A recent article published in The Archives of Internal Medicine examined the affect that pharmaceutical industry interactions have on the attitudes and behaviors of medical residents. It would seem however, that such attitudes and behaviors are minimally affected by such interactions because the American Medical Association, the Association of American Medical Colleges, the Accreditation Council for Graduate Medical Education and the American College of Physicians all have issued guidelines for appropriate relationships between physicians and the pharmaceutical industry.
Still, the authors of the study set out with the objectives to assess (1) the current attitudes of program directors regarding pharmaceutical industry support of internal medicine residency program activities, (2) the practices of internal medicine residency programs with regard to acceptance of industry support, and (3) potential associations between program characteristics and the acceptance of industry support.
The Study and Results
The authors sent an e-mail notification in November 2006 with a program-specific hyperlink to a Web-based questionnaire to each of the 381 member programs of the Association of Program Directors in Internal Medicine. E-mails were also sent in December 2006 and January 2007. The emails asked residency program directors whether their programs accept support of any kind from the pharmaceutical industry. (This is research?)
Those who responded yes were asked to identify specific forms of support, including food for conferences, educational materials, office supplies, drug samples, and unrestricted educational funds, as well as types of industry involvement, such as direct contact with residents (off-site and on-site). Program directors were also asked why the residency program accepts pharmaceutical support. Information regarding the residency programs (e.g. sponsor type, ownership of the hospital, etc.) and program director characteristics (e.g. rank, salary, etc.) were also gathered.
Responses were categorized into a group that thought industry support of residency was “never acceptable,” support was “not desirable and should not be accepted in any case,” “desirable and should be encouraged” or “not desirable, but acceptable when other sources not available.” 236 program directors (61.9%) responded to the survey with the following results:
– 55.9% reported accepting support from the pharmaceutical industry;
– 72.0% expressed the opinion that pharmaceutical support is not desirable;
– Residency programs were less likely to receive pharmaceutical support when the program director held the opinion that industry support was not acceptable;
– The New York Times noted that “69.7% of the directors who reported taking industry money was due to inadequate financing from other sources;
– Other reasons to accept support included popularity with residents (40.9%), important educational value other than financial support (28.0%), ease of attainment (26.5%); and being encouraged by the department chair or administration to accept the support (19.7%); 59.8% indicated more than 1 reason for accepting industry support;
– The most common forms of industry support included food for conferences (90.9%), educational materials (83.3%), office supplies (68.9%), and drug samples (57.6%);
– Among programs that accept industry support, many reported allowing direct off-site contact with residents (74.2%) and more than one-third reported direct on-site contact (40.2%); and
– 15.7% of all responding program directors reported acceptance of industry support because of its nonfinancial educational value.
To the surprise of the authors (although not ours), “153 programs (64.8%) had established formal written guidelines (which had doubled since 1990), and 29.2% had implemented a specific curriculum to educate residents on these interactions.”
Overall, the authors found that although support from “the pharmaceutical industry remains common among internal medicine residency programs, it has decreased substantially from 88.6% in 1990 to 55.9% of the current programs.
Discussion
Interestingly, in discussing their own findings the authors cite earlier studies, which showed that “the majority of residency program leadership indicated that the benefits of pharmaceutical company representatives outweighed any negative results.” So what exactly has changed since these earlier studies? Since the AMA, AAMC, ACP, and ACGME all have implemented policies to maintain industry interactions and 65% of programs have guidelines and 30% have specific curriculum, it seems like the authors concerns are unnecessary.
The authors even go on to cite another study which showed that “residents often do not believe that their own actions are influenced by industry contact or gifts.” This kind of evidence seems to contradict any kind of belief that residency programs with industry funding are doing something “wrong,” especially as the authors also acknowledge that “residency programs have sought to address this potential conflict of interest through the development of curricula and guidelines that outline appropriate residency industry interactions.”
Another piece of evidence that the authors downplay is the fact that two-thirds of the 55.9% of program directors who accept industry funding do so because of inadequate funding from other sources. As a result, the authors should have recommended that further study is needed to determine where such funding would come from if industry interactions with residencies are eliminated, and the impact it would have on medical training and patients.
The fact that industry support is a “readily available funding source for specific activities” is reassuring for many doctors who have huge debts to pay and need the training, as well as academic medical centers and hospitals who need the support. In fact, the authors showed that “the most commonly cited use of industry funding was for provision of food at conferences or educational activities, a strategy that has been shown to boost conference attendance.” If industry funding gets more residents to participate and learn about how to treat patients, aren’t we all winning?
Conclusion
We agree with the authors that residency “program leadership may have the best opportunity to further define appropriate industry residency interactions.” In order to use this leadership, programs must recognize that the quick availability of industry funding when other sources are non-existent will almost certainly make the difference in hundreds of patients of lives someday very soon.
The limitations of this study are concerning because the authors noted that “the degree to which programs rely on pharmaceutical funding for residency activities requires clarification.” The study also was not designed to “demonstrate a causal relationship” between industry funding and residencies. As a result, because the study acknowledged that “all of the underlying reasons are not yet fully elucidated” regarding industry interactions with residents, further research is indeed needed into the relationships between professionalism and training environments where pharmaceutical support is accepted.
Moreover, since policies “set boundaries for what the individual institutions believe are appropriate” for interactions with industry, it must be up to the programs, administration and directors to educate trainees who “are often unaware of the position of their own institution.” Educating residents—which is what they are there for in the first place—on interactions with industry is crucial, otherwise when they get into practice they will have no experience dealing with industry one way or another.