Exposure of medical students to pharmaceutical marketing in primary care settings: frequent and influential

Effect of pharmaceutical promotion and incentives offered by pharmaceutical companies on the prescribing pattern of medical students: a cross-sectional study from a developing nation Pakistan

Background

Pharmaceutical companies continuously pursue healthcare professionals, starting from the medical college level, which can ultimately lead to irrational prescribing of drugs and antibiotics. Therefore, our main aim was to evaluate the opinions and attitudes of medical students toward pharmaceutical promotion.

Methods

This study utilized a cross-sectional online survey that applied the snowball sampling technique. Data were collected from three public and three private sector medical colleges in Punjab, Pakistan using snowball sampling. A modified version of a pre-structured questionnaire was used to collect data between October 2020 and January 2021. Medical students from the third year onward were captivated. The tool was made available on Google Forms and students could access it by clicking the link shared. The effect of promotion on prescribing pattern and future prescribing of antibiotics were measured. Descriptive statistics, chi-square, and t-test were used to analyze the data.

Results

A total of 1,301 students filled out the survey, but only 1,227 responses were acceptable. The average age was found to be 23.4 ± 1.59 years. Slightly more than half of the respondents were male participants (57.7%), and a significant proportion (84.1%) reported being aware of pharmaceutical promotion. A smaller number (27.7%) felt that physicians who meet medical representatives more frequently tend to prescribe more antibiotics and 46.3% indicated they would be willing to prescribe antibiotics under the promotional influence. Medical students who were male, in senior college years, attended government institutions, and had lower parental income showed significantly higher perception and attitude scores (p < 0.05) which, in turn, may show their inclination to promotional activities. Many students agreed with the view that pharmaceutical promotion (PP) activities may alter prescribing practices and also believed that they contribute to the increased irrational prescribing of drugs and antibiotics.

Conclusion

The study revealed that only a small number of students are willing to engage in promotional activities and accept rewards, which influences their choice toward selection of drugs and antibiotics. This study highlighted the necessity of giving proper educational instructions regarding the promotion of drugs to medical students. This study also focused on the educational prerequisites of the students.

A follow-up study on the effects of an educational intervention against pharmaceutical promotion

Background

The promotion strategies of pharmaceutical companies create many problems including irrational prescribing, diminished trust in the patient-physician relationship and unnecessary increases in pharmaceutical costs. Educating prescribers is known to be one of the few potentially effective measures to counteract those impacts. However such educational programs are limited in the literature, and their effectiveness against the effects of hidden curriculum in the long term is unknown. This study aims to evaluate the effectiveness of an education program both in the short term and the long term after the students have been exposed to informal and hidden curriculum and various pharmaceutical promotion methods.

Methods

A longitudinal and controlled study was carried out in a school of medicine in Turkey where there are no restrictive policies for pharmaceutical promotion. A survey was applied to 123 students who attended the class throughout the terms of 2011–12, 2012–13, and 2013–14, evaluating the pre-educational status of students’ opinions of promotion and any post-educational changes. A follow-up study four years later asked those three cohorts to fill out the same survey to see the possible effects of the clinical environment and various promotion methods. Also, the opinions of all 518 sixth-year students who had not taken the class in those three terms were compared to the educated students.

Results

The program was significantly effective in the short term in changing students’ opinions and attitudes positively towards recognizing companies’ discourse and promotion strategies. But in the long term, the education lost its ability to convince students of the importance of not getting financial support for scientific activities from pharmaceutical companies (p:0.006) and carrying out research (p<0.001). In addition, although the educated students were more aware that trivial gifts could influence prescriptions compared to the uneducated 6th year students (p<0.001), the difference between them and the uneducated students generally becomes less significant when they encounter the clinical environment. The study also evaluated students highly-exposed to promotion; for this sub-group, the educated students kept their consciousness level about the influences of trivial gifts (p<0.001) while the uneducated students were confident that they were immune to the influence of trivial gifts.

Conclusions

The education program could be used for creating awareness of, increasing skepticism towards, and inculcating disapproval about pharmaceutical promotion practices. However, the effectiveness of the educational intervention is susceptible to erosion after exposure to the informal and hidden curriculum together with exposure to promotion. The impact of role-models, organizational culture, and institutional policies could be important aspects to be addressed for sustaining the effectiveness of such education programs.

Medical students' attitudes toward interactions with the pharmaceutical industry: a national survey in Japan

BACKGROUND

The relationship between students and the pharmaceutical industry has received substantial attention for decades. However, there have been few reports on this issue from East Asia. We aimed to investigate Japanese medical students' interactions with and attitudes toward the pharmaceutical industry, and to assess the correlation between exposures to a formal curriculum on drug promotion and perceptions of the appropriateness of the physician-industry relationship.

METHOD

We invited all 80 medical schools in Japan to participate. A cross-sectional anonymous survey was administered to medical students and school staff at the 40 schools that participated. The questionnaire for students assessed interactions with and attitudes toward the pharmaceutical industry. The questionnaire for school staff assessed the formal undergraduate curriculum.

RESULTS

Forty of the 80 medical schools in Japan participated. The response rate to the medical student survey was 74.1%, with 6771 evaluable responses. More than 98% of clinical students had previously accepted a small gift of stationery, a brochure, or lunch, and significantly higher percentages of clinical than preclinical students had accepted one or more gifts (P < .001). Among preclinical and clinical students, respectively, 62.7 and 71.9% believed it was appropriate to accept stationery, and 60.5 and 71.0% thought that attending an industry-sponsored lunch did not influence clinical practice. Of the 40 participating schools, 13 (33.0%) had a formal curriculum on drug promotion. A multivariate analysis showed an association between exposure to a formal curriculum and students' perceptions of the appropriateness of the physician-industry relationship only for gifts of stationery, which were perceived as inappropriate (OR: 0.81, 95% CI: 0.69-0.95, P = .02).

CONCLUSIONS

Most Japanese medical students interact with the pharmaceutical industry and believe that gift acceptance is appropriate and not influential. This study demonstrated a limited association between students' perceptions of gift appropriateness and exposure to a formal curriculum.

Exposure to the drug company marketing in Greece: Interactions and attitudes in a non-regulated environment for medical students

BACKGROUND

Medical students are targeted by the pharmaceutical industry and are exposed to their marketing strategies even in the preclinical years of study. The marketing strategies used by pharmaceutical companies with physicians are also applied to students, affecting their future prescribing behaviour, and include low-cost non-educational gifts, travel expenses and conferences registration fees. In Greece, there are no national or institutional regulations and guidelines concerning drug company-medical student interactions. This study is the first time this estimate has been made in Greece and assessed a) the interactions between pharmaceutical companies and medical students, and b) students' attitudes towards pharmaceutical marketing.

METHODS

A sampling of undergraduate medical students completed an anonymous, self-administered, web-based survey. The first part of the survey investigated the interaction between the students and pharmaceutical companies; the possible answers were the binomial variables 'yes' or 'no'. The second part assessed the students' opinions of pharmaceutical company marketing and the answer options were 'agree', 'don't know/don't answer' and 'disagree'.

RESULTS

The survey was completed by 412 undergraduate medical students (mean age 22 ± 2.2 years, 52.7% were women); the overall response rate was 58.9%. Although the majority did not consider accepting gifts and meals from drug companies as ethical, most of them (59%) had accepted meals and low-cost non-educational gifts, especially the clinical-level students. Further, 52,6% of the students did not believe that accepting gifts from pharmaceutical companies would affect their own prescription behaviour, whereas surprisingly they held the opposite opinion of their classmates. The vast majority (85.9%) agreed that sponsored lectures were biased in favour of a company's products; however, 47.6% agreed that promotional material is useful for learning about new medications and 34.5% believed that medical schools should allow drug company representatives to interact with students.

CONCLUSION

Our results suggest that medical students in Greece are notably exposed to pharmaceutical industry marketing and their conflicting answers demonstrate that they are inadequately prepared for this interaction. Interventions are needed so that students are prepared and able to manage these interactions critically.

Turkish Final Year Medical Students' Exposure to and Attitudes Concerning Drug Company Interactions: A Perspective from a Minimally Regulated Environment for Medical Students

Interactions between drug companies and medical students may affect evidence-based medical practice and patient safety. The aim of this study was to assess drug company-medical student interactions in a medical faculty where limited specific national or institutional regulations apply between drug companies and medical students. The objectives of the study were to determine the exposure and attitudes of final year medical students in terms of drug company-medical student and physician interactions, to identify factors affecting those attitudes and to provide data for policymakers working on the regulation of interactions between drug companies and medical students. This anonymous questionnaire-based study of 154 medical final year medical students at the Karadeniz Technical University Medical Faculty, Trabzon, Turkey, in April and May 2015 attracted a response rate of 92.2% (n/N, 154/164). Exposure to interaction with a pharmaceutical representative was reported by 90.3% (139/154) of students, and 68.8% (106/154) reported experiencing such interaction alongside a resident. In addition, 83.7% (128/153) of students reported an interaction during internship. Furthermore, 69.9% (107/153) of students agreed that interactions influence physicians' prescription preferences, while 33.1% (51/154) thought that a medical student should never accept a gift from a drug company and 24.7% (38/154) agreed with the proposition that "drug companies should not hold activities in medical faculties". Students with rational prescription training expressed greater agreement with the statement "I am skeptical concerning the information provided by drug companies during interactions" than those who had not received such training, and this finding was supported by logistic regression [O.R.(C.I), p -3.7(1.2-11.5), p = 0.022]. Acceptance of advertisement brochures was found to significantly reduce the level of agreement with the proposition that "A physician should not accept any gift from a drug company." (0.3[0.1-0.9], p = 0.030). In summary, exposure to drug companies was widespread among our final year medical students who, like students in both Western and non-Western societies, hold permissive attitudes concerning accepting gifts, and drug advertising brochures may relax those permissive attitudes still further. Rational prescription training was useful in generating rational attitudes. Policies concerning drug company-medical student relationships should be developed in Turkey as well as internationally.

Interaction and medical inducement between pharmaceutical representatives and physicians: a meta-synthesis

Background

It has been proven that the interaction between pharmaceutical representatives and physicians can directly influence the latter’s prescribing behaviour. This meta-synthesis aims to explore the available studies regarding the nature of the interaction that takes place between pharmaceutical representatives and physicians. It highlights the different aspects of that interaction by investigating the reasons why these meetings happen in the first place, their benefits and drawbacks and their impact on patients’ health and, ultimately, the health of the public.

Methods

A search for published articles was conducted in April 2015. Three databases (PubMed, Ovid Medline, and ProQuest) were searched for articles published between January 2000 and April 2015. Authors worked autonomously and in pairs to select eligible articles. In this case, the meta-synthesis approach was used to develop a fuller understanding and to facilitate new knowledge by bringing together qualitative findings on physician-PR interaction. ‘Meta-synthesis’ is the process of amalgamation of a group of similar studies with the aim of developing an explanation for their findings (Walsh and Downe, J Advanc Nurs 50: 204–211, 2005). A thematic content analysis was conducted on the 15 included full text articles (qualitative and quantitative studies) whereby the original authors’ understanding of key concepts in each study was identified and listed in a summary form in the data extraction sheet under “key findings” column. These findings were then juxtaposed to identify homogeneity and dissonance (Walsh and Downe, J Advanc Nurs 50: 204–211, 2005). Homogenous findings were then coded together on a different data extraction table to form a theme.

Results

A total of 15 articles met the inclusion criteria and were included in this meta-synthesis;six from the United States, two from Libya, and one each from Turkey, Peru, India, Germany, the United Kingdom, Yemen, and Japan. Six main themes were derived from the included articles: 1-the frequency of pharmaceutical representatives’ visits, 2-the perceived ethical acceptability of the interactions between pharmaceutical representatives and physicians, 3-the attitudes held by physicians towards visits by pharmaceutical representatives, 4-their perception of the effect of such visits on prescription patterns, 5-reasons to accept or reject pharmaceutical representatives, and lastly, 6-guidelines.

Conclusions

The physicians referred to pharmaceutical representatives as efficient and convenient information resources and were willing to meet them and accept their gifts. It was also evident that most physicians believed that their prescribing would not be influenced by pharmaceutical representatives.

Electronic supplementary material

The online version of this article (doi:10.1186/s40545-016-0089-z) contains supplementary material, which is available to authorized users.

Attitudes of medical students towards incentives offered by pharmaceutical companies -- perspective from a developing nation -- a cross-sectional study

Background

A training physician has his first interaction with a pharmaceutical representative during medical school. Medical students are often provided with small gifts such as pens, calendars and books, as well as free lunches as part of drug promotion offers. Ethical impact of these transactions as perceived by young medical students has not been investigated in Pakistan before. This study aimed to assess the association of socio-demographic variables with the attitudes of medical students towards pharmaceutical companies and their incentives.

Methods

As part of a cross-sectional survey, a validated questionnaire previously used for assessing attitude of medical students towards pharmaceutical industry, was modified, pre-tested and distributed among consenting clinical year students at DUHS and AKU. Questions included acceptability of pharmaceutically sponsored gifts, events and tuition fee, and their impact on future prescription. Responses were graded as agree, disagree or neutral which were then scored according to the AMSA guidelines of ethical conduct.

Results

Out of a total of 353 targeted students 303 responded, corresponding to a response rate of 85.8%. Responses indicated that 42.7% students believed in no interaction with drug companies during medical school. However, 81% of students favored pharmaceutical sponsorship of student-body events/seminars at medical colleges. More than one-third of the students were comfortable receiving gifts from drug companies. Overall, the results of this study offer an interesting comparison between the students of a private medical school (AKU) and a public medical school (DUHS); AKU students exhibited a greater degree of mistrust towards drug information provided by pharmaceutical companies compared to DUHS students (p = 0.040). Furthermore, when asked if there was a need to incorporate guidelines in the undergraduate curriculum with regard to interaction with drug companies, 84.2% students at AKU agreed, compared to 54.9% at DUHS. Medical student Attitude Scores are more or less similar to each other independent of their various demographical differences.

Conclusion

This study highlights that medical students in our population have a high level of acceptability towards incentives offered by pharmaceutical industry and that formal guidance regarding the subject should be incorporated into medical curriculum.

Pharmacists' and physicians' perception and exposure to drug promotion: A Saudi study

Introduction

Drug promotion has to contribute to a more rational use of drugs. Concerns arise if promotion negatively influences prescribing/dispensing pattern. It is warranted to assess exposure and attitudes to, and acceptance of, drug promotion among pharmacists and physicians.

Methodology

Adopting a randomized, multiple site and cross-sectional survey study, questionnaires (n = 250) were completed by physicians and pharmacists to investigate the exposure, acceptance or skepticism of Saudi physicians/pharmacists to drug promotion as well as their perception of the appropriateness of gifts and to check if they had any teaching/training about dealing with medical representatives (MRs) and Pharma promotion.

Results

Significantly more pharmacists than physicians (32% vs. 23%; p < 0.05) reported being taught or educated about the ethics of drug promotion. The experience level was significantly associated with the teaching or training that the physicians and pharmacists received. Conference registration fees and drug samples were the most appropriate promotional gift for the physicians (67% and 66%, respectively; p < 0.01) whereas for pharmacists, the drug sample was considered the most suitable donation (79%). More pharmacists perceived drug companies as a useful way to gain knowledge about drugs than physicians (75% vs. 65%; p < 0.01). A higher proportion of both groups were accepting drug promotion than those skeptical about it.

Conclusion

The majority of physicians or pharmacists participating in this study have received gifts from pharmaceutical companies. The drug samples and printed educational materials are the most widely accepted gifts. Recent graduates and those with few years of experience had higher teaching/training than experienced physicians and pharmacists in pharmaceutical promotion ethics and tactics to deal with MRs. On the other hand, experienced healthcare team were more approached and targeted by pharmaceutical companies and MRs. It is highly recommended to implement courses/discussion groups on the ethical interaction between healthcare professionals and pharmaceutical companies in the curriculum of both pharmacy and medicine. Updating the physicians and pharmacists after graduation, as part of continued medical/pharmacy education, will eventually improve the healthcare professionals’ capability to act to the patients’ welfare.

[Medical students and drug marketing]

Objetivo

Conocer la exposición de los estudiantes de medicina a las actividades promocionales de la industria farmacéutica, e identificar sus opiniones y actitudes, así como los posibles efectos de esta exposición en su formación y futura práctica profesional.

Diseño

Estudio descriptivo transversal.

Emplazamiento

Facultad de Medicina de la Universidad de Zaragoza.

Participantes

Estudiantes de medicina de los cursos tercero, cuarto, quinto y sexto.

Métodos

La información se obtuvo mediante un cuestionario autoaplicado, previamente adaptado, sobre exposición, actitudes e idoneidad percibida de las actividades de marketing farmacéutico. Se estimaron porcentajes para las variables categóricas, aplicando el test de ji al cuadrado para la comparación entre grupos. Regresión logística para determinar los factores asociados a actitudes proclives a dichas actividades.

Resultados

Se obtuvieron 369 encuestas (93% de los asistentes a clase). La exposición a las actividades promocionales es elevada, sobre todo en la etapa clínica (el 78,6% declara haber recibido un regalo no formativo). Los estudiantes reconocen los sesgos y posibles repercusiones en la práctica profesional, aunque con ambigüedad y contradicciones. Las actividades mejor aceptadas son las relacionadas con la formación y las actitudes más críticas aparecen en la etapa clínica, sobre todo en el sexto curso.

Conclusiones

La exposición de los estudiantes al marketing farmacéutico y sus posibles repercusiones formativas y profesionales son frecuentes e importantes. El ámbito de la formación resulta especialmente permeable a las actividades promocionales. Las diferencias observadas en los últimos cursos señalan la necesidad de formación específica curricular y desarrollo de actitudes reflexivas por los propios estudiantes.

Medical students' exposure to and attitudes about the pharmaceutical industry: a systematic review

BACKGROUND

The relationship between health professionals and the pharmaceutical industry has become a source of controversy. Physicians' attitudes towards the industry can form early in their careers, but little is known about this key stage of development.

METHODS AND FINDINGS

We performed a systematic review reported according to 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. We searched MEDLINE, EMBASE, Web of Science, and ERIC from the earliest available dates through May 2010, as well as bibliographies of selected studies. We sought original studies that reported quantitative or qualitative data about medical students' exposure to pharmaceutical marketing, their attitudes about marketing practices, relationships with industry, and related pharmaceutical policy issues. Studies were separated, where possible, into those that addressed preclinical versus clinical training, and were quality rated using a standard methodology. Thirty-two studies met inclusion criteria. We found that 40%-100% of medical students reported interacting with the pharmaceutical industry. A substantial proportion of students (13%-69%) were reported as believing that gifts from industry influence prescribing. Eight studies reported a correlation between frequency of contact and favorable attitudes toward industry interactions. Students were more approving of gifts to physicians or medical students than to government officials. Certain attitudes appeared to change during medical school, though a time trend was not performed; for example, clinical students (53%-71%) were more likely than preclinical students (29%-62%) to report that promotional information helps educate about new drugs.

CONCLUSIONS

Undergraduate medical education provides substantial contact with pharmaceutical marketing, and the extent of such contact is associated with positive attitudes about marketing and skepticism about negative implications of these interactions. These results support future research into the association between exposure and attitudes, as well as any modifiable factors that contribute to attitudinal changes during medical education. Please see later in the article for the Editors' Summary.