It is a concern to us that this letter has been directed to Rockpointe as a result of a group meeting that we initiated with the Aging Committee staff. That initiative was intended to provide information, understanding and insight concerning CME and the proposed Physician Payment Sunshine Act. The meeting, and the required time and preparation, constituted a good faith effort to bring relevant information to the Committee. Our intent was to differentiate accredited CME from promotional marketing. Under the credo of "no good deed goes unpunished," this initiative led directly to your singling us out among the hundreds of similar CME providers to submit confidential business records. We have expended considerable time, expense and professional fees identifying, locating, reviewing and organizing nearly 4 years of business records in order to digest and prepare the accurate summary you requested. An inquiry of this nature will likely discourage other concerned "good Samaritans" from exercising their rights as involved citizens to bring issues of concern to the attention of the committee."

Image of Alicia Mundy from the New America Foundation; reproduced through a Creative Commons license.

Earlier this week, the WSJ Health Blog reported on a newly published study by Boston researchers Zinner et al (Participation of academic scientists in relationships with industry. Health Aff (Millwood). 2009;28:1814-1825), who assessed the extent to which academic physicians and other scientists have financial ties with the drug or device industry. The story was also predictably picked up by Ed Silverman at Pharmalot.

The blogs' respective ledes highlighted the finding that about 53% of academic researchers have some kind of financial relationship with industry—an observation plucked from the article's abstract. But if one reads the article, the most face-slapping result, IMNSHO, was the horrifying uniformity of the surveyed respondents: 72% were male, and 77% were white. The ethnic/racial diversity, or obvious lack thereof, is flabbergasting. The only minority represented to any notable extent was "Asian."* Among the 2168 respondents** from clinical or nonclinical "life-science" departments, 22 described themselves as black or African American. That's one percent.

Ethnicity/Race	No.	%
White	1705	77
Asian	314	14
Hispanic, any race	56	3
Declined to report	57	3
Other	47	2
Black or African American	22	1
Total	2201*	100

And it's not as if the survey candidates were cherry picked. The authors selected a random sample of faculty from the life-science departments at the 50 US universities that received the most NIH funding in 2004. Survey responses were collected between December 2006 and March 2007. The findings are, therefore, one hell of an indictment of those making contemporary academic appointments in the life sciences at our top programs.

Unfortunately the authors (who include my favorite, sociologist Eric Campbell) did not address the homogeneity of their survey population; perhaps they believed it to be off point. But such a stunning revelation demands examination.

* The ethnic/race breakdown was similar for clinical and nonclinical faculty. The authors did not break down race by professorship level (full, associate, and assistant). The findings are probably even more disheartening.

* It's assumed, although not clarified by the authors, that 34 respondents selected more than one ethnicity/race in the survey.

IMNSHO = in my not-so-humble opinion.

There is a particular irritation to be found in the criticism of continuing medical education (CME) by a nonphysician. There is even more irritation to be found in the criticism of CME by a purveyor of sociology. There may be practical benefits of the so-called science, but its merits have eluded me in a life that's had its fill of academia.

In the latest issue of JAMA—a journal becoming known for its overbearing editorials—sociologist Eric Campbell, PhD, and health economist Meredith Rosenthal, PhD, condemn the current state of physician CME by applying general critiques from the landmark Flexner Report of 1910. They also advocate investment in something they call "physician human capital," a term adapted from economists to convey the medical knowledge and skills that are required to provide "high-quality, efficient, and cost-effective care."

By using the Flexner Report, Campbell and Rosenthal attempt to draw parallels between the heterogenous state of early American medical education and the quality of today's CME, which they allege is equally scattershot. The comparison is meant to empower their criticism of CME, but the comparison is invalid.

In the early twentieth century, educator Abraham Flexner visited more than 100 US medical schools at the behest of the Carnegie Foundation for the Advancement of Teaching, which conducted its survey at the behest of the AMA's Council on Medical Education. The 2 major reforms for graduate medical education that were promoted (and ultimately realized) by the AMA Council were 1) the standardization of the preliminary requirements for entry into medical school and 2) the implementation of a nationally recognized curriculum of 2 years of basic sciences and 2 years of clinical instruction in a teaching hospital.

Among Flexner's findings in 1910 was, as suspected, the fact that medical curricula varied widely from school to school. But Campbell and Rosenthal wrongly apply Flexner's observation to today's CME by maligning physicians' autonomy when selecting from the varied number of certified CME activities. They argue, "While the diversity of CME offerings provides benefits to physicians, it also deprives CME of representing the mastery of an essential core set of knowledge and competencies."

The problem with the authors' criticism is that, for practicing physicians, the foundation or "essential core" of medical education has already been established, thanks to the Flexner-inspired curriculum of accredited medical schools and postgraduate clinical-training programs. Perhaps if Campbell and Rosenthal had undergone medical education themselves, this blatant fact would not have been so stunningly overlooked. 

It is also entirely reasonable to assume that individual physicians are in the best positions to select the CME activities that may be most beneficial to their practices. Moreover, as Campbell and Rosenthal indicate, the mastery of an essential core set of knowledge and skills is already periodically reinforced by the required maintenance-of-certification examinations through the American Board of Medical Specialties (ABMS). It hardly seems necessary, or even desirable, that participation in specific CME activities should be dictated to practicing physicians beyond the state-mandated requirement of so many certified hours per year. I would be no more inclined to require that Dr. Campbell read certain sociology journals.

Flexner also lambasted the for-profit medical schools of his time, largely because of their substandard curricula. Campbell and Rosenthal proceed to make a very loose correlate between Flexner's observation and the "excessive commercialization" of current CME activities. They cite the ACCME's 2007 report, which indicated that 58% of the income of accredited CME providers came from industry. (The 2008 report indicates that about 44% of total income came from industry, a drop of nearly 25%.) However, there are no objective data to show that commercially supported CME is inferior or less effective at improving medical practice or patient outcomes than CME activities funded by other sources. In fact, Campbell and Rosenthal acknowledge, "[T]here is scant evidence that CME actually improves patient outcomes." In this statement, Campbell and Rosenthal do not distinguish between commercially and noncommercially supported CME. The inferiority of industry-funded CME is merely assumed by the authors, apparently because it has been argued or assumed by others.

Campbell and Rosenthal also maintain that CME relies too heavily on the lecture format, a criticism that Flexner threw at unregulated medical schools 100 years ago. By extension of their argument, the authors claim that CME "is not adequately focused on improving patient outcomes." However, later in their editorial, while advocating CME reform the authors anticipate a transition to CME that is provided by hospitals. But already overburdened hospitals are unlikely to pioneer innovative formats for CME activities.

To realize their "new model of CME" and to ensure physician human capital, Campbell and Rosenthal conclude by advocating 3 lofty reforms. They might as well advocate a tilt of the Earth's axis without proving why it's really better or specifying how to bring it about. Two of their reforms require monumental changes to US medical practice: 1) physician-payment reform to motivate practice quality and efficiency (as if physicians aren't sufficiently motivated to achieve these ends at present) and 2) the use of "sophisticated health information technology" to facilitate on-the-job learning. In addition, the authors propose specialty certification as a requirement for state licensure—an admittedly nice idea that will never happen.

"Boston Ivy" from Flickr.

Medical-education communications companies (MECCs) must brace for more retrenchment.

GlaxoSmithKline announced today that it will no longer provide continuing medical education (CME) grants to MECCs, according to Reuters. The drug company's decision, which is part of a new grant policy, is effective immediately. GSK joins Pfizer, which announced its decision to cut off educational grants to MECCs more than a year ago.

GSK also reports that it will fund fewer CME programs and "invite grant applications from approximately 20 medical education providers with a documented track record of developing and delivering high quality medical education programs that have a measurable impact on improved patient health." Invited applicants are limited to unnamed, accredited academic medical centers and national physicians' organizations.

It's been argued here that the move by drug firms to deny grants to MECCs is based on the perception of bias, not actual bias, in MECC-generated CME. In any event, it's bad news for companies like CE Alliance ($225,000), Discovery Communications* ($426,500), Physicians' Education Resource Group ($363,700), Pri-Med Institute ($1,024,773), Research to Practice ($530,000), and Vindico Medical Education ($225,338), which received a total of nearly $2.8 million in grants from GSK in the first half of this year. (Values in parentheses indicate GSK funds to the individual company for the first 2 quarters of 2009.)

According to data from the ACCME, total income for "publishing and education companies" (in other words, MECCs) dropped 20% from 2007 to 2008. The income drop is largely due to the loss of grant support from pharma.

Whether CME leads to positive changes in healthcare delivery remains up for debate. A recent Cochrane review concluded that professional educational meetings, particularly when combining didactic and interactive formats, can improve healthcare delivery and patient outcomes. However, the effect is typically small and similar to that of other types of CME activities, like audit and feeback programs. The effectiveness of CME increases when serious outcomes or less complex behaviors are considered.

* Suspected to be the Discovery Institute of Medical Education.

09/23/09 addendum: According to Daniel Carlat, blanket critic of all pharma-supported CME, GSK will still provide CME grants to invited applicants that partner with MECCs. Carlat ignorantly describes the MECC-cosponsor arrangement as adding another layer to a "money laundering operation." The description, which Carlat appears to be in love with, is simply wrong.

Money laundering refers to methods by which illegally obtained income (eg, from drug trafficking, prostitution) is moved around to disguise its source. There are at least 2 very important ways in which "money laundering" fails to describe pharma-funded CME. First and foremost: Providing educational grants to MECCs or any other organization is not illegal (although on Planet Carlat, it would be). Second: The source of the funding is not hidden; the pharma grantor must be disclosed on CME materials to the program participant. This requirement is stipulated by the ACCME.

Last Thursday the Accreditation Council for Continuing Medical Education (ACCME)—the organization that accredits other organizations to provide certified CME in the United States—released detailed data on 729 providers. In an e-mailed press release, the ACCME's Chief Executive, Murray Kopelow, stated that these data were being made public in an effort to "increase the system's transparency and accountability."

Among the accredited providers, 124 (17%) received the designation of "Accreditation with Commendation" from the ACCME; 16 received commendation under the more stringent 2006 criteria, which is intended to foster providers' participation in "institutional or system-wide initiatives" to improve the quality of healthcare (whatever that entails exactly).

An examination of the ACCME's stats, which can be downloaded from the organization's web site, identifies all accredited organizations by name and their relevant data. The 16 commended providers include 8 academic institutions, 4 medical societies, 1 medical center (Memorial Sloan-Kettering), 1 government medical institute (the FAA's Civil Aerospace Medical Institute), 1 professional-liability insurance company (Norcal Mutual), and 1 medical-education communications company, or MECC (Discovery). According to the ACCME's data, only 21% of all providers have been reviewed under the 2006 criteria.

A total of 33 providers (4.5%) are on "probation." The designation means that providers may continue to offer certified CME, but they are also required to show their plans to improve areas of noncompliance within a specified time. Contrary to popular expectations, MECCs are not disproportionately represented among the CME providers on probation. Among the warned providers that were assessed under the 2006 ACCME criteria (n = 15), there are 4 academic institutions, 4 MECCs, 3 medical societies, 3 hospitals, and 1 physician group. The 18 providers on probation that were not assessed under the 2006 criteria include 16 medical societies, 1 MECC, and 1 community-based organization.

Among all accredited providers, 81% reported receiving commercial (ie, pharmaceutical) support; 66% received income from advertising and exhibits. Of those 124 commended providers, only 14 (11%) did not receive commercial support; 4 of the 14, however, did report advertising and exhibits income.

In the National Review, conservative journalist Mary Claire Kendall questions the influence that the private Josiah Macy, Jr, Foundation has on the nonprofit Institute of Medicine (IOM). At stake, evidently, is the Foundation's interest in removing all sources of commercial funding for physicians' continuing medical education (CME)—funding which is argued (without supporting evidence) to adversely influence physician practice and, consequently, patient outcomes.

Kendall highlights the possibility that the Foundation itself, a private philanthropy established by the descendant of merchant seamen, is unduly influencing the IOM by funding various IOM committees that are concerned with medical education. The possibility that the Foundation is buying off the IOM to push its own predetermined, but unfounded, idea that commercial support of CME is bad is implicit in the Foundation's support of the IOM's Conflict of Interest Committee ($75,000) and the IOM's upcoming ad-hoc Committee on Planning a Continuing Health Care Professional Education Institute ($428,177). The ad-hoc committee, Kendall notes, will include representatives from the Association of American Medical Colleges and the Institute of Health Policy—both of which have received a cumulative $738,000 from the Macy Foundation.

"What is damning is that they [the Macy Foundation] are dedicated to pushing private industry out of CME in the name of an entirely self-serving definition of 'bias' that reaches predetermined conclusions," Kendall writes. What is also damning and, moreover, ironic is the fact that the IOM has failed to provide detailed evidence of its funding sources, despite a united call for transparency in CME to uncover possible conflicts of interest.

HT: Policy and Medicine

Do college premeds really need a second semester of organic chemistry? That's the question asked and answered by Jules Dienstag, MD, in this week's issue of the NEJM. Dienstag argues that the longstanding premed requirements of 1 year of biology, 2 years of chemistry (including 1 year of organic chemistry), and 1 year of physics "fail to...prepare students for tackling the sciences fundamental to medicine at the advanced molecular level." He continues, "We should expect a higher standard from students who wish to pursue medicine in an era in which genomics and informatics will revolutionize biomedical science and health care."

Dienstag argues for premed science requirements that are more relevant to today's medicine, as opposed to teaching the principles of 19th-century chemistry (as my orgo professor mused more than 20 years ago) to budding doctors. Instead of a second round of orgo,* go right into introductory biochem, he proposes—introducing molecular reactions that are actually relevant to bodily function and the manifestation of disease.

Dienstag also urges the integration of traditionally compartmentalized disciplines, like physiology, anatomy, and genetics, to foster a holistic approach to health and disease. And he rightly emphasizes a foundation in writing and communications skills. On this subject, I would stress a full semester of basic grammar and style (even if it's a bloody review), perhaps focusing on medical and scientific communications. Having been on the receiving end of medical manuscripts, I've noted these skills to be embarrassingly poor in too many established, academically based physicians.

* Not once do I recall the benefit in medical practice of knowing the Grignard reaction, and I was one of those freaks who liked organic chemistry.

Image of formation of Grignard reagent from Wikipedia.

In an attempt to encourage lower-paying careers in academic medicine, the Cleveland Clinic Lerner College of Medicine of Case Western University will offer full tuition scholarships to all incoming students beginning this academic year, reports the WSJ. The current estimated tuition is $43,500, so that's $4350 for every word in the school's name.

Photo: Cuyahoga River (near Cleveland) on fire in 1952. Yes, an acknowledged cheap shot.

Damn, kids. Just say "no" to free tuna hoagies.

That's the recommendation from a task force created by the Association of American Medical Colleges. The report proposes that any gifts from pharma—including food, medical instruments, or ghostwriting services*—should be banned from all US medical schools. And because a large chunk of medical-school education takes place within affiliated hospitals, the proposal would logically extend to these training sites as well.

The task force included representatives from medical academia and organizations concerned with medial education (the AMA and ACCME), but pharma input was also represented by Pfizer CEO Jeff Kindler, Amgen CEO Kevin Sharer, and former Lilly CEO Sidney Taurel. The task force was chaired by P. Roy Vagelos, MD, a former Merck exec.

While seemingly happy agreements were achieved on most of the task force's recommendations, Kindler and Taurel specifically objected to the report's proposal that faculty be discouraged from participating in industry-sponsored speakers' bureaus. These programs typically involve the "training" of scores of key opinion leaders (a term often loosely applied) to give talks to their regional collegues by using industry-supplied slide decks. Robert Alpern, MD, dean at Yale, likened the practice (and the Pathophilia blog agrees with him) to "ghost talking," according to today's NYT. The practice creates a conflict of interest much more egregious than whatever comes with hoovering a free sandwich on the fly.

*Gifts thoroughly enjoyed by preceding generations of medical trainees and/or their faculty.

Photo: iStockphoto.