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Pharmaceutical exposure: what is the lethal dose?

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I stood in the waiting room, looking around the sea of faces for the next patient on the list.

It was a Wednesday. Like every Wednesday, the room was filled with the usual warm smiles I had come to expect in this country general practice. One face, however, stood out. Each time I called another patient in, the same tall, handsome man in a well-fitted suit sat patiently in the corner, reading the newspaper.

After I had called in my last patient for the day, I approached the principle GP of the practice, concerned that the man must have been sitting there neglected for many hours. The GP identified him as a regular pharmaceutical representative. The man had been sitting there neglected, but deliberately. The GP had made a personal decision not to engage with him.

He offered me the opportunity to talk to the rep and ‘make up my own mind’, and so I invited the man into my clinical room and we discussed the mechanism of action of a new medication. He provided no food or presents, and I found the information delivered to be both informative and useful. Throughout the interaction, however, I couldn’t help but feel that I was doing something wrong.

Evidence of a relationship between exposure to pharmaceutical products and prescribing behaviour is well established. There are legitimate and substantiated concerns that exposure correlates to altered prescribing behaviour, with no evidence of higher quality prescribing[1].

A systematic review in 2011[2] showed that, even for medical students, exposure to pharmaceutical company marketing may influence attitudes towards certain pharmaceuticals. Perhaps more concerning is that many students believed themselves to be immune to bias.

In the last few decades, the medical profession has experienced a monumental cultural shift away from expensive pharma-funded conferences and towards taking individual responsibility in safe-guarding one’s exposure to pharmaceutical marketing. This has meant gradually decreased spending and smaller promotional products.

But how much exposure is too much?

There exists evidence that even smaller promotional items still exert influence on medical students’ attitudes.[3]

The Australian Medical Students’ Association has had pharmaceutical guidelines in place for almost a decade that define ‘pharmaceutical company’ very broadly, prohibit any direct sponsorship, and put in place rigorous evidence-based guidelines for any interactions with relevant marketing.

It’s become increasingly clear that there is no safe level of exposure to pharmaceutical marketing

For more information please see AMSA’s Pharmaceutical Sponsorship Policy here:


Jessica Dean is the President of the Australian Medical Students’ Association. Jessica is a 6th year Medicine/Law student at Monash University. She is currently completing an Honours Project in Bioethics at The Alfred. Follow on Twitter @AMSAPresident or @yourAMSA


[1] Spurling GK, Mansfield PR, Montgomery BD, Lexchin J, Doust J, Othman N, et al. Information from pharmaceutical companies and the quality, quantity, and cost of physicians’ prescribing: a systematic review. PLoS medicine. 2010;7(10):e1000352.

[2] Austad KE, Avorn J, Kesselheim AS. Medical students’ exposure to and attitudes about the pharmaceutical industry: a systematic review. PLoS medicine. 2011;8(5):e1001037.

[3] Grande D, Frosch DL, Perkins AW, Kahn BE. Effect of exposure to small pharmaceutical promotional items on treatment preferences. Archives of internal medicine. 2009;169(9):887-93.