The relationship between health professionals and the pharmaceutical industry has become a source of controversy and a major topic of concern for health services researchers and policymakers, as well as in the lay media. Physicians’ attitudes towards industry can form early in their careers, but authors of a recent article published in PLoS noted that, “little is known about this key stage of development.”
The authors noted that, “while opinions about such relationships vary, physicians have a high level of exposure to industry marketing in a variety of forms,” which they claim affects clinical decision-making.
For example, the authors noted that, “industry involvement in medical education occurs on multiple levels, including one-on-one meetings between trainees and pharmaceutical sales representatives (PSRs) and sponsored publications and educational events (such as Continuing Medical Education (CME) courses).”
The authors also noted that, “because pharmaceutical companies recognize the potential for education to be used as a marketing tool, there is concern that such exposure may communicate a biased message encouraging overuse of particular products.”
Despite this claim, a 2003 NEJM study commissioned by the RAND Corporation found that four times more Americans do not get (enough of) the medicines they need than
those who get too much or the wrong medicine. Even if aggressive industry marketing practices are responsible for 100% of excessive drug use, the problem of insufficiency is four times as large. In this case, the question of appropriate access to medically indicated medications based on evidence-based recommendations has been grossly perverted.
In addition, the references the authors cite related to overdosing—one about irresponsible Neurotonin marketing practices and the other about inaccurate sales information from drug reps—do not support their claim of patient over-medication, only an alleged predisposition by sales people to vigorously market their products and often with minimal discussion about alternatives. However, FDA strictly limits claims sales people can make about their products, including indications and contraindications.
Nevertheless, the authors claimed that, “interactions with PSRs can increase prescriptions of the drug being promoted and shift prescribing in ways that may not be consistent with evidence-based guidelines.” This can have the effect of physicians using “expensive treatments without therapeutic advantage over less costly alternatives.” The authors also asserted that, “industry sponsored education may also influence physicians’ ability to weigh the risk-benefit profiles of new, heavily promoted drugs.”
They pointed to the case of rofecoxib (Vioxx) as an example, where the pharmaceutical manufacturer–sponsored educational materials downplayed the drug’s cardiac risks (a nearly 2-fold increased risk of heart attack and stroke).
The authors propose that one reason why pharmaceutical industry marketing has an effect on physicians is that their attitudes towards industry and their propensity to be influenced by its marketing form very early in their careers. They assert that, “the socialization effect of professional schooling is strong, and plays a lasting role in shaping students’ views and behaviors.”
As a result, the authors note that, “encouraging more rational prescribing among practicing physicians may require a better understanding of how medical students interact with the pharmaceutical industry.”
Consequently, medical schools have already instituted guidelines for speaking and consulting relationships and mandated faculty disclosure of potential conflicts of interest on a public website. Many have argued however, that these restrictions are detrimental to students’ education and the future of biomedical research.
Study
To address the “controversy over the pharmaceutical industry’s role in undergraduate medical training,” the authors systematically examined the peer-reviewed literature through May 2010 to collect empirical data quantifying medical students’ exposure to and perspectives on pharmaceutical marketing practices, including relationships with industry and their behaviors related to prescribing and attitudes about important drug policy topics. Studies were separated, where possible, into those that addressed preclinical versus clinical training, and were quality rated using a standard methodology.
The authors used PRISMA guidelines to determine the frequency and nature of medical students’ exposure to the drug industry, as well as students’ attitudes concerning pharmaceutical policy issues. They searched MEDLINE, EMBASE, Web of Science, and ERIC, as well as bibliographies of selected studies. Specifically, the authors examined:
- The extent of pharmaceutical industry interactions with medical students,
- Whether such interactions influenced students’ views on related topics, and
- Whether any differences exist between students in their preclinical versus clinical years or in different learning environments in relation to these issues.
Findings
Using thirty-two studies the authors found that 40%–100% of medical students reported interacting with the pharmaceutical industry. In addition, they found that:
A substantial proportion of students (13%–69%) were reported as believing that gifts from industry influence prescribing.
- Students were more approving of gifts to physicians or medical students than to government officials
- Clinical students (53%–71%) were more likely than preclinical students (29%–62%) to report that promotional information helps educate about new drugs
The study also found that common types of interactions involved:
- Gifts
- Industry-sponsored educational sessions, and
- Direct communications with sales representatives
The authors found that 89%–98% of students in the clinical years reported having accepted a lunch or snack provided by the pharmaceutical industry and many of these students approved of meals, small promotional items, and gifts with an educational purpose, but were less accepting of social events and travel.
In addition, up to 90% of surveyed students in their clinical years had received educational materials such as textbooks or journal reprints from industry. Overall, the authors noted that contact with the pharmaceutical industry increased over the course of medical school.
When asked about the appropriateness of accepting gifts from industry overall, the majority of students in their clinical training years found it ethically permissible for medical students to accept gifts from drug manufacturers, while a smaller percentage (28%–48%) of preclinical students reported such attitudes. This same trend was seen in student opinion regarding whether physicians should accept gifts.
One of the most consistently held student attitudes was the belief that education from industry sources is biased, especially among clinical students (67%–92%). Despite this, students variably reported (22%–89%) that information obtained from industry sources was useful and a valuable part of their education, with clinical students more frequently endorsing the utility.
In most studies, almost two-thirds of students reported that they were immune to bias induced by promotion, gifts, or interactions with sales representatives in general. This perception of immunity to bias was prevalent in both the preclinical and clinical years. It appeared that students were more likely to report that fellow medical students (38%–69%) or doctors (13%–71%) are influenced by such encounters than they were personally (24%–63%).
Students who interacted with PSRs were more likely than those who did not meet with PSRs to report positive perceptions of industry marketing and were less likely to perceive this marketing as negative.
The authors also noted that students generally did not support excluding sales representatives or industry presentations from the learning environment, and student opinions were split on whether physician–industry interactions should be regulated by medical schools or the government.
86% of American medical students reported that during their residencies they would like to interact with PSRs and 69%–77% of students across all studies endorsed faculty disclosure of conflicts of interest before lecturing. However, most medical students reported not feeling adequately educated on physician–industry interactions with 62%–86% requesting more instruction in this area
While 39% of clinical students reported being adequately educated on the topic, only 11% of preclinical students reported that the amount of instruction they received was sufficient. The pharmaceutical industry was identified as one source of information used by students to learn about therapeutics (16%– 49%).
Discussion
Based on these findings, the authors asserted that students “are frequently exposed to pharmaceutical marketing, even in the preclinical years when learning is mostly done in the classroom setting.” Additionally, they found that the extent of students’ contact “with industry is associated with positive attitudes about marketing and skepticism about any negative implications of these interactions.”
Consequently, the authors also noted that students’ opinions about the pharmaceutical industry differed between the preclinical and clinical years and with the presence “of policies restricting drug industry interactions with. For example, compared with preclinical students, those in their clinical years reported more educational value in industry-provided material and were more accepting of gifts from industry—both to themselves and to professional physicians.
The authors suggested that, “long hours spent working and studying and increasing financial hardship may have contributed to these feelings of entitlement.” However, we did not find anywhere in the survey that students felt “entitled” to gifts, only that they felt accepting gifts, under the circumstances described, was acceptable. Both the authors and editor introduce the inflammatory word ‘entitlement’ egregiously.
In addition, the authors noted that one possible explanation why student attitudes change over the course of medical education is that “industry representatives are effective in directly molding medical students’ attitudes about these issues.” They also suggested that the “characteristics of medical students’ learning environments shape attitudes about the pharmaceutical industry.”
It was also noted that, “shifts in attitude that occur during the course of training may be attributable to clinicians’ greater confidence in their ability to objectively evaluate scientific evidence and distinguish credible information from overstatements in marketing messages.
Conclusion
What is particularly problematic about this study, is that there does not appear to be any misconduct, or any harms caused by the students as a result of their interactions with sales reps. As far as we learn from the survey, the interactions are benign or potentially beneficial and there’s nothing to suggest from the surveys that the students are not already capable of properly evaluating medical evidence.
Moreover, the study’s conclusion suggests that because students were not more critical of PSRs during the survey, they must become more “professional” through censorship policies by their “more knowing mentors.” Such an idea is disturbing considering the survey shows no evidence that the students are disrespectful of scientific principles or possess unprofessional values.
Given that most student (22%–89%) believed that information obtained from industry sources was useful and a valuable part of their education, the results from this study show that industry’s relationship with students in all stages of medical education is valuable. Moreover, because students used industry as a source to learn about therapeutics, it seems clear that removing such interactions and relationships could have a detrimental affect on patients and medical training and education.
Additionally, with 86% of American medical students reporting that during their residencies they would like to interact with PSRs, prohibiting such contact could create more problems for these future physicians when they face PSRs in their own practice. Accordingly, future research on medical student interactions with industry, throughout various stages of medical education, should focus on the potential negative impact removing these relationships could have on patient care and physician training.
We should be encouraging medical schools and students to gather as much information from as many sources as possible so that students can be trained to learn how to objectively evaluate and differentiate truthful information from marketing. If we continue to limit medical education from students, our next generation of doctors will be ill equipped to treat patients and train future generations of physicians.