Healthy Skepticism Library item: 2168

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Publication type: news

Should there be systems in place to educate students and residents on appropriate interactions with pharmaceuticals? If so, what should they be?
AAMC Reporter 2001 Jul 10

Full text:

Speaking as a former academic medical and now industry scientist/medical administrator , I think formalized training could be helpful to all, especially those of us in the pharmaceutical/biotech industry. Perhaps this training should be part of a broader didactic on medical economics that all medical students take. Concepts/issues as to what is ethical and even legal with respect to enticements, advertising, etc. are not well understood. Most pharmaceutical companies have strict rules on such things as gifts, speaker fees, advertisements, and off-label detailing, and I doubt most medical students know about these policies.
Steven M. Paul, M.D.
Group Vice President Lilly Research Laboratories
Eli Lilly and Company

Medical students and residents need to appreciate that there is no free lunch in this era of pervasive infiltration of pharmaceutical dollars into all aspects of academic health centers. AHCs have become addicted to pharmaceutical industry dollars. The growing business of clinical trials wherein the industry holds the data and the trial drug is run against placebo and not against other proprietary as well as generic compounds corrupts the very nature of what academia is about.
Kenneth R. Silk, M.D. Associate Chair, Clinical and Administrative Affairs, Department of Psychiatry
University of Michigan Medical School
Vice Chair, Faculty Group Practice Board
University of Michigan Health System

I suspect there will be a lot of rhetoric about goals and objectives, but the only practical approach is the one that works for families and that is by example. It is the obligation of faculty and staff to define the role of industry in all venues by setting limits on their participation and behavior.
Lazar Greenfield, M.D.
University of Michigan Medical School

Academic medical centers should lead the effort to unmask the influence of pharmaceutical companies in patient care, which adversely affects cost and best practices. However, first academic medical centers must clean up our own acts by having all faculty members whose research is sponsored or are employed as speakers by pharmaceutical companies identified on faculty home pages for students and residents to use to make their own judgements about the impartiality of their teachers.
John J. Frey III, M.D.
Professor and Chair Department of Family Medicine
University of Wisconsin – Madison

I believe the interaction with the pharmaceutical industry is inevitable. We can take two positions: denial and indifference, or proactive responsible and engaged faculty who adapt to the realities of our changing world. I chose to take the second since I believe in arming and preparing our residents for the future instead of sheltering them. I believe seminars that invite drug reps to talk about their products in turns of 10 minutes each and then have a faculty member comment and give feedback would help. Another way is to talk directly and constantly to residents about the pitfalls of developing questionable relationship with any third party.
Maher A. Karam-Hage, M.D.
Clinical Assistant Professor of Psychiatry
University of Michigan

All pre- and post-graduate doctors and pharmacists would benefit from using the teaching materials on pharmaceutical promotion being developed by Healthy Skepticism under contract with the World Health Organisation.
Dr. Peter Mansfield, BMBS
Director, www.healthyskepticism.org

The pharmaceutical industry’s influence on research, education, and practice is perhaps the greatest ethical threat to our profession. Given the increasing reliance of academic centers, journals, and researchers on company money, this problem is only getting worse. Trainees are encouraged to believe they are “entitled” to “gifts” from the very beginning of their careers. An educational counterbalance, highlighting the pervasive and distorting influence of industry-physician interaction, must also become a regular aspect of training. Jerome R Hoffman, M.D.
Professor of Medicine/Emergency Medicine
UCLA School of Medicine

In my judgment, there should be some system in place to educate medical students and residents about interactions with drug companies. This entire area will become more important with time and there are ethical issues involved as well. Perhaps a series of seminars involving interactions not just with drug companies but other potential supporters of research and educational programs should be included. I would suggest perhaps two or three seminars with required attendance be held each year.
Robert D. Yates
Chair, Department of Structural and Cellular Biology
Tulane University School of Medicine

Yes, without doubt. In my department, we already do this important and easy teaching. Information valuable to patient care can be gotten from drug companies, but it must be separated from the marketing chicanery. Rational reasons to consider using a drug are the S.T.E.P.S. criteria: Safety, Tolerability, Efficacy, Price, and Simplicity. Non-rational appeals include appeals to authority, popularity (bandwagon effect), the red herring effect, appeals to curiosity, appeals to pity, etc. Teach learners to ask for the rational reasons (STEPS), while rejecting all other non-rational appeals. Joshua Steinberg, M.D.
Assistant Professor, Family Medicine
SUNY Upstate Medical University at Syracuse

It would seem obvious that medical students and residents need direction on appropriate interactions with pharmaceutical companies. But this question begs a more serious one. Medical schools, teaching hospitals, and attending physicians all need direction regarding this issue. We must start with issues of professionalism with the faculty prior to addressing our students. Anything else will appear or be hypocritical.
Sidney Weissman

Absolutely. Interactions between pharmaceutical companies and physicians have substantial effects on medical practice, the cost of health care, and possibly the quality of health care. These systems should consist of case-based instruction about principles, current practices, and their effects; role-playing in different situations relating to these interactions; and modeling by the educational institution and educators of appropriate standards and behaviors.
Seth Landefeld, M.D.
Professor of Medicine and Chief, Division of Geriatrics
University of California, San Francisco, School of Medicine

When a pharmaceutical sales representative gives a medical student or resident a new stethoscope, with the name of one of the company’s drugs engraved on the instrument, is it a gift, an advertisement for the product, or a bribe to prescribe it? Should the physician-in-training accept the stethoscope? The pharmaceutical industry spends more than $8,000 per physician per year on marketing. Pens, note pads, stethoscopes, books, and free meals may affect the physician-patient relationship insofar as the physician is a fiduciary whose first consideration should be the patient in all clinical decisions. In attempting to influence the physician, the pharmaceutical company may compromise the physician’s objectivity.

Research shows that only 10 percent of physicians think they have had sufficient training regarding professional interactions with pharmaceutical sales representatives. We clearly need to initiate educational programs for physicians-in-training concerning proper and improper interactions with representatives of pharmaceutical companies, the interpretation of information provided by these individuals, and the ethics of accepting gifts from them. It is imperative that medical school faculty set a good example by refusing such gifts and eliminating corporate sponsorship from our professional meetings and continuing medical education programs. Edward C. Halperin, M.D.
The L.R. Prosnitz Professor and Chair
Department of Radiation Oncology
Duke University Medical Center

Yes, we should be teaching students and residents about dealing with pharmaceutical reps. A good teaching model for this was developed by Shaughnessy and Slawson (see J Gen Int Med 1994; p 563-567). They have also developed a tool to evaluate drug rep presentations at lunchtime meetings with residents and students. This teaches how to evaluate the process by which reps market their products, rather than simply focusing on arguing over content specifics.
Eric Henley, M.D., MPH
University of Illinois at Rockford

Most academicians and clinicians have contact with pharmaceutical companies. These interactions are inevitable and often beneficial. We should teach an ethical framework for these contacts, discussing gifts, honoraria, objectivity in research and education, and clinical decision-making. Extreme positions (e.g., banning all contacts, permitting unlimited exchanges) are unrealistic. This should be taught the way we teach everything in medicine: discussion of underlying issues, review of pertinent cases and research, and modeling of ethical decision-making.
Michael Jibson, M.D.
Associate Professor
University of Michigan Medical School

Residents and students must definitely be taught that there can often be conflict between companies which have a vested interest in selling their product, and physicians whose interests are what is best for a patient based on multiple considerations that go beyond newness, dosage and indications. Physicians prescribing behavior CAN be unduly influenced by drug companies marketing and financial influence. This can best be taught by example, by case discussion, chart review, CQI and grand rounds using an evidence-based focus. Patrick A. Tranmer, M.D., MPH
Associate Professor, Clinical Family Medicine
University of Illinois College of Medicine

Ethical decisions are omnipresent in medical practice, and inextricably linked to medical reasoning. Research has shown that moral reasoning of medical students defers from gender/age matched controls. Top-to-bottom and one-size-fits-all recommendations regarding interactions between medical trainees and the pharmaceutical companies do not address a more fundamental problem in medical education. Understanding and changing the causes of this stagnation of medical students’ moral development would balance individual responsibility with group guidelines regulating pharmaceutical companies-medical trainees interactions. Andres Sciolla, M.D.
Chief resident
Department of Psychiatry
University of California, San Diego

There is no consensus on what would be “appropriate interaction” with pharmaceutical companies. When I was a medical student, my interaction constituted accepting a gift doctor’s bag to hold my medical instruments, and that was about it. More recently, pharmaceutical companies began giving out drug samples regularly once a week. I interact with others that support clinical conferences by paying for food and giving out literature and pens (they still do). I would like to receive money for research expenses from pharmaceutical (or equipment) makers.

I am aware of the risk of prescriptions dominated by agents one has been given or told about by pharmaceutical representatives. I am aware of the conflicts of interest that arise when doing clinical trials supported by drug dollars. Are these interactions risky or inappropriate? It depends on how much of a purist you are. I think it is premature to have a “system” to educate residents and medical students on this matter, and that defining “appropriate” would backfire as standards evolve. Just keep today’s students as aware of the risks of being courted by pharmaceutical manufacturers as I was in my training. In other words, disclosure rather than foreclosure. Paul J. Friedman, M.D.
Professor of Radiology
UCSD School of Medicine

There should be a small curriculum on this subject. Ample evidence suggests that the pharmaceutical reps are effective. Techniques include reliance on surrogate markers to demonstrate a drugs efficacy and on statistics such a relative risk reduction to amplify the apparent effect of the drug. Persuasion techniques such as offering gifts, however small, have also been shown to be effective. In my opinion, identifying the ways that pharmaceutical reps interact with the profession may be a useful curriculum addition.
Gary Ferenchick, M.D., MS
Associate Professor of Internal Medicine
Michigan State University

The role of pharmaceutical companies in our profession is profound and requires discussion and training. The interplay of our obligations as faculty with the pharmaceutical business is apparent in a number of places. Take a look at some of the new ACGME general competencies, for instance:

Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Residents are expected to: demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development

Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. Residents are expected to: understand how their patient care and other professional practices affect other health care professionals, the health care organization, and the larger society and how these elements of the system affect their own practice know how types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources practice cost-effective health care and resource allocation that does not compromise quality of care advocate for quality patient care and assist patients in dealing with system complexities know how to partner with health care managers and health care providers to assess, coordinate, and improve health care and know how these activities can affect system performance.

These competencies seem, to me at least, to require that we provide training in the role of pharmaceutical reps in influencing prescribing patterns, the ethical issues that these efforts present, and the requirement that physicians consider the long-term well-being of their patients before accepting pharmaceutical gifts or sponsorship. While physicians are not prohibited from accepting gifts from vendors, we do need to be ensure we understand the obligations we incur. Few of us can achieve that sensitivity without training.
Lloyd Michener, M.D.
Clinical Professor and Chair
Department of Community and Family Medicine
Duke University Medical Center

Unless there is outcome data to show otherwise, I recommend not decreasing curriculum time in other areas to provide curriculum time for this. Good doctors need good medical training to effectively deal with many different potential influences. We must avoid the temptation to change the curriculum, because it sounds good. Let’s practice evidence-based education as well as evidence-based medicine.
Randall C. Cork, M.D., Ph.D.
Chair, Department of Anesthesiology
Louisiana State University Health Sciences Center

The location of such education could be placed within the educational unit of ethics for all impacted groups, e.g., medical students, residents and attendings. The content of the material is still evolving. Discussion would need to include such questions as: How is funding by a pharmaceutical company different from funding by other sources? Is receiving money “bad” per se? How much of a person’s individual loyalty and sense of what ought to be, can be “bought”? Ruth L. Fuller, M.D.
Associate Professor, Psychiatry
University of Colorado Health Sciences Center

Absolutely. Decisions about medication choices for patients must be made upon the scientific literature. Despite ample evidence that pharmaceutical marketing practices influence prescribing practices of physicians, there exists a wide variation in beliefs and behaviors about these interactions. There also appears to be a negative correlation between residents’ sensitivity to general ethical issues and their willingness to accept gifts from pharmaceutical representatives. Education, not restrictive policy, is the best strategy to promote an appropriate relationship between students/housestaff and the pharmaceutical industry. The system should be an evidence-based review of what the practices are, where the potential conflicts of interest are, and examples of best practices used in medical schools and residencies.
Sam Keim, M.D.
Residency Director, Emergency Medicine
University of Arizona College of Medicine

Medical student education on pharmaceutical industry interactions must begin early in their medical school experience. We know that even casual interactions (free lunches) with pharmaceutical representatives result in an increase in prescriptions of expensive new drugs. Our students are trained in critical appraisal of the medical literature from the first year. Anecdotal reports from practices demonstrate that our students can challenge statements of drug representatives that are based upon poor evidence.
Dan Mayer, M.D.

Drug companies know that the habits that medical students and residents form early in their careers carry forward to when they are in independent practice. One of the habits that the companies want to encourage is frequent contacts between industry and physicians. That is why there are a plethora of drug lunches and gifts directed at these groups. The companies don’t care if students and residents cannot remember who sponsored the lunches as long as that “gift relationship” is established. Ideally students and residents should “just say no” but most will not and therefore there needs to be a system in place to educate these groups about how companies influence prescribing and how to recognize the techniques that companies use. Joel Lexchin M.D.
Associate Professor
Department of Family and Community Medicine
University of Toronto

I agree with this. The problem is how do we regulate faculty members who give all of the drug dinner talks. We have significantly reduced the drug lunch talks that happen at the hospital, but the drug reps have realized that the drug dinners are much better. They don’t need to abide by any of the department’s restrictions at these events. Residents are happy to go to a free dinner at a nice restaurant and hear a talk by one of their favorite attendings. Even more discouraging is the powerful message that residents take home.: “Since the faculty doesn’t believe that drug reps affect their behavior, why should I believe it affects mine.” Has anyone found a way to regulate faculty behavior?
David Neely, M.D.
Director, Undergraduate Education
Department of Medicine
Northwestern University

We must have education in place for all medical students. Such a curriculum, which ideally would be integrated across the four years of training, should include (in order of priority): 1) ethical issues, such as conflict-of-interest issues that arise when the interests of a patient and a particular drug manufacturer may be at cross purposes; the physician’s fiduciary duty always to act primarily in the best interests of the patient must be taught and reinforced across all years of education; 2) the importance of always selecting the least costly and safest medication alternative, which is most often not the most recently released agent on the market; 3) the ethical admonition to the physician to engage in lifelong learning and to “make relevant information available to patients, colleagues, and the public” (Section 5, AMA Ethics Principles) must be illuminated for students in terms of the risk of biased learning should physicians rely too heavily on information from pharmaceutical cos. and their reps; 4) the extremely high profit rates of drug manufacturers, along with the long history of same, needs to be presented, along with information about how nothing that appears to come “free” from a drug company is truly “free”—the cost is ultimately borne by patients and third parties (and, therefore, all of us), and such “freebies” are always encumbered—perhaps the more so precisely when we think that they aren’t — with potential influences upon the clinical behavior of the physician (not just which drug is selected, but the fact that any drug is selected over some non-pharmaceutical alternative, for example); and 5) the potential for governmental control of drug manufacturer’s prices and profit rates (i.e., regulation).
Gregg E. Gorton, M.D.
Assistant Professor of Psychiatry
Jefferson Medical College

Any human interaction is subject to unconscious reactions and associations. The pharmaceutical companies have a primary goal: to market the product, but also a secondary goal of providing education, and a questionable tertiary “goal” of giving out stuff for free. An ethically-centered orientation of the residents or medical students would help them set up their own goals, and to avoid unconscious associations that would make the prescribing process a less objective one.
Dinu Gangure

We have come to regard this topic as so important that we expanded our ethics teaching to include it. I think there needs to be two components to any teaching on this: (1) data on the impact of drug company gifts on physician prescribing practices, since trainees need the science of this; and (2) case studies that help residents wrestle with the issues.
Paul C. Mohl, M.D.
Professor and Residency Training Director
University of Texas Southwestern Medical Center

I think such education would be very helpful to medical trainees. It should put these companies marketing efforts in context: how much money is at stake, what their options are (i.e., what they can and cannot say or do), and what they hope to accomplish. Pharmaceutical representatives often encourage physicians and trainees to think of their companies as benevolent “foundations,” and they are anything but. This must be made clear early in medical education.
Thomas A.M. Kramer, M.D.
Senior Vice President
American Board of Psychiatry and Neurology Inc.

Use of medications is central to the practice of medicine. Therefore, residents and medical students must be instructed throughout their training about the respective roles of the physician and pharmaceutical companies and their appropriate interactions. This should include an understanding of the value of pharmaceutical research; the regulatory, scientific and business aspects of new drug development; rational therapeutics; and the ethical issues around the potential for conflicts of interest and inappropriate marketing influences on clinical decision-making.
Scott A. Waldman, M.D., Ph.D.
President
American Society for Clinical Pharmacology and Therapeutics

I strongly believe that education regarding pharmaceutical industry-physician interactions needs to be a part of medical student and residency training. The literature on this interaction uniformly demonstrates the following:

1. Physician prescribing is indeed influenced by industry advertising through detailing, ads, drug lunches, sponsored CME, gifting, etc. despite the fact that most physicians, especially trainees, believe they are not influenced.

2. Industry sources of information are biased and inaccurate, and damage to patient care is done through over-prescribing of inappropriate and expensive medications, as well as the enormous costs of such marketing.

3. Studies also show that patients, when informed of these relationships, disapprove of such interactions, correctly perceiving that they influence physician prescribing practices and increase health care costs.

Trainees have been shown to be particularly vulnerable to influence when unchallenged the habit of frequent industry interactions persist into their professional careers.

Information and discussion about the industry, marketing techniques, rational selection of pharmaceutical agents, and ethics must be integrated into the four years of medical school, and followed up in residency training. Lectures, group discussions, role plays, and interaction with faculty who deal thoughtfully with these issues would all be appropriate. A number of educators throughout the U.S. and elsewhere have developed curricular material in these areas and would be happy to share them.
Amy Brodkey, M.D.
Clinical Associate Professor of Psychiatry
University of Pennsylvania School of Medicine

A better question is: “Why are there not systems in place to educate residents and medical students?” At my school I have given several presentations this year on the influence of the pharmaceutical industry on medical education. I presented the research that has been done to demonstrate the effects that the pharmaceutical representatives, gifts, samples, and advertising have on the prescribing practices of physicians and the attitudes of medical students. And the evidence is quite compelling. Not surprisingly, the vast majority of the staff, residents, and students who have attended acknowledged no previous formal education or discussion on the topic. I have also received significant feedback from participants who noted that they were not aware of any influence, since interactions with pharmaceutical companies are so ingrained in medical education, that they never even thought to question the propriety of the interactions.

I believe formal education should begin in the first year of medical school with recognition of the topic; a “refresher” should be given immediately prior to the start of clinical rotations in the third year; and, finally, a discussion during orientation to residency should be included. Ideally, institutional policies should be in place which deny pharmaceutical companies access to medical students. Access to residents should be limited. In both cases, exchange of food, books, gifts, pens, trinkets, etc should be prohibited. Not only does the literature clearly support such measures, but our patients deserve immediate intervention.

The pharmaceutical companies are engaged in practices which increase their profits, as any good business should be doing. However, we should not allow our medical students and residents to be used, unwittingly or otherwise, to enhance the pharmaceutical industries bottom line, to the detriment of our patients. Until we recognize that we have a problem, we cannot engage the solution. Christopher F. Young
Tulane University Medical School
Class of 2002

Today, I had my last seminar with a group of graduating PGY-4 residents in psychiatry. They were fresh from a drug company sponsored graduation cruise. The seminar table and room were littered with drug company paraphernalia, “educational materials” and gifts. They all believe that this largesse has no effect upon them. They believe that they are getting something for nothing. The departmental grand rounds, the trips to drug company-sponsored professional meetings, and the medical student awards in psychiatry are sponsored by drug companies. Those departmental faculty and administrators who are responsible for these decisions also believe this largesse has no effect on them.

I think that educational efforts regarding interactions with drug company representatives would be misplaced with trainees. They are simply doing what they are taught to do. Your efforts to stimulate a discussion should begin with the programs chairs, training directors, heads of “professional” organizations, hospital directors, and relevant government officials who are put in the position of substituting drug company commercials for training at all levels of an abandoned and often corrupted system of medical education in general and psychiatry in particular.
Phillip S. Freeman, M.D.
Former Vice Chair for Medical Student Education
Department of Psychiatry
Assistant Professor of Psychiatry
Boston University

No, let us figure it out on our own. I am learning how to deal with drug companies and the reps by observing other current doctors. Some things they do I like, others I will not do when I am in their position. We as medical students have a enough to learn now. We can figure other non-school related things out by ourselves (hopefully).
Nancy Delanoche

We delude ourselves if we think that we are “good guys” and pharmaceutical companies are “bad guys.” The ethical issues here are urgent, complex and subtle, but the idea that anyone can write anything meaningful about this in 75 words or less is the problem, not the solution. In a secular, sound bite, bumper-sticker culture, there can be no true morality — merely reinforcing prejudice or thoughtless conformity to shifting fads and norms.
Michael Alan Schwartz, M.D.
Clinical Professor of Psychiatry
Case Western Reserve University
Founding President
Association for the Advancement of Philosophy and Psychiatry

I don’t know if you have any interest in the opinion of someone who just completed the first year of medical school, but I absolutely think that we need some education about the influences of pharmaceutical companies on prescription patterns of physicians and how attending conferences, lunches, etc., does, in fact, affect behaviors. We are barely exposed to these issues during first year, and I suspect that the education is not much better during the other years either.

I assume (or at least hope) that the earlier our awareness of these issues is heightened in our training, the better we will become at recognizing potential conflicts of interest with and inappropriate influences by the pharmaceutical industry on our beliefs and behaviors. Also, it seems that heightened awareness early in the training process, would help prevent the development of these long-term relationships that the industry seeks to establish.

I think that it would be easy to incorporate education on these issues within the curriculum on ethics/professional behavior (at Columbia — the course of “Clinical Practice”) with both lectures and small group discussions in which appropriate conduct for given scenarios could be debated.
E. Jennifer Edelman
Columbia University College of Physicians and Surgeons, Class of 2004

Pharmaceutical companies are blurring education and advertising as never before. They have stepped up their influence campaigns from pens and pizza for medical students to dinners and trips for practicing docs and their spouses. We must start reminding third-year students of Psychology 101 — i.e., by accepting drug company freebies, they are becoming willing subjects of Pavlovian conditioning procedures, with real, and not necessarily beneficial, effects on their future prescribing habits.
H. Jonathan Polan, M.D.
Associate Professor of Clinical Psychiatry and Director of Medical Student Education
Department of Psychiatry
Weill Medical College of Cornell University
President, Association of Directors of Medical Student Education in Psychiatry

Professionalism mandates that every institution and medical school have guidelines on interaction with industry. These guidelines should not only apply to residents and medical students but to faculty as well, for they set an example for us all. At a minimum, guidelines should address the issues of gifting, conflict of interest, and public perception of interaction. Ideally, the guidelines would be supported by training workshops designed to help participants understand marketing strategies and product promotion.
Devdutta Sangvai, M.D.
Chief Resident, Family Medicine
Medical College of Ohio

Shamiram Feinglass, M.D.
Robert Wood Johnson Clinical Scholar
University of Washington School of Medicine

The system that should be in place is faculty role models.
Eric Radin, M.D.
Tufts University

I have not seen it referenced with respect to this issue yet, but I think the answer to the first question and at least a partial response to the second were published in 1990:

“Medical students and residents should receive education on acceptable responses to offerings from the pharmaceutical industry. Relationships with representatives from the pharmaceutical industry from the pharmaceutical industry begin early in the medical career, often during the first year of medical school. Many students and physicians-in-training experience opportunities to receive, as gifts, instructional materials, medical equipment, or even ‘creature comfort’ amenities. Such offerings often raise ethical concerns among them.

Educational institutions and individual training programs should reinforce the sensitivities evoked at this time, or establish sensitivity if it is not evoked, by providing education as well as specific policy concerning acceptable and unacceptable practices. Faculty members should set examples for their students by conducting their own relationships with the pharmaceutical industry in a highly principled manner. One relevant strategy would be to notify drug companies of the scope and boundaries of activities judged to be suitable for a given campus.”
Rationale, Position 1, p. 625
ACP Position Paper:
Physicians and the Pharmaceutical Industry
Ann Intern Med 1990; 112: 624-6

As an aside, it would seem we are still discussing the mandate of the first sentence more than 10 years later because of the continued lack of adherence to the recommendations of the second paragraph.
Todd Hulgan, M.D.
Clinical Fellow, Infectious Diseases
Vanderbilt University