Changes in medical students' exposure to and attitudes about drug company interactions from 2003 to 2012: a multi-institutional follow-up survey

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.

Industry payments to family medicine residents in Portugal: a descriptive analysis of the national transparency database

OBJECTIVE

To analyse payments made to family medicine residents by the pharmaceutical industry during their residency in Portugal, using mandatory disclosure data.

DESIGN AND PARTICIPANTS

Cohort study of residents starting their family medicine training in 2015, using data collected from the public national transparency database (Plataforma de Comunicações Transparência e Publicidade). Payments were categorised into six groups, including scientific meetings, educational activities, travel allowances, fees, gifts and undetermined.

MAIN OUTCOME MEASURES

Number of payments and the total value received by family medicine residents during their training period; number of payments according to their nature (six categories); number of payments and total value by paying entity.

RESULTS

We analysed data of 457 family medicine residents. A total of 2790 payments were made to 424 (92.8%) residents, amounting to €826 271.14. Thirty-three residents did not receive any payment. The median number of payments per resident was 5 and the median amount received per resident was €1309.51. Residents who ranked in the top 25%, according to value received, were subsidised more than €2500.90 over the course of their residency. This subset of residents received 59.1% of the total amount disbursed in payments. Payments were primarily for attending scientific meetings (80.9%) and educational activities (17.1%). The top 10 paying entities accounted for 69.2% of the total amount paid.

CONCLUSION

Pharmaceutical industry funding for family medicine residents was highly prevalent, raising concerns over industry influence on medical education, while payment distribution was heterogeneous.

Changes in Japanese physicians' relationships with the pharmaceutical industry between 2008 and 2021: A national survey

BACKGROUND

A national survey we conducted in 2008 showed that many Japanese physicians interacted with and received gifts from pharmaceutical representatives (PRs) and had a positive attitude toward relationships with PRs. The revised promotion code of the Japan Pharmaceutical Manufacturers Association in 2019 prohibited the provision of non-educational promotional aids including sticky notes, mouse pads, and calendars. During the COVID-19 pandemic in 2020, face-to-face meetings were socially restricted. This study assessed the extent of current Japanese physicians' involvement in pharmaceutical promotional activities and their attitudes toward relationships with PRs and to ascertain any changes between 2008 and 2021. We also examined the factors that predicted positive attitudes toward gifts from PRs.

METHODS

From January to March 2021, we conducted a national mail survey of Japanese physicians in seven specialties: internal medicine, surgery, orthopedics, pediatrics, obstetrics-gynecology, psychiatry, and ophthalmology.

RESULTS

There were 1636 participants and the response rate was 63.2%. Most physicians met face-to-face with PRs (78.8%), whereas only a minority received meals outside the workplace (4.5%). PRs were thought to have an important role in continuing medical education (66.1%) and to provide accurate information about new drugs (74.2%). Opinions were divided on the appropriateness of gifts from PRs. Most thought that stationery and meals provided by the industry did not affect prescribing behavior (89.7% and 75.8%, respectively). Factors that predicted a positive attitude toward gifts from PRs were male, orthopedic specialty vs. internal medicine, more interactions with PRs, a positive attitude toward informational value, and no rules banning meetings with PRs.

CONCLUSION

Involvement in pharmaceutical promotional activities is still common among practicing physicians in Japan, although the extent of the involvement had declined. Rules banning meetings with PRs appear to continue being effective at limiting a physician's involvement with promotional activities and their critical attitudes toward gifts from PRs.

Medical students' exposure to and attitudes towards product promotion and incentives from the pharmaceutical industry in 2019: a national cross-sectional study in France

OBJECTIVES

To measure medical students' exposure to pharmaceutical product promotion and incentives nationwide, and to evaluate students' attitudes towards the pharmaceutical industry, access to education on promotional strategies and knowledge of institutional policies about drug company-student relationships.

DESIGN

Cross-sectional survey based on a 48-item anonymous questionnaire.

SETTING

All 37 French medical schools, from March to April 2019.

PARTICIPANTS

French medical students in their 4th year of study and beyond, having studied exclusively in France.

MAIN OUTCOME MEASURE

Cumulative frequency of students' exposure to pharmaceutical product promotion and incentives.

SECONDARY OUTCOME MEASURES

Exposure within the last 6 months, attitudes regarding interactions with the industry, access to education on pharmaceutical product promotion and incentives and knowledge of institutional policies.

RESULTS

6280 responses were analysed (10.4% out of a total of 60 550 eligible students). 5992 students (96.3% poststratification, 99% CI (96.1% to 96.5%)) had already been exposed to pharmaceutical product promotion and incentives and 4650 (78.1%, 99% CI (77.7% to 78.6%)) within the last 6 months. 5140 students (85.4%, 99% CI (84.8% to 85.8%)) had met a pharmaceutical representative. Regarding attitudes, 2195 students (36.8%, 99% CI (36.0% to 37.5%)) thought receiving a gift could influence their own prescriptions while 3252 (53.6%, 99% CI (53.1% to 54.2%)) thought it could influence their colleagues' prescriptions. 4533 students (76.0%, 99% CI (75.6% to 76.5%)) reported never having attended any lecture on promotional strategies. Exposure seemed to depend on the year of study and specialty. 5122 (88.1%, 99% CI (87.7% to 88.4%)) did not know whether their faculty had a policy regarding drug company-student interactions.

CONCLUSION

In France in 2019, medical students' exposure to pharmaceutical product promotion and incentives remains considerable and starts early during medical training. Education on promotional strategies and institutional policies should be improved to ensure responsible and ethical behaviour in prescribing medications.

Ten years later: a review of the US 2009 institute of medicine report on conflicts of interest and solutions for further reform

Conflicts of interest (COIs) in healthcare are increasingly discussed in the literature, yet these relationships continue to influence healthcare. Research has consistently shown that financial COIs shape prescribing practices, medical education and guideline recommendations. In 2009, the Institute of Medicine (IOM, now the National Academy of Medicine) published Conflicts of Interest in Medical Research, Practice, and Education-one of the most comprehensive reviews of empirical research on COIs in medicine. Ten years after publication of theIOM's report, we review the current state of COIs within medicine. We also provide specific recommendations for enhancing scientific integrity in medical research, practice, education and editorial practices.

What influences healthcare providers' prescribing decisions? Results from a national survey

BACKGROUND

Prior U.S. Food and Drug Administration (FDA) surveys with healthcare providers (HCPs) have focused on attitudes toward direct-to-consumer advertising and have not specifically examined professionally-targeted prescription drug promotion. Similarly, there are no recent national surveys of HCPs examining their interactions with the pharmaceutical industry.

OBJECTIVES

The goal of this study was to use a national sample of HCPs to examine exposure to professionally-targeted prescription drug promotions and interactions with industry, and knowledge, attitudes and practices related to FDA approval of prescription drugs.

METHODS

An online national survey was conducted with 2000 HCPs representing primary care physicians (PCPs), specialists (SPs), physician assistants (PAs), and nurse practitioners (NPs). The sample was randomly drawn from WebMD's Medscape subscriber network, stratified by HCP group, and designed to yield target numbers of completed surveys in each group. Weights were computed to correct for unequal selection probabilities, differential response rates, and differential coverage and used to generalize completed surveys to a national population of PCPs, SPs, NPs, and PAs.

RESULTS

Exposure and attention to pharmaceutical promotions and contact with industry were significantly associated with reported increase in pharmaceutical industry influence on decisions about prescription drugs. SPs were significantly more likely to prescribe off-label and serve as opinion leaders for the pharmaceutical industry compared to other provider groups.

CONCLUSIONS

Findings indicate pharmaceutical promotions directed at HCPs occur in many forms and are disseminated through multiple channels. By using a nationally representative sample of HCPs, this study provides population-level estimates for exposure and attention to prescription drug promotion and contact with industry and evidence for their influence on prescriber decisions. Findings from this study will help to inform FDA of HCP responses to and impacts of prescription drug promotion.

Conflict of interest policies at Belgian medical faculties: Cross-sectional study indicates little oversight

BACKGROUND

Medical students encounter pharmaceutical promotion from the very start of their training. Medical schools have an important role to play in educating medical students regarding the interactions between healthcare professionals (HCPs) and industry and in protecting them from commercial influence and conflict of interest (COI). In 2019, medical student associations in Belgium and abroad called for more preparation in dealing with COI and for a more independent medical training. As little information is available on the situation in our country, we undertook an assessment of conflict of interest policies at Belgium's medical schools. We relied on a methodology already used in studies from USA, Canada, Australia, France and Germany and adapted it to the Belgian context.

METHODS

We identified 10 medical schools in Belgium. We searched the website of each medical school in November 2019 with standardized keywords for COI policies and learning activities on COI in the curriculum. The deans of medicine were invited to participate by sending us information that we could have overlooked during our web-based searches. We also consulted personal contacts within faculties among students and teachers. Based on a list of 15 criteria adapted from North American and French studies, we calculated a total for each faculty of medicine with a maximum score of 30 points.

RESULTS

By December 2019, we had gathered a set of written documents for four faculties of medicine (40%) containing policies with varying degrees of precision and relevance to our survey. We found elements of the curriculum addressing the COI issue for one faculty (10%). In all cases, these policies consisted of "moderate" initiatives with little or no "restrictive" elements. Only one faculty showed interest in our study by providing us with relevant information (10%). Half of the faculty notified us of their refusal to participate in the study (50%) and the other faculties either did not respond or did not provide us with any information (40%). The maximum score obtained was 3 out of 30 points with six faculties scoring 0 (60%).

CONCLUSION

There is little transparency regarding interactions between medical students and pharmaceutical companies at Belgian medical faculties, which may create COI issues. Initiatives to protect students from pharmaceutical promotion and to train them to manage their future interaction with pharmaceutical companies have a limited scope and are isolated. This is inconsistent with international recommendations from Health Action International, World Health Organization or the American Medical Students' Association. The Belgian government has legislated in favor of more transparency in the relation between HCPs and pharmaceutical industry. Indeed, it made the disclosure of benefits granted by the industry compulsory and limited their value. Our results show that there is still some way to go to ensure an independent medical training for future Belgian physicians.

An Elective Course for Student Pharmacists on Pharmaceutical Industry Practice

Objective. To design and implement an elective course on pharmaceutical industry practice and assess its impact on student pharmacists' knowledge and perceptions. Methods. This was a two-credit hour, elective course offered to second- and third-year student pharmacists during the 2015 and 2016 spring semesters. The goal of this course was to provide instruction regarding skills and competencies for pharmaceutical industry practice. Curricular content included didactic instruction, assigned readings, weekly quizzes, classroom discussion of industry-based functions and responsibilities, and three application projects. A 65-item survey instrument was developed to assess changes in student pharmacists' perceptions and understanding of pharmaceutical industry practice. Results. Forty-four students enrolled in the elective course over the two offerings. The average rating on the course evaluation was 4.7 out of 5. Average scores on graded quizzes were 90%, and grades on the application projects ranged from 92% to 99%. There was an increase in the number of students who perceived that they understood various functions and roles in the pharmaceutical industry, and who rated themselves confident in completing unique tasks associated with pharmaceutical industry practice. Furthermore, there was an increase in the number of students who reported improved perceptions regarding the trustworthiness of the pharmaceutical industry, costs of prescription medications, and promotional advertising for branded prescription medication. Conclusion. Student pharmacists' perceptions of the course were positive, and overall perceptions and understanding of the pharmaceutical industry improved. Active collaboration between colleges and pharmaceutical companies can lead to positive educational opportunities for students interested in pharmaceutical industry careers.

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.

Follow-up survey of Japanese medical students' interactions with the pharmaceutical industry

Interaction of medical students with the pharmaceutical industry is common. However, students are thought to be vulnerable to the influence of this interaction, and regulations to limit such interactions are required. The Japan Pharmaceutical Manufacturers Association revised its promotion code in 2013 and specified upper limits for promotional aids. We aimed to investigate whether Japanese medical students’ interactions with the pharmaceutical industry changed from 2012 to 2016. This study solicited the participation of all medical schools in Japan. An anonymous cross-sectional survey was administered to medical students from May 2016 to March 2017 to investigate their interactions with the pharmaceutical industry. The results were compared with those of a previous study conducted in 2012. Forty of the 80 medical schools in Japan participated. The student response rate was 74.1%, with 6771 (3395 preclinical, 3376 clinical) evaluable responses. More than 98% of clinical students had previously accepted stationery, a brochure, or a lunch, and significantly higher percentages of clinical students had accepted these items in 2016 than in 2012 (p < .001). The interactions between clinical students and pharmaceutical companies increased slightly between 2012 and 2016. This study will hopefully promote discussion regarding the regulation of student–industry interactions.

Evaluation of first year student pharmacists' perceptions of the pharmaceutical industry

BACKGROUND AND PURPOSE

There are a limited number of pedagogical studies evaluating student pharmacists' perceptions of the pharmaceutical industry. The objective of this two year prospective study was to evaluate changes in student pharmacists' perceptions of the pharmaceutical industry during the first year of enrollment in the doctor of pharmacy curriculum.

EDUCATIONAL ACTIVITY AND SETTING

An online survey was developed and offered to all first-year student pharmacists during the 2014 and 2015 Fall semesters prior to didactic instruction on the pharmaceutical industry and then again at the end of the respective academic years. Descriptive and inferential statistics were used to analyze the data.

FINDINGS

A majority of students had a positive impression of the pharmaceutical industry in both the fall (75%) and spring semesters (78%). Over the course of the year, significantly greater numbers of student pharmacists reported favorable impressions of the pharmaceutical industry with respect to research innovation, drug safety, and the provision of drug information. On the other hand, findings suggest that many students remain skeptical regarding the benefits of prescription medications relative to cost and there were significant increases in the number of students who perceived pharmaceutical industry-based marketing practices to have a negative impact on patients and society.

DISCUSSION AND SUMMARY

Didactic education may influence student pharmacists' perceptions of the pharmaceutical industry. Further research is warranted to evaluate the role of pharmacy curricula and extra-curricular activities in influencing changes in student pharmacists' perceptions and the potential implications of these changes to pharmacy practice.

Conflicts of Interest in Emergency Medicine

Conflicts of interest (COIs) are common in the practice of emergency medicine and may be present in the areas of clinical practice, relations with industry, expert witness testimony, medical education, research, and organizations. A COI occurs when there is dissonance between a primary interest and another interest. The concept of professionalism in medicine places the patient as the primary interest in any interaction with a physician. We contend that patient welfare is the ultimate interest in the entire enterprise of medicine. Recognition and management of potential, real, and perceived COIs is essential to the ethical practice of emergency medicine. This paper discusses how to recognize, address, and manage them.

Medical student and medical school teaching faculty perceptions of conflict of interest

Background

Attitudes towards conflict of interest (COI) and COI policy are shaped during medical school and influence both the education of medical students and their future medical practice. Understanding the current attitudes of medical students and medical school teaching faculty may provide insight into what is taught about COI and COI policy within the ‘hidden’ medical curriculum. Differences between medical student and medical school teaching faculty perceptions of COI and COI policy have not been compared in detail. The authors surveyed first year medical students and medical school teaching faculty at one academic medical center.

Results

The response rate was 98.7% (150/152) for students and 34.2% (69/202) for faculty. Students were less likely than faculty to agree that lecturers should disclose COI to any learners (4.06 vs. 4.31, p = 0.01), but more likely to agree that COI disclosure decreases the presentation of biased material (3.80 vs. 3.21, p < 0.001). Student and faculty responses for all other questions were not different. Many of these responses suggest student and faculty support for stronger COI policy at academic medical centers.

Conclusions

Students and faculty perceptions regarding COI and COI policy are largely similar, but differ in terms of the perceived effectiveness of COI disclosure. This study also suggests that medical students and medical school teaching faculty support for stronger COI policy at academic medical centers.

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.