As a medical student, Anthony Fleg is at the center of the latest wave of rebellion against the pharmaceutical industry's cozy ties to doctors, hospitals and medical schools.

Fleg, in his fourth year of training at UNC-Chapel Hill, is national coordinator of the American Medical Student Association's effort to wean medical schools from their pervasive relationships with drug companies. And he's had quite a year.

Fleg helped AMSA's PharmFree campaign, established in 2002, produce the first scorecard to grade medical schools based on whether they have policies curbing the pharmaceutical industry's influence. The effort generated national press coverage. He also expanded PharmFree's national annual awareness day to an awareness week this fall, giving the issue its biggest splash to date.

In October, Fleg testified before the U.S. Senate, explaining why he believes physicians who accept lunches and even small gifts such as notepads and mugs from drug companies open the door to influence. In the end, he contends, the sacred doctor-patient relationship is compromised. Next month, Fleg will lead a PharmFree delegation to Washington, D.C., to lobby for changes that would require physicians to publicly disclose all industry gifts valued at more than $25.

The bill would strengthen existing guidelines for industry gifts developed in the early 1990s, when organized medicine responded to a backlash over lavish golf outings and other favors provided to doctors. Now PharmFree and other activist organizations such as No Free Lunch are out to limit or abolish the token gifts that have continued to be acceptable under the current standards.

Even prescription samples don't meet with Fleg's approval, though the future family doctor sets aside his rules if that ensures patients get the medicine they need.

"My patients come before my ethical concerns," says Fleg, 29. "But let's call samples what they are. They are promotional samples; they are not free. It's an ingenious way to ensure the patient goes home with a more expensive drug."

The pharmaceutical industry, led by its advocacy group Pharmaceutical Research and Manufacturers of America, contends free samples help patients, especially those who are poor or uninsured and may not otherwise be able to afford needed medicines.

Bound to his cause

Fleg's zeal for the cause is boundless.

He often wears his PharmFree T-shirt on campus, hoping to spark conversation. And he keeps alert to hospital clinics that overflow with drug company freebies. Fleg grins as he recalls a "covert operation" at a New Mexico hospital where he recently completed a family medicine rotation. He had a field day carefully plastering PharmFree stickers over the brand names of pharmaceutical products.

"That was some of my best work," he says.

Fleg's wife, Shannon Fleg, who is expecting the couple's first child this summer, jokes that her husband will probably be at her side in the delivery room with a tiny PharmFree sign for the baby to hold.

It would be easy for such a strident advocate to become a figure of controversy and strife. But colleagues and mentors say Fleg, who stands 6-foot-4 and towers over most people, tempers his principles with a genuine respect for others' opinions, even when they are at odds with his own.

He frequently uses humor to challenge the status quo and invite conversation. Fleg signs his e-mail messages with offbeat taglines such as, "Card-carrying member (with overdue fines), Chapel Hill Public Library," or "Intramural Debate Team Alternative (occasionally), Atholton High School." It's Fleg's way of getting a smile while poking fun at the self-important practice of following one's name with credentials and associations -- common among physicians.

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