Dutifully wearing collared shirts, ties, and the short white coats meant to keep all medical students humble, Chen Kenyon and Dustin Petersen don't look like rebels. They look scrubbed and eager to learn from any doctor in a long white coat.
But in the pockets of their shorter garments lurk symbols of a movement aiming to topple one of medicine's most entrenched traditions. Their pens read "PharmFree," which means they don't take personal gifts of any size from the pharmaceutical industry. And that is touching off a quiet ethics war reverberating through the halls of academia and hospitals across the country.
Messrs. Kenyon and Petersen are among a growing band of stethoscope-wearing students who believe the medical profession needs more detachment from big pharmaceutical firms.
Consequently, they're turning down everything from free catered meals to notepads, provoking debates among fellow students and quizzical looks from doctors.
"People will often ask, 'why didn't you take the pen? Or, why didn't you eat the lunch?'," says Kenyon, a Boston University medical student who packs a sandwich, apple, and granola bar almost every day so he won't have to eat meals sponsored by drugmakers.
"It gives you the green light to talk about it when somebody asks," adds Petersen, who swears his home-cooked pot roast and clam chowder leftovers taste better than the catered meals he refuses each week.
Behind the modest rebellion is the belief that taking gifts from drug companies creates a conflict of interest for doctors. The argument: To accept handouts is to feel indebted, and doctors indebted to drug firms may not be prescribing medicines based solely on what's best for their patients. The 60,000-member American Medical Student Association (AMSA) urges students and doctors alike to just say "no" to all personal gifts from drugmakers.
Doctors on the whole seem far less worried about the practice. The American Medical Association condones gift-taking from pharmaceutical representatives as long as no single gift is worth much more than $100. And drug companies seem to be finding plenty of takers: spending on marketing to physicians jumped from $12.1 billion in 1999 to $22 billion in 2003 ($16 billion of which was in free samples), according to data from Pharmaceutical Research and Manufacturers of America (PhRMA).
Against this backdrop, students are still convinced their cause is worth fighting, even if it means giving up a hot meal every day. "I don't think patients can trust us anymore," says Kristin Rising, a medical student at the University of California, San Francisco. "By accepting gifts, we're taking in biases that are going to affect patient care."
Others feel the same way. For the first time this year, between 500 and 1,000 students at 150 medical schools are canvassing 40,000 physicians nationwide. Their aim is to steer them to independent sources of information about drugs.
This "counter-detailing initiative" takes AMSA's three-year-old PharmFree project out of medical schools and into the trenches of the profession, where students hope to pique the consciences of future colleagues.
Other phases of the movement have been more brazen. Last year, for instance, a brigade of students marched on Pfizer offices in New York and dumped thousands of logo- emblazoned pens, given to the students by the company as gifts and intended as advertisements in their hands, back on the firm's doorstep.
Activist students insist their beef is more with the medical profession, which, they say, has come to feel it's entitled to the giveaways, than it is with the drugmakers. Even PhRMA distances itself somewhat from the practice, saying its member firms honor AMA guidelines to keep gift-giving at modest levels. "Any physician can decline a gift at any time," says Dr. Paul T. Antony, PhRMA's chief medical officer.
Challenging medicine's status quo, however subtly, often comes at personal cost. Example: Last year in Philadelphia, Kenyon wanted to make a good first impression with his new supervisor on a medicine rotation. But after the firm handshake, things deteriorated as the attending physician suggested they grab lunch - at a seminar sponsored by a drug company.
"I told him, 'I don't eat pharmaceutical lunches,' " Kenyon recalls. "He was sort of, like, 'Oh.' And stopped it there. In some way, it doesn't really matter to me, but he is the person evaluating me in the end."
Kenyon's predicament illustrates the heart of this struggle: Those making the moral case against gift-taking hold junior status in a hierarchical and tradition-bound profession.
"While I think we're right, people don't always want to hear what we have to say," says Ms. Rising. "I'm not in a position to say, 'you, my supervisor, are wrong' " to accept giveaways.
With no real standing to make their case to higher-ups, students rely instead on the shock power that comes with saying "no thanks" when offered coveted freebies. Fellow students, they say, respond with a mixture of surprise, curiosity, ridicule - and lots of discussion.
Take the case of Chris McCoy. A 2004 graduate of Case Western Reserve University in Cleveland, Ohio, Mr. McCoy had earned a reputation as a stickler for ethics by complaining when fellow students proposed to get drug companies to sponsor the medical school's social events. After the proposal was defeated, students kept eating meals provided by drug firms, but discussion about the ethics of doing so lingered like garlic.
"They'd say, 'What would Chris think if he saw us eating the drug lunch?' " McCoy recalls.
Where tensions arise, activists say, is when a student sets a higher ethical standard than a supervisor. No words need be spoken for a supervisor in a buffet line to feel a bit snubbed when a student settles for a granola bar instead of "tainted" pharmaceutical food.
"In a lot of cases, people feel like you're pulling the moral high ground," Kenyon says.
Students who dream of higher ethical standards for medicine expect to pay higher personal prices as time goes by. As medical residents, they'll be among peers who feel they've "earned" drug-industry perks, says Bob Goodman, founder of "No Free Lunch," a physician group that urges colleagues to stop taking gifts from drugmakers.
What's more, residents with low salaries and high debt levels are famous for relying on drugmakers to keep them fed during long shifts. Residents say "once you see the reality of the way medicine is, you won't be so idealistic," says Yavar Moghimi, a George Washington University medical student. "I worry about that. [But] family members always congratulate me and tell me how important they think this is."