In this month’s issue of the Archives of Surgery, one of the Journal of the American Medical Association’s (JAMA)/Archives journals, a study was published regarding “Physician Attitudes Toward Industry: A View Across the Specialties.” The study claims to be the first to assess attitudes of faculty and trainee physicians toward directed marketing activities of the pharmaceutical and device industries across specialties and levels of training and to describe attitudes toward the device industry in particular.
The objective of the study, which was done by Deborah Korenstein, MD; Salomeh Keyhani, MD, MPH; and Joseph S. Ross, MD, MHS, was to explore attitudes of physicians from all specialties toward gifts from and interactions with the pharmaceutical and medical device industries. Consequently, data was collected between June 1 and September 1, 2008 from faculty and trainee physicians from all clinical departments in hospitals in the Mount Sinai School of Medicine consortium in the New York, New York, metropolitan area. A total of 590 physicians and medical students completed the survey from 11 local affiliated hospitals, of which 8 had residency training programs.
It was noted that the school has a policy that bans or limits marketing-related interactions between physicians and industry and that applies to faculty and trainees at all affiliated hospitals.
In citing previous studies, the authors found similar findings “that physicians hold generally positive attitudes toward these interactions with industry.” Specifically, the study found that “most physicians favored the use of samples and industry-sponsored lunches, educational materials, and funding for education.” In addition, “many participants found large gifts unacceptable and, like participants in previous surveys, believed that other physicians were more likely to be influenced by gifts and food from industry than they were.”
These positive results demonstrate that relationships with industry, which “nearly all physicians maintain,” are important and valued by doctors. The belief that such relationships need greater awareness because of their prevalence and potential for conflict of interest is accordingly misplaced, especially since numerous recommendations from individuals, organizations and companies to improve transparency and independent regulation already exist. While the authors believe that “the effectiveness of these policies is uncertain,” their results clearly show that whatever potential risk there may be, the benefits of such relationships for physicians far outweigh them.
Findings
To determine exactly why physicians have such positive attitudes toward industry, participants were asked to fill out a survey containing demographic questions, questions about attitudes toward types of pharmaceutical or device marketing, and questions about the appropriateness of receiving types of gifts from the pharmaceutical or device industries. Their responses—attitude and appropriateness—were scored on different 4-point Likert scales. Participants were asked to rate their attitudes toward pharmaceutical marketing as “strongly agree,” “agree,” “disagree,” or “strongly disagree” and to rate the appropriateness of interactions as “very appropriate,” “appropriate,” “inappropriate,” or “very inappropriate.”
Of those participants responding, 54.2% were familiar with their institution’s policy on industry interactions, and 24.6% had collaborated with industry.
Accordingly, “attitudes toward industry and “gifts” were generally positive: 72.2% found sponsored lunches appropriate, whereas 25.4% considered large gifts appropriate. Surgeons, trainees, and those unfamiliar with institutional policies on industry interactions held more positive attitudes than others and were more likely to deem some gifts appropriate, including industry funding of residency programs and, among surgeons, receiving meals, travel expenses, and payments for attending lectures. Non-attending physicians held more positive attitudes toward receiving meals in clinical settings, textbooks, and samples.”
Participants had overall positive attitudes toward marketing-related interactions with the pharmaceutical or device industries, with most agreeing that industry educational materials and industry funding of education are useful, although 68.0% perceived bias in sponsored lectures. Most believed it was acceptable to receive gifts and lunches, and few thought that industry representatives should be banned from meeting with physicians.
Overall, respondents believed that small gifts related to clinical practice, such as modest meals 72.2% and textbooks 83.2%, were appropriate.
Physicians from surgical specialties held generally more positive attitudes toward industry, for example they were more likely to approve of industry funding of residency, and fewer believed that trainees, and attending physicians should be prohibited from interacting with industry representatives when compared with all other physician specialties. Similarly, surgeons were more likely overall to rate gifts from industry, such as meals, travel expenses, and payments for attending lectures as appropriate.
Pediatricians held slightly less favorable attitudes toward industry, for example fewer pediatricians approved of industry funding of residency programs when compared with all other physician specialties, and they were less likely to rate some gifts, such as dinners with no educational component and industry reimbursement of travel expenses, as appropriate.
Non-attending physicians held more positive attitudes toward gifts and lunches and were less likely to support a prohibition on trainee interactions with industry representatives compared with attending physicians. Similarly, trainees were more likely to approve of a variety of industry gifts, such as meals in clinical settings, textbooks, and samples, although they were more likely to perceive bias in sponsored lectures.
Physicians who were familiar with guidelines were less likely to agree that samples improve patient care when compared with those who were not familiar. In general, guideline familiar physicians gave lower appropriateness ratings to some meals, textbooks, samples, and payments for attending lectures. Attending physicians and those who were aware of relevant institutional policies had less positive attitudes toward industry, particularly with regard to samples, meals, and interactions with industry representatives.
In responding to whether a participant’s institution should prohibit attending physician interactions with pharmaceutical and device company representatives only:
– 28.2% of family, internal or general medicine agreed;
– 26.3% of internal medicine subspecialty agreed;
– 25.9% pediatrics agreed;
– 10.9% of surgery and OBGYN agreed; and
– 39.6% psychiatry agreed
In responding to whether a participant’s device use is NOT influenced by device company marketing:
– 71.5% of family, internal or general medicine agreed;
– 71.7% of internal medicine subspecialty agreed;
– 84.6% pediatrics agreed;
– 74.8% of surgery and OBGYN agreed; and
– 82.4% of psychiatry agreed
In responding to whether a participants prescribing is NOT influenced by pharmaceutical company marketing:
– 70.0% of family, internal or general medicine agreed;
– 70.7 internal medicine subspecialty agreed;
– 85.2% pediatrics agreed;
– 71.7% surgery and OBGYN agreed; and
– 75.5 psychiatry agreed
In responding to whether receiving gifts or food affects prescribing, only
– 38.5% of family, internal or general medicine agreed;
– 38.6% of internal medicine subspecialty agreed;
– 34.6% pediatrics agreed;
– 36.2% surgery and OBGYN agreed; and
– 34.0% psychiatry agreed
In responding to whether samples improve care for their patients:
– 59.1% of family, internal or general medicine agreed;
– 53.6% internal medicine subspecialty agreed;
– 45.3% pediatrics agreed;
– 68.5% surgery and OBGYN agreed; and
– 60.8% psychiatry agreed
In responding to whether pharmaceutical company/device company materials are useful for learning about new drugs:
– 60.9%/73.4% of family, internal or general medicine agreed;
– 64.9%/72.4% internal medicine subspecialty agreed;
– 66.7%/73.6% pediatrics agreed;
– 68.0%/89.7% surgery and OBGYN agreed; and
– 60.4%/63.5% psychiatry agreed
In responding to whether pharmaceutical and device company funds are useful for funding medical school/residency programs:
– 66.1%/53.1% of family, internal or general medicine agreed;
– 66.1%/54.4% internal medicine subspecialty agreed;
– 59.3%/47.2% pediatrics agreed;
– 82.8%/75.8% surgery and OBGYN agreed; and
– 66.0%/55.8% psychiatry agreed
In responding to whether sponsored grand rounds are instructive and educational:
– 82.7% of family, internal or general medicine agreed;
– 85.7% internal medicine subspecialty agreed;
– 79.3% pediatrics agreed;
– 82.7% surgery and OBGYN agreed; and
– 72.6% psychiatry agreed
With regards to samples, participants responded that samples for professional use were very appropriate or appropriate for:
– 77.5% of family, internal or general medicine;
– 74.6% internal medicine subspecialty;
– 69.8% pediatrics;
– 89.1% surgery and OBGYN; and
– 82.7% psychiatry
With regards to donated textbooks, participants responded that textbooks were very appropriate or appropriate for:
– 78.1% family, internal or general medicine;
– 80.4% internal medicine subspecialty;
– 73.6% pediatrics;
– 89.1% surgery and OBGYN; and
– 88.5% psychiatry
With regards to dinner at a modest restaurant where educational component is provided by pharmaceutical or device company representatives, participants said it was very appropriate or appropriate for:
– 55.8% family, internal or general medicine;
– 50.9% internal medicine subspecialty;
– 58.5% pediatrics;
– 78.9% surgery and OBGYN; and
– 57.7% psychiatry
With regards to Dinner at a modest restaurant where educational component is provided by a physician (pharmaceutical or device company representatives present) participants said it was very appropriate or appropriate for:
– 65.6% family, internal or general medicine;
– 71.4% internal medicine subspecialty;
– 64.2% pediatrics;
– 84.4% surgery and OBGYN; and
– 61.5% psychiatry
For a Meal in a clinical setting, participants said it was very appropriate or appropriate for:
– 71.9% of family, internal or general medicine;
– 57.1% of internal medicine subspecialty;
– 62.3% of pediatrics;
– 83.3% of surgery and OBGYN; and
– 63.5% of psychiatry
Discussion
Although some may feel that relationships of surgical specialists with representatives from the device industry may be more complex than relationships of medical specialists with the pharmaceutical industry, these results unquestionably show that physicians find such partnerships positive and important for ongoing education. And because limitations of the study were that some participants were voluntary physicians or they may have oversampled more academically oriented physicians who may be more aware of the influence of industry, the study may have been more biased toward more negative attitudes. In other words, it’s likely that attitudes were even more positive for industry.
While physicians can readily access independent information about drugs through journal articles and studies, “surgical specialists rely on industry representatives for information about new devices and the training to use them, with industry representatives present even in the operating room.” Critics who believe that these kinds of relationships “blur the line between scientific collaboration and marketing and make it more difficult for surgical specialists to adopt restrictive guidelines for interactions,” are mistaken. Such access is critical for the continued progress in medical devices and treatments of patients.
Consequently, because the authors of this study set out to prove the negative impact of industry’s influence, and instead found the exact opposite—that “physicians continue to hold positive attitudes toward marketing-oriented activities of the pharmaceutical and device industries”—the authors attempt to shift the debate even in the face of conflicting data. By trying to suggest that “favorable physician attitudes toward industry suggests that individual physicians may be out of synch with trends among medical schools and public opinion and even industry itself,” completely ignores the data itself—physicians have positive attitudes toward industry. What is out of synch about that?
Their results overwhelmingly show that “changes in medical culture and physician education focused on surgeons and trainees” are not needed to align physician attitudes with current policy trends (e.g. less interaction with industry). To the contrary, this study shows that recent trends in policies regarding interactions with industry must be curtailed and changed since the results of this study show precisely how important they are to physicians and their training.
Accordingly, in attempting to bring negative attention to such relationships, the authors claim that “there is widespread public concern that financial relationships between physicians and industry lead to conflicts of interest.” Such a claim is unsubstantiated considering the authors acknowledge that “evidence of physician-industry marketing relationships resulting in patient harm is inconclusive.”
As a result, the studies own recognition that the results were remarkably similar to other studies of physician attitudes toward industry from as early as 2001 should come as no surprise. The value and impact industry-physician relationships has had in the past decade has only grown and led to better patient outcomes, stronger training for physicians, and greater innovation in medicine, which is why physicians continue to strongly believe such partnerships are positive.
The results are also similar to a study in the Journal of General Internal Medicine entitled “Prescribers and Pharmaceutical Representatives: Why Are We Still Meeting?,” in which the authors determined that “most prescribers participating in our focus groups believe that overall pharmaceutical representative (PRs) interactions are beneficial to patient care and practice health, and that they either trust the information from PRs or feel that they are equipped to evaluate it independently.” The study also found that prescribers “are able to effectively manage PR interactions such that their own prescribing is not adversely impacted.” As a result, the study offered a parallel conclusion that “providers from several health professions continue to believe that PR interactions improve patient care, and that they can adequately evaluate and filter information presented to them by PRs.”
Conclusion
Ultimately, to impede such collaboration in surgery, or any medical practice, “would surely hinder progress and patient care.” Surgeons and physicians require such partnerships with industry to develop teams that can explain how such devices or treatments work, what did not work, and what is needed to improve safety. Without such relationships, numerous advances (e.g. advanced laparoscopy) would still be in its infancy.
Clearly then, physician attitudes are in fact aligned with those of the public because patients are living longer and healthier lives, physicians are receiving better training and information, and medicine is continuing to advance. These results show that by working with industry, physicians are being viewed as part of the solution, and as such, “physicians must make it known that collaboration is in the best interests of the public.”