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

Prevalence of Self-Medication Practice and Associated Factors among Pregnant Women Who Attended Antenatal Care at Public Hospitals of North Shewa Zone, Amhara Region, Ethiopia

Background

Self-medication practice is the use of medicine without consulting health professionals to treat self-recognized illness by the general population including pregnant women. Inappropriate self-medication practice during pregnancy may pose harmful consequences for the fetus as well as the mother. There is not given much attention on the practice of self-medication among pregnant women in our setting. Therefore, this study aimed to assess the prevalence of self-medication practice and associated factors among pregnant women who attended antenatal care at North Shewa Zone public hospitals.

Methods

An institution-based cross-sectional study was conducted from June 01, 2022 to July 30, 2022, among 650 pregnant women who attended antenatal care at North Shewa Zone public hospitals. A multistage sampling technique was employed. The questionnaires were pretested. A structured interviewer-administered questionnaire and reviewed medical records were used for data collection. Epi-data version 4.6.2 and SPSS version 20 were utilized for data entry and analysis, respectively. Bivariate and multivariable logistic regression was done to identify associated factors, and P values less than 0.05 were considered statistically significant.

Results

The prevalence of self-medication practice among pregnant women was 65.38%. Housewives (AOR = 0.097 95% CI 0.030, 0.310), farmers (AOR = 0.117, 95% CI 0.028, 0.493), people with health insurance (AOR = 0.507, 95% CI 0.300, 0.858), and people in preconception care (AOR = 0.038, 95% CI 0.011-0.135) were less likely to practice self-medication, while people with primary education (AOR = 3.00, 95% CI 1.217, 7.435), income less than 3,000 birr (AOR = 5.46, 95% CI 1.41, 21.1), participants in the first (AOR = 4.183, 95% CI 2.12, 8.24) and second trimesters (AOR = 2.05, 95% CI 1.18, 3.56), pregnant women who lived in rural areas (AOR = 1.579, 95% CI 1.103-2.260), and people who previously practiced self-medication (AOR = 8.2, 95% CI 5.04, 13.3) were more likely to practice self-medication.

Conclusion

From the present finding, it can be concluded that self-medication among pregnant women is high. Previous self-medication practice, gestation period, educational status, monthly income, no preconception care, no health insurance, being a housewife, farmer, and place of residence were significantly associated with self-medication practice. Therefore, preventive measures such as proper counseling during dispensing, awareness creation programs on preconception care, and enrolling in health insurance programs to minimize the practice of self-medication are necessary.

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.

Attitudes Towards Conflicts of Interest in Medical Research: A Survey of US Medical Students

Industry funds nearly two-thirds of US healthcare research, and industry-sponsorship may produce more favorable research results and conclusions. Medical students report feeling inadequately prepared to avoid negative industry influence. Research of educational interventions that educate students on the potential effects of industry influence is lacking, and no interventions have demonstrated long-term benefit. Surveying and assessing student opinions of the relationship between industry and research may help improve future educational interventions. We surveyed preclinical and clinical students at seven US medical schools regarding their attitudes towards industry conflicts of interest (COIs) in medical research. A total of 466 medical students including 232 preclinical and 234 clinical students completed the survey. Of those who had research experience, clinical students were more likely than preclinical students to look for COIs (62.0% v 45.9%, p = .014) and to consider whether author COIs are pertinent to the article (68.1% v 54.1%, p = .023). Many disagreed that they felt adequately educated on the issue of COIs (42.7%), but most agreed that medical school should take a role in guiding student interactions with industry (65.0%). Students responded that all listed financial relationships between industry and investigator, except for providing food and/or beverage, would likely bias the investigator's research. Many students feel inadequately educated on industry issues in biomedical research, and most believe medical schools should help guide interactions with industry. Our findings support further development of educational interventions that prepare students to navigate the relationship between industry and medical research during and after medical school.

Conflict of interest policies at Australian medical schools

BACKGROUND

Pharmaceutical industry exposure is widespread during medical training and may affect education and clinical decision-making. Medical faculties' conflict of interest (COI) policies help to limit this exposure and protect students against commercial influence.

AIMS

Our aim was to investigate the prevalence, content and strength of COI policies at Australian medical schools and changes since a previous assessment conducted in 2009.

METHODS

We identified policies by searching medical school and host university websites in January 2021, and contacted deans to identify any missed policies. We applied a modified version of a scorecard developed in previous studies to examine the content of COI policies. All data were coded in duplicate. COI policies were rated on a scale from 0 (no policy) to 2 (strong policy) across 11 items per medical school. Oversight mechanisms and sanctions were also assessed, and current policies were compared with the 2009 study.

RESULTS

Of 155 potentially relevant policies, 153 were university-wide and two were specific to medical schools. No policies covered sales representatives, on-site sponsored education or free samples. Oversight of consultancies had improved substantially, with 76% of schools requiring preapproval. Disclosure policies, while usually present, were weak, with no public disclosure required.

CONCLUSION

We found little indication that Australian medical students are protected from commercial influence on medical education, and there has been limited COI policy development within the past decade. More attention is needed to ensure the independence of medical education in Australia.

Attitudes of medical students on conflict of interest: A comparative study of Korea and France

Medical students are potential marketing targets for pharmaceutical companies because established prescribing habits are not easily altered. In 2014, Bruno Etain and several other researchers published a paper which investigated the knowledge of and opinions on potential conflict of interest (COI) with regard to preclinical and clinical students enrolled in medical schools in France and residents working in hospitals. An empirical survey study with Korean medical students concerning their educational experiences and views on conflicts of interest and comparing and contrasting the results with Etain's study of French medical students. Receipt of direct or indirect financial offerings from pharmaceutical industries was not properly recognised as COI by the medical students. Therefore, strengthening education on COI and implementing institutional improvements for COI disclosure are essential to prevent bias caused by COI and enhance awareness levels regarding COI.

Pharmaceutical policies: effects of policies regulating drug marketing

BACKGROUND

The costs of developing new treatments and bringing them to the market are substantial. The pharmaceutical industry uses drug promotion to gain a competitive market share, and drive sale volumes and industry profitability. This involves disseminating information about new treatments to relevant targets. However, conflicts of interest can arise when profits are prioritised over patient care and its benefits. Drug promotion regulations are complex interventions that aim to prevent potential harm associated with these activities.

OBJECTIVES

To assess the effects of policies that regulate drug promotion on drug utilisation, coverage or access, healthcare utilisation, patient outcomes, adverse events and costs.

SEARCH METHODS

We searched Epistemonikos for related reviews and their included studies. To find primary studies we searched MEDLINE, CENTRAL, Embase, EconLit, Global Index Medicus, Virtual Health Library, INRUD Bibliography, two trial registries and two sources of grey literature. All databases and sources were searched in January 2023.

SELECTION CRITERIA

We planned to include studies that assessed policies regulating drug promotion to consumers, healthcare professionals or regulators and third-party payers, or any combination of these groups.In this review we defined policies as laws, rules, guidelines, codes of practice, and financial or administrative orders made by governments, non-government organisations or private insurers. One of the following outcomes had to be reported: drug utilisation, coverage or access, healthcare utilisation, patient health outcomes, any adverse effects (unintended consequences), and costs. The study had to be a randomised or non-randomised trial, an interrupted time series analysis (ITS), a repeated measures (RM) study or a controlled before-after (CBA) study.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed eligibility for inclusion of studies. When consensus was not reached, any disagreements were discussed with a third review author.  We planned to use the criteria suggested by Cochrane Effective Practice and Organisation of Care (EPOC) to assess the risk of bias of included studies. For randomised trials, non-randomised trials, and CBA studies, we planned to estimate relative effects, with 95% confidence intervals (CI). For dichotomous outcomes, we planned to report the risk ratio (RR) when possible and adjusted for baseline differences in the outcome measures. For ITS and RM, we planned to compute changes along two dimensions: change in level and change in slope. We planned to undertake a structured synthesis following EPOC guidance.  MAIN RESULTS: The search yielded 4593 citations, and 13 studies were selected for full-text review. No study met the inclusion criteria.

AUTHORS' CONCLUSIONS

We sought to assess the effects of policies that regulate drug promotion on drug use, coverage or access, use of health services, patient outcomes, adverse events, and costs, however we did not find studies that met the review's inclusion criteria. As pharmaceutical policies that regulate drug promotion have untested effects, their impact, as well as their positive and negative influences, is currently only a matter of opinion, debate, informal or descriptive reporting. There is an urgent need to assess the effects of pharmaceutical policies that regulate drug promotion using well-conducted studies with high methodological rigour.

The Role of Physician Networks and Receipt of Opioid-Related Payments

BACKGROUND

Opioid-related promotional payments are associated with increased prescribing of the promoted drug, but little is known about whether physicians receiving payments influence peers to accept similar payments.

OBJECTIVE

We examine the association of physician network-level position among peers and the acceptance of opioid-related promotional payments using national publicly available datasets from 2015. Design National cross-sectional data from the Centers for Medicare and Medicaid Services (CMS) National Downloadable File and Open Payment data.

SUBJECTS

Physicians who shared Medicare patients with at least two other physicians in 2015.

MAIN MEASURES

Modified Poisson's regressions are used to estimate the adjusted incidence rate ratio (aIRR) for social network position (i.e., degree, betweenness, and transitivity) and number of peers with payments as a function of individual receipt of opioid-related promotional payment and among those with payments, those who have five or more payments, and those who have $100 or more in payments.

KEY RESULTS

Physicians with opioid-related payments were significantly more likely to have at least one peer with an opioid-related payment (IRR: 2.5, 95% CI: 2.3-2.8), but had fewer shared patients (i.e., top quartile compared to the first quartile for degree centrality: 0.4, 95% CI: 0.3-0.4) and belonged to less cohesive networks (i.e., top quartile compared to the first quartile for betweenness centrality: 0.9, 95% CI: 0.8-0.9).

CONCLUSIONS

Our study demonstrates that physicians receiving opioid-related payments are more likely to cluster within physician networks.

Teaching medical students how to interact with the pharmaceutical industry: A scoping review

Objectives: The influence of the pharmaceutical industry is of significant concern in physician prescribing decisions; medical students may not be fully equipped with the knowledge or skills to manage interactions with industry prior to graduation. The aim of this study was to evaluate the characteristics of educational interventions undertaken to improve students' knowledge, attitudes, and skills in managing interactions with the pharmaceutical industry. Methods: A systematic search of Ovid Medline, EMBASE, CINAHL and ERIC databases identified 3210 primary studies with keywords related to "pharmaceutical industry" and "undergraduate medical education". Eleven articles were included for review. Results: Disparate methods of teaching medical students how to interact with the pharmaceutical industry were identified, making it difficult to compare the effectiveness of different educational interventions. All the included studies achieved the aims of the described intervention, at least in the short term, suggesting perhaps any education related to interactions with the pharmaceutical industry can aid students in managing these situations. Conclusions: The lack of an evidence-base means more research into the identification of educational interventions which engender durable changes in students' knowledge, attitudes, and skills to manage interactions with the pharmaceutical industry are required. Any intervention will likely be context-dependent, as a universal approach is hindered by the fact different countries have different laws governing pharmaceutical industry-physician interaction.

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.

Medical Students’ Perception Regarding Health Policy Teaching and Their Participation in Health Policy Roles: A Survey at a Public University in Malaysia

Background: Health policy is a set of comprehensive principles and legislations that guide how healthcare should be effectively delivered in the community. Medical schools should prepare students to undertake managerial responsibilities by incorporating health policy into the curriculum to deal with the intricacies of healthcare systems and their clinical roles in their future professional careers. Objective: To examine medical students’ perception at a Public University in Malaysia regarding teaching health policy and their participation in health policy roles. Material and Methods: A cross-sectional study using universal sampling was carried out among the medical students using a paper-based questionnaire to collect the data. Results: Most respondents opined their willingness to learn health policy (80.9%) and that teaching health policy (83.6%) should be compulsory for medical students. The respondents thought health policy should be introduced earlier in Year 1 or 2. The student scores on their knowledge regarding health policy and year of study were significantly associated with their involvement in the health policy roles in both the simple and multiple logistic regression. Both statistical tests reported higher participation in health policy roles with the higher year of study, though only Year 4 and 5 were significant in the simple logistic regression and only Year 5 in the multiple logistic regression compared to Year 1. On the other hand, age and type of admission show significant results only in the simple logistic regression, while the race was only significant at the multivariate level. Conclusions: This study demonstrated that most respondents showed their willingness to learn health policy, participate in the health policy programs, and recommend that health policy be considered an essential topic in the medical curriculum, which should be taught right from the first year of medical school. We recommend encouraging students’ participation in health policy activities.

Health Care Clinicians and Product Promotion by Industry

Medical pharmaceutical and device manufacturers are essential in making products that benefit patients, and collaboration between health care clinicians and the industry is necessary for the design and manufacture of these medical products. However, health care clinicians must recognize that their duties and the interests of the industry may at times diverge. Relationships with the industry, even seemingly minor ones, have the potential to shape the decisions made on behalf of patients. The marketing divisions of pharmaceutical and medical device firms view health care clinicians as targets of their efforts, and some of the interactions that occur between the industry and health care clinicians have the potential to alter decision making in ways that may not necessarily benefit patients. Health care clinicians have an ethical duty to recognize situations and marketing strategies that are designed to influence their choice of diagnostic and therapeutic options for their patients. At a minimum, health care clinicians should be aware of the techniques used to attempt to alter their behavior and guard against them.

Awareness and Perceptions among Members of a Japanese Cancer Patient Advocacy Group Concerning the Financial Relationships between the Pharmaceutical Industry and Physicians

Objectives: Awareness and perceptions of financial conflicts of interest (FCOI) between pharmaceutical companies (Pharma) and healthcare domains remain unclear in Japanese cancer patient communities. This study aimed to assess awareness (RQ1), the influence of FCOI on physician trustworthiness (RQ2), and their perception (RQ3) among the Japanese cancer patient advocacy group members. Methods: A cross-sectional study using a self-administered survey was conducted with a Japanese cancer patient advocacy group between January and February 2019. The main outcome measures included awareness and perceptions of physician–Pharma interactions, their impact on physician trustworthiness, and attitudes towards FCOI among medical and other professions. Furthermore, we performed thematic analyses on the comments which responders provided in the surveys. Results: Among the 524 contacted members, 96 (18.3%) completed the questionnaire, including 69 (77.5%) cancer patients. In RQ1, most of the respondents were aware of physician–Pharma interactions, although the extent differed based on the nature of the interaction. Furthermore, the respondents mainly considered these interactions influential on clinical practice (RQ2) and agreed to the need for further regulation of physician–Pharma interactions (QR3). In qualitative analyses (n = 56), we identified the 4 following themes: perception towards the FCOI (Theme 1), concerns about the respondent’s treatment (Theme 2), reason of physician–Pharma interactions (Theme 3), and possible solutions from the patient perspective (Theme 4). Conclusions: Most respondents were generally aware of physician–Pharma-associated FCOI and perceived them negatively. Additionally, participants appeared supportive of further FCOI regulation to protect patient-centred care. Abbreviations: FCOI—financial conflicts of interest; United States—US; Pharma—pharmaceutical companies; RQ—research question.

How Polish medical students are socialised to cooperate with the pharmaceutical industry: a focus group study of the importance of informal, hidden and null curricula

This study analysed how Polish medical students are socialised to cooperate with the pharmaceutical industry via informal, hidden, and null curricula. Nine focus groups were run with medical students in their second year and upwards at three Polish medical universities. Initially, most students had difficulty in discerning pharmaceutical companies' presence in their education, but on reflection they all recognised this presence. Students said that they were surrounded by small medical gifts provided by companies, met pharmaceutical representatives, and took part in events for physicians organised and/or sponsored by the pharmaceutical industry. Nevertheless, they did not think they were the main target of the industry's marketing activities, saying that these were largely aimed at practicing doctors, and that they were only targeted as opportunities arose. Students' statements make it clear that their socialisation takes place within a culture which consents to medical professionals' cooperation with the industry. Medical students come to perceive cooperation with the industry as natural, and benefits from the industry as a privilege of doctors. Medical schools can prevent this by introducing guidelines, conflict of interest polices, and changing the formal curriculum, but the need for such measures is not currently recognised in Poland.

General practitioners and sales representatives: Why are we so ambivalent?

INTRODUCTION

Accepting gifts from pharmaceutical sales representatives (sales reps) or meeting them is correlated with excessive, more expensive and sometimes less rational prescribing. French general practitioners (GPs) tend to hold an unfavorable opinion of the pharmaceutical industry, yet the behavior they adopt with sales reps is generally favorable. Until now, no study has sought to explain the reasons for this discrepancy. This study explores GP experiences to better understand their ambivalent behavior.

METHOD

This qualitative descriptive study was based on semi-structured face-to-face interviews with French GPs in the south-east of France. An interpretative phenomenological approach was chosen to explore individual professional practices and to model the phenomenon through in-depth analysis of semi-structured interviews. A general inductive analysis was carried out. Data were analyzed by researchers from different disciplines (psychology, sociology and general practice).

RESULTS

Ten GPs were interviewed for an average of 50 minutes. The analysis revealed three forces that combine to motivate GPs to keep meeting sales reps despite their unfavorable opinion of these visits: practical reasons such as the need for a substitute for continuing education; social and cultural reasons such as courtesy towards representatives; and psychological mechanisms such as cognitive dissonance and a hidden curriculum.

DISCUSSION

The GP-representative relationship is complex and involves psychological mechanisms that the medical profession often fails to recognize. GPs use reps as a convenient tool for continuing education, particularly in the setting of a private practice where GPs feel pressed for time. Cognitive dissonance is a well-supported theory in social psychology that explains how a person maintains a behavior while having an unfavorable opinion of it. Since GP meetings with sales reps start during their internship, they could also be considered as part of a hidden curriculum. The strength of this work is to combine medical, social psychological and sociological perspectives with the original interpretative phenomenological approach. When the veil is lifted on individual ambivalence, the questions raised are more social and political than individual.

Transparency or restricting gifts? Polish medical students' opinions about regulating relationships with pharmaceutical sales representatives

Relationships between physicians and pharmaceutical sales representatives (PSRs) often create conflicts of interest, not least because of the various benefits received by physicians. Many countries attempt to control pharmaceutical industry marketing strategies through legal regulation, and this is true in Poland where efforts are underway to eliminate any practices that might be considered corrupt in medicine. The present research considered Polish medical students' opinions about domestic laws restricting doctors' acceptance of expensive gifts from the industry, the idea of compulsory transparency, and the possibility of introducing a Polish Sunshine Law. A qualitative, focus group-based, interview method was used. Data were gathered from nine focus groups involving 92 medical students from three universities located in major Polish cities. The article presents a classification of opposing student views with regard to the consequences of introducing different legal solutions; this should be useful for policy makers deliberating on how to optimally regulate pharmaceutical marketing. The study's results are discussed in the context of the public bioethical debate in Poland.

Implementation of the Arizona Pain and Addiction Curriculum: Findings and Implications From a Statewide Evaluation

Purpose: The U.S. is struggling with dual crises of chronic pain and opioid overdoses. To improve statewide pain and addiction care, the Arizona Department of Health Services and 18 health education programs collaboratively created the evidence-based, comprehensive Arizona Pain and Addiction Curriculum which includes a Toolbox for Operationalization with adult learning theory applications and an annual program survey to assess curriculum implementation. The purpose of this study is to analyze the first year's survey data to better understand the implementation of a novel curriculum across all programs in the state.

Materials and Methods: Program surveys were sent 6 months after curriculum publication to all 18 health education programs in Arizona to assess the 6 Ds of curriculum implementation: Degree of implementation, Difficulty of implementation, Delivery methods, Faculty Development, Didactic dissonance and Discussion Opportunities.

Results: Responses from all program types (14/18 programs) indicated that there was widespread implementation of the curriculum, with 71% reporting that all ten Core Components had been included in the past academic year. The majority of programs did not find the Components difficult to implement and had implemented them through lectures. Seventy-seven percent of programs did not have a process to ensure clinical rotation supervisors are teaching content consistent with the curriculum, 77% reported not addressing student's didactic dissonance, and 77% of programs did not report asking students about their interactions with industry representatives.

Conclusion: In < 1 year after creation of the Arizona Pain and Addiction Curriculum, all program types reported wide implementation with little difficulty. This may represent a first step toward the transformation of pain and addiction education, and occurred statewide, across program types. Further focus on didactic dissonance, problem solving and faculty development is indicated, along with systematic education on pharmaceutical and industry influence on learners. Other programs may benefit from adopting this curriculum and may not experience significant challenges in doing so.

AMR-Intervene: a social-ecological framework to capture the diversity of actions to tackle antimicrobial resistance from a One Health perspective

The global threat of antimicrobial resistance (AMR) requires coordinated actions by and across different sectors. Increasing attention at the global and national levels has led to different strategies to tackle the challenge. The diversity of possible actions to address AMR is currently not well understood from a One Health perspective. AMR-Intervene, an interdisciplinary social-ecological framework, describes interventions to tackle AMR in terms of six components: (i) core information about the publication; (ii) social system; (iii) bio-ecological system; (iv) triggers and goals; (v) implementation and governance; and (vi) assessment. AMR-Intervene provides a broadly applicable framework, which can inform the design, implementation, assessment and reporting of interventions to tackle AMR and, in turn, enable faster uptake of successful interventions to build societal resilience to AMR.

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.

The feasibility and effectiveness of a blended-learning course for detecting and avoiding bias in medical data: a pilot study

BACKGROUND

Conflicts of interest (COIs), including those arising from interactions with pharmaceutical companies, may lead to bias in medical data. Although medical students are now requesting more education on COIs and bias, they are still not adequately taught during medical school, and few published courses on this topic exist. The objective of our study was therefore to evaluate the feasibility and effectiveness of a blended-learning course for detecting and avoiding bias in medical data, with a special focus on COIs.

METHODS

We developed a blended learning course on bias detection, COIs, and risk communication. It was piloted in the Fall Semester of 2019/2020 using a pre/post-test design. The primary outcome was a gain in bias detection skills, tested by a novel key feature test. Secondary outcomes were (i) skepticism (tested using an attitude questionnaire), (ii) the intention to manage COIs in a professional way so as to avoid bias (tested using a situational judgment test) and (iii) the course evaluation by the students.

RESULTS

Seventeen students participated in the study. The key feature test showed a significant improvement in bias detection skills at post-testing, with a difference in means of 3.1 points (95%-CI: 1.7-4.4, p-value: < 0.001; highest possible score: 16 points). The mean score after the course was 6.21 (SD: 2.62). The attitude questionnaire and situational judgment test also showed an improvement in skepticism and intentions to manage COIs, respectively. Students evaluated the course as having been worthwhile (Median: 5, IQR: 0.75, Likert-Scale 1-6, 6 = fully applicable).

CONCLUSIONS

The blended learning format of the course was feasible and effective. The results suggest a relevant learning gain; however, the low mean score on the key feature test after the course reflects the difficulty of the subject matter. Although a single course has the potential to induce significant short-term improvements in bias detection skills, the complexity of this important subject necessitates its longitudinal integration into medical curricula. This concept should include specific courses such as that presented here as well as an integration of the topic into clinical courses to improve context-related understanding of COIs and medical data bias.

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.

Quantity and quality of conflict of interest policies at German medical schools: a cross-sectional study and survey

OBJECTIVES

To assess the quantity and evaluate the quality of policies and curricula focusing on conflicts of interests (COI) at medical schools across Germany.

DESIGN

Cross-sectional study, survey of medical schools, standardised web search.

SETTING

Medical schools, Germany.

PARTICIPANTS

38 German medical schools.

INTERVENTIONS

We collected relevant COI policies, including teaching activities, by conducting a search of the websites of all 38 German medical schools using standardised keywords for COI policies and teaching. Further, we surveyed all medical schools' dean's offices. Finally, we adapted a scoring system for results we obtained with 13 categories based on prior similar studies.

MAIN OUTCOMES AND MEASURES

Presence or absence of COI-related policies, including teaching activities at medical school. The secondary outcome was the achieved score on a scale from 0 to 26, with high scores representing restrictive policies and sufficient teaching activities.

RESULTS

We identified relevant policies for one medical school via the web search. The response rate of the deans' survey was 16 of 38 (42.1%). In total, we identified COI-related policies for 2 of 38 (5.3%) German medical schools, yet no policy was sufficient to address all COI-related categories that were assessed in this study. The maximum score achieved was 12 of 26. 36 (94.7%) schools scored 0. No medical school reported curricular teaching on COI.

CONCLUSIONS

Our results indicate a low level of action by medical schools to protect students from undue commercial influence. No participating dean was aware of any curriculum or instruction on COI at the respective school and only two schools had policies in place. The German Medical Students Association and international counterparts have called for a stronger focus on COI in the classroom. We conclude that for German medical schools, there is still a long way to go.

Drug Promotion in India Since 2000: Problems Remain

Pharmaceutical companies engage heavily in promoting their products worldwide, and India is no exception. This article begins with an analysis of the therapeutic value of medications on the Indian market because, by definition, if a drug has no therapeutic value or has a negative benefit-to-harm ratio, then any promotion of that drug is inappropriate. It then examines 2 Indian case studies: drug promotion in Mumbai and the misuse of the World Health Organization logo in promotion. Next it describes specific types of promotion: advertisements in medical journals, brochures, and pamphlets; the actions of sales representatives; and the content of continuing medical education courses and medical conferences. The next sections examine medical students' and trainees' exposure to promotion and their attitudes about promotion; the attitudes of doctors about their interactions with the pharmaceutical industry; and whether promotion has an influence on prescribing. The article concludes with a critique of the existing industry, professional, and government regulatory regimes in India.

Mental Health as a Basic Human Right and the Interference of Commercialized Science

Although there is consensus that a rights-based approach to mental health is needed, there is disagreement about how best to conceptualize and execute it. The dominance of the medical model and industry's influence on psychiatry has led to an over-emphasis on intra-individual solutions, namely increasing individuals' access to biomedical treatments, with a resultant under-appreciation for the social and psychosocial determinants of health and the need for population-based health promotion. This paper argues that a robust rights-based approach to mental health is needed in order to overcome the effects of commercial interests on the mental health field. We show how commercialized science-the use of science primarily to meet industry needs-deflects attention away from the sociopolitical determinants of health, and we offer solutions for reform.

Pharmaceutical industry interactions of psychiatric trainees from 20 European countries

Background:

Interactions between the pharmaceutical industry (PI) and psychiatrists have been under scrutiny recently, though there is little empirical evidence on the nature of the relationship and its intensity at psychiatry trainee level. We therefore studied the level of PI interactions and the underlying beliefs and attitudes in a large sample of European psychiatric trainees.

Methods:

One thousand four hundred and forty-four psychiatric trainees in 20 European countries were assessed cross-sectionally, with a 62-item questionnaire.

Results:

The total number of PI interactions in the preceding two months varied between countries, with least interactions in The Netherlands (M (Mean) = 0.92, SD = 1.44, range = 0–12) and most in Portugal (M = 19.06, SD = 17.44, range = 0–100). Trainees were more likely to believe that PI interactions have no impact on their own prescribing behaviour than that of other physicians (M = 3.30, SD = 1.26 vs. M = 2.39, SD = 1.06 on a 5-point Likert scale: 1 “completely disagree” to 5 “completely agree”). Assigning an educational role to the pharmaceutical industry was associated with more interactions and higher gift value (IRR (incidence rate ratio) = 1.21, 95%CI = 1.12–1.30 and OR = 1.18, 95%CI = 1.02–1.37).

Conclusions:

There are frequent interactions between European psychiatric trainees and the PI, with significant variation between countries. We identified several factors affecting this interaction, including attribution of an educational role to the PI. Creating alternative educational opportunities and specific training dedicated to PI interactions may therefore help to reduce the impact of the PI on psychiatric training.

Medical, pharmacy and nursing students in the Baltic countries: interactions with the pharmaceutical and medical device industries

BACKGROUND

Interactions between pharmaceutical and medical device industries and students can lead to commercial influences on educational messages, with a potential to bias future treatment choice. This is the first study in the Baltic countries describing exposure and attitudes of medical, pharmacy and nursing students towards cooperation with industry.

METHODS

A cross-sectional on-line survey of current medical, pharmacy and nursing students (n = 918) in three Baltic countries was carried out.

RESULTS

We found that most students participate in events organized or sponsored by industry and accept a range of gifts and benefits. Students in the Baltic countries consider cooperation with industry important; at the same time, most do not feel that they have sufficient training on how to ethically interact with pharmaceutical and medical device companies and believe that these interactions can influence their prescribing or dispensing patterns. There is a tendency to rationalize cooperation with industry by referring to the current economic situation and patient benefits. Pharmacy students have higher rates of participation and they accept gifts and other benefits more often than nursing or medical students; therefore, they are likely to be more vulnerable to potential industry influence.

CONCLUSIONS

The findings highlight the need to include topics on ethics and conflicts of interests in cooperation with industry in curriculum of health care students in Baltic countries. Without proper training, students continue to be at risk to industry influence and may develop habits for their further practice differing from evidence-based practice in prescribing and dispensing of medicines, as well as use of medical devices.

Ethics and Industry Interactions: Impact on Specialty Training, Clinical Practice, and Research

Physicians in training and their mentors must be cognizant of ethical concerns related to industry interactions. Mentors perceived to have conflicts of interest or to be engaging in misconduct can unconsciously and profoundly affect the learning and academic environment by implying certain values and expectations. Despite increased awareness of ethical concerns related to industry interactions in clinical practice and research, there remains a need for interventions to prevent ethical transgressions. Ethics education is essential and a move in the right direction, but it alone is likely inadequate in preventing unethical behavior. Education should be supplemented with ethical environments at institutions.

Inadequate conflict of interest policies at most French teaching hospitals: A survey and website analysis

BACKGROUND

There are 32 teaching hospitals in France, including 30 University hospitals and two Regional teaching hospitals. Teaching hospitals have three roles: health care provision, training of healthcare professionals, and medical research. These roles lead to frequent interactions with pharmaceutical and medical device companies, inevitably raising risks of conflicts of interests. Therefore, policies to manage conflict of interests (COI) are crucial. This study aims to examine COI policies in French teaching hospitals.

METHODS

All French teaching hospitals (n = 32) were included in this study. All hospitals websites were screened for institutional COI policies and curriculum on COI, using standardized keyword searches. More data were collected through a questionnaire addressed to each chief executive officer (CEO) of the teaching hospital. We used predefined criteria (n = 20) inspired by similar surveys on COI policies in French, US and Canadian medical schools, with some additions to reflect the local hospital context. A global score for each hospital, ranging from 0 to 60 (higher scores denoting stronger policies) was calculated by summing points obtained for each criterion.

RESULTS

All 32 hospitals had websites; 21 hospitals listed policies or regulations on their websites or provided them on request. In December 2017, 17 (53.1%) had rules and regulations for some items only, four of which (12.5%) have considered implementing a policy, and only two (6.3%) have begun implementation. 15 (46.9%) had no evidence of COI policies and a null score. The maximum score was 24 out of 60.

CONCLUSION

This is the first systematic assessment of COI policies in teaching hospitals in France. Such policies are needed to protect patients, clinicians and students from undue commercial influence. Despite public and political pressure for better management of COI, few teaching hospitals have implemented comprehensive and protective policies, and some hospitals lacked policies altogether. These results highlight the need for greater attention to management of COI within teaching hospitals. One potential solution would be to integrate COI policies into hospital accreditation procedures, in order to ensure a baseline of management at all teaching hospitals.

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.

Academic conflict of interest

PURPOSE

We set out to summarize the current challenges in academic conflict of interest.

METHODS

This is a narrative review by a multidisciplinary, multinational panel of academic officers including deans of medical/pharmacy schools.

RESULTS AND CONCLUSIONS

Disclosing conflict of interest has become the appropriate professional behavior since the 1990s in response to the necessity to fix moral and financial fences around medical activities. The nature of the conflict of interest is academic when either the conflict relates to academic duties and/or the nature of the interest is academic. People usually distinguish between real conflict of interest, when private interest overtly influences one's professional obligations; potential conflict of interest, when there is no obvious direct link between a person interests and current duties without ruling out that expected changes in duties cause a situation of conflict; and apparent conflict of interest, when the risk does not really exist, but serious doubts remain. Areas at risk of academic conflict of interest include peer review process for grant evaluation or journals, scientific communications such as elaborating and disseminating clinical guidelines, lecturing at meeting, advising decision-makers, teaching activities, and mentoring. The management of academic conflict of interest should consider actions in four domains, i.e., education, prevention, measures for enforcement and solving, and communication. Academic conflicts of interest are as frequent as financial conflicts but more difficult to identify and assess, and much less addressed in the literature. Generating more evidence from high-quality research is mandated to improve the management of academic and more generally non-financial conflicts of interest.

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.

Closed Financial Loops: When They Happen in Government, They're Called Corruption; in Medicine, They're Just a Footnote

Many physicians are involved in relationships that create tension between a physician's duty to work in her patients' best interest at all times and her financial arrangement with a third party, most often a pharmaceutical manufacturer, whose primary goal is maximizing sales or profit. Despite the prevalence of this threat, in the United States and globally, the most common reaction to conflicts of interest in medicine is timid acceptance. There are few calls for conflicts of interest to be banned, and, to our knowledge, no one calls for conflicted practitioners to be reprimanded. Contrast our attitudes in medicine with public attitudes toward financial conflicts among government employees. When enforcement of rules against conflict of interest slackens in the public sector, news organizations investigate and publish their criticism. Yet even when doctors are quoted in the media promoting specific drugs, their personal financial ties to the drug maker are rarely mentioned. Policies for governmental employees are strict, condemnation is strong, and criminal statutes exist (allowing for corruption charges). Yet the evidence that conflict is problematic is, if anything, stronger in medicine than in the public sector. Policies against conflicts of interest in medicine should be at least as strong as those already existing in the public sector.

Conflicts of interest in infection prevention and control research: no smoke without fire. A narrative review

Conflicts of interest (COIs) do occur in healthcare research, yet their impact on research in the field of infection prevention and control (IPC) is unknown. We conducted a narrative review aiming to identify examples of COIs in IPC research. In addition to well-known instances, we conducted PubMed and Google searches to identify and report case studies of COIs in IPC and antimicrobial resistance (AMR), which were chosen arbitrarily following consensus meetings, to illustrate different types of COIs. We also searched the Retraction Watch database and blog to systematically identify retracted IPC and/or infectious disease-related papers. Our review highlights COIs in academic research linked to ties between industry and physicians, journal editors, peer-reviewed journals' choice for publication, and guideline committees participants and authors. It explores how COIs can affect research and could be managed. We also present several selected case studies that involve (1) the chlorhexidine industry and how it has used marketing trials and key opinion leaders to promote off-label use of its products; (2) the copper industry and how reporting of its trials in IPC have furthered their agenda; (3) the influence of a company developing "closed infusion systems" for catheters and how this affects networks in low- and middle-income countries and guideline development; (4) potential perverse incentives hospitals may have in reporting healthcare-associated infection or AMR rates and how government intervention may restrict AMR research for fear of bad publicity and subsequent negative economic consequences. Finally, the analysis of reasons for the retraction of previously published papers highlights the fact that misconduct in research may have other motivations than financial gain, the most visible form of COIs. COIs occur in the field of research in general, and IPC and AMR are no exceptions. Their effects pervade all aspects of the research and publication processes. We believe that, in addition to improvements in management strategies of COIs, increased public funding should be available to decrease researchers' dependency on industry ties. Further research is needed on COIs and their management.

Conflicts of Interest in Medicine. A Systematic Review of Published and Scientifically evaluated Curricula

Objective: Conflicts of interests resulting from interactions with pharmaceutical companies are pervasive in medicine and can result in an undue influence on physicians' decision-making. The objective of this systematic review is to analyze published and scientifically evaluated curricula for medical students and residents regarding such conflicts of interest. We begin by describing the covered topics and teaching methods; afterwards we analyze the quality of the curricula using the published data on their evaluations and comparing the content with content recommended for such curricula. Methods: We searched Pubmed, PsycInfo, EMBASE, OECD, WISO, SOWI and googlescholar up to and including the 5th of September 2016. Publications describing curricula for residents or medical students on the topic of conflicts of interest in medicine and evaluating them for their effects on the participants' learning were included. We analyzed the covered topics and the teaching methods used and compared them with recommendations by the American Medical Students' Association (AMSA) and Health Action International (HAI). Results: The literature search resulted in 20 publications that fulfilled our search criteria. In five trials, a control group was used, in no trial the participants were randomized to intervention or control group. 16/20 published curricula primarily covered marketing strategies by pharmaceutical companies, especially the interaction with pharmaceutical sales representatives (PSRs). Most curricula only covered a limited number of topics recommended by AMSA/HAI. The most frequent teaching method was a group discussion, which was used in 18/20 curricula; all curricula used at least one interactive teaching method. The evaluation of the curricula was heterogeneous in results as well as design. Some publications described a change of attitudes toward a stronger skepticism regarding interactions with pharmaceutical companies. Four publications described improved knowledge, one publication described a change in behavior toward a reduction of the acceptance of gifts. Conclusion: The trials conducted to this date regarding curricula on conflicts of interests are methodologically flawed and the described curricula lack important topics beyond marketing strategies of pharmaceutical companies. In addition, there are no data so far on the sustainability of the courses' effects on participants' behavior. It is therefore necessary to develop a model curriculum that covers a broader variety of topics and to evaluate it using a well thought-out methodology to create a foundation for the further improvement of teaching conflicts of interest in medicine.

Does growing up with a physician influence the ethics of medical students' relationships with the pharmaceutical industry? The cases of the US and Poland

Background

Medical schools have a major impact on future doctors’ ethics and their attitudes towards cooperation with the pharmaceutical industry. From childhood, medical students who are related to a physician are exposed to the characteristics of a medical career and learn its professional ethics not only in school but also in the family setting. The present paper sought to answer the research question: ‘How does growing up with a physician influence medical students' perceptions of conflicts of interest in their relationships with industry?’

Methods

An anonymous questionnaire was completed by 451 medical students from four Philadelphia medical schools and 554 medical students from Warsaw Medical University during 2013. Medical schools in these two cities were chosen because they are both university cities with similar population sizes. Students who had and who did not have a family member working as a physician were compared using chi-square analysis. Data were analysed for each country separately.

Results

For both the US and Poland, there were statistically significant differences (p < .05) between medical students with a physician as a family member and other students with respect to views regarding relationship with the pharmaceutical industry. In both groups, this difference occurred for three important dimensions: students’ relationship with the pharmaceutical industry; students’ views on physicians’ rights to cooperate with the pharmaceutical industry; trust in the pharmaceutical industry. In the US, students related to a doctor were characterized by more restrictive opinions on all three dimensions than other students (e.g., 27.8% of the former students vs. 31.4% of the latter students thought doctors had unrestricted rights to cooperate with the industry). However, the contrary was observed in Poland: students with a physician in the family had less strict views than their colleagues (e.g., 56.8% of the former vs. 39.7% of the latter thought that doctors should have unrestricted rights of cooperation).

Conclusions

In Poland, a former communist country, physicians transmit a more liberal approach towards collaboration with the pharmaceutical industry to their student relatives than those in the US.

Assessment of a Pharmaceutical Advertisement Analysis Module in a Drug Literature Evaluation Course

Objective. To evaluate the impact of an educational module on students' self-efficacy when analyzing the content of promotional drug brochures (PDBs) and to assess the students' value of PDBs' as an educational tool. Methods. Third-year bachelor of pharmacy students participated in a one-hour lecture and a two-hour laboratory. Students completed a survey before and after participating in the module. Results. The module elicited a statistically significant change in students' self-efficacy beliefs regarding evaluating promotional drug brochures, while the average perceived value of promotional drug brochures did not change significantly after the module. Conclusion. A brief educational module can increase students' self-efficacy in evaluating the content of PDBs.

Artículo retirado de la tabla de contenidos por duplicidad

Artículo retirado de la tabla de contenidos por duplicidad

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.

A cross-sectional analysis of pharmaceutical industry-funded events for health professionals in Australia

OBJECTIVES

To analyse patterns and characteristics of pharmaceutical industry sponsorship of events for Australian health professionals and to understand the implications of recent changes in transparency provisions that no longer require reporting of payments for food and beverages.

DESIGN

Cross-sectional analysis.

PARTICIPANTS AND SETTING

301 publicly available company transparency reports downloaded from the website of Medicines Australia, the pharmaceutical industry trade association, covering the period from October 2011 to September 2015.

RESULTS

Forty-two companies sponsored 116 845 events for health professionals, on average 608 per week with 30 attendees per event. Events typically included a broad range of health professionals: 82.0% included medical doctors, including specialists and primary care doctors, and 38.3% trainees. Oncology, surgery and endocrinology were the most frequent clinical areas of focus. Most events (64.2%) were held in a clinical setting. The median cost per event was $A263 (IQR $A153-1195) and over 90% included food and beverages.

CONCLUSIONS

Over this 4-year period, industry-sponsored events were widespread and pharmaceutical companies maintained a high frequency of contact with health professionals. Most events were held in clinical settings, suggesting a pervasive commercial presence in everyday clinical practice. Food and beverages, known to be associated with changes to prescribing practice, were almost always provided. New Australian transparency provisions explicitly exclude meals from the reporting requirements; thus, a large proportion of potentially influential payments from pharmaceutical companies to health professionals will disappear from public view.

Public health matters: Innovative approaches for engaging medical students

BACKGROUND

Public health faces the paradox of being increasingly emphasized by the key health and social care regulators and stakeholders, while remaining a largely under-represented discipline in the context of medical curricula. Enhancing medical student engagement in public health teaching is one way to address this concern.

METHODS

We discuss four key solutions to the challenges faced by public health educators in medical schools, and present five case studies which demonstrate innovative approaches to engaging medical students in our discipline.

RESULTS

Four different approaches have been piloted by members of the Public Health Educators in Medical Schools (PHEMS) network: (i) ensuring social accountability, (ii) demonstrating clinical relevance, (iii) mapping the core curriculum, and (iv) using technology enhanced learning. Preliminary student feedback suggests that these approaches can be used to position public health as an enabler of modern medical practice, and promote a more holistic understanding of medicine by linking patient-centred care to the population level.

CONCLUSIONS

The zeitgeist in both academia and the healthcare system supports the teaching of public health within the medical curriculum; there is also consensus at the political and pedagogical level. The challenge of ensuring engagement now needs to be met at the student-teacher interface.

Conflict of Interest Policies at French Medical Schools: Starting from the Bottom

BACKGROUND

Medical faculties have a role in ensuring that their students are protected from undue commercial influence during their training, and are educated about professional-industry interactions. In North America, many medical faculties have introduced more stringent conflict of interest (COI) policies during the last decade. We asked whether similar steps had been taken in France. We hypothesized that such policies may have been introduced following a 2009-2010 drug safety scandal (benfluorex, Mediator) in which COIs in medicine received prominent press attention.

METHODS

We searched the websites of all 37 French Faculties of Medicine in May 2015 for COI policies and curriculum, using standardized keyword searches. We also surveyed all deans of medicine on institutional COI policies and curriculum, based on criteria developed in similar US and Canadian surveys. Personal contacts were also consulted. We calculated a summary score per faculty based on 13 criteria. [range 0-26; higher scores denoting stronger policies].

RESULTS

In total, we found that 9/37 (24%) of French medical schools had either introduced related curriculum or implemented a COI-related policy. Of these, only 1 (2.5%) had restrictive policies for any category. No official COI policies were found at any of the schools. However, at 2 (5%), informal policies were reported. The maximum score per faculty was 5/26, with 28 (76%) scoring 0.

CONCLUSION

This is the first survey in France to examine COI policies at medical faculties. We found little evidence that protection of medical students from undue commercial influence is a priority, either through institutional policies or education. This is despite national transparency legislation on industry financing of health professionals and limits on gifts. The French National Medical Students Association (ANEMF) has called for more attention to COI in medical education; our results strongly support such a call.

Addressing Antimicrobial Resistance: An Overview of Priority Actions to Prevent Suboptimal Antimicrobial Use in Food-Animal Production

The growing concern regarding emergence of bacteria resistant to antimicrobials and their potential for transmission to humans via animal production has led various authorities worldwide to implement measures to decrease antimicrobial use (AMU) in livestock production. These measures are influenced by those implemented in human medicine, and emphasize the importance of antimicrobial stewardship, surveillance, infection prevention and control and research. In food producing animals, unlike human medicine, antimicrobials are used to control diseases which cause economic losses. This major difference may explain the failure of the public policies implemented to control antimicrobial usage. Here we first review the specific factors influencing AMU across the farm animal sector and highlighting the farmers' decision-making process of AMU. We then discuss the efficiency of existing regulations implemented by policy makers, and assess the need for alternative strategies, such as substitution between antimicrobials and other measures for infectious disease control. We also discuss the interests of regulating antimicrobial prices. Finally, we emphasize the value of optimizing antimicrobial regimens, and developing veterinary precision medicine to achieve clinical efficacy in animals while limiting negative impacts on public health. The fight against antimicrobial resistance requires both a reduction and an optimization of antimicrobial consumption. The set of actions currently implemented by policy makers does not adequately address the economic interests of farmers' use of antimicrobials.

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.

Knowledge, beliefs and attitudes of physicians in low and middle-income countries regarding interacting with pharmaceutical companies: a systematic review

Background

Understanding the perceptions and attitudes of physicians is important. This knowledge assists in the efforts to reduce the impact of their interactions with the pharmaceutical industry on clinical practice. It appears that most studies on such perceptions and attitudes have been conducted in high-income countries. The objective was to systematically review the knowledge, beliefs and attitudes of physicians in low and middle-income countries regarding interactions with pharmaceutical companies.

Methods

Eligible studies addressed any type of interaction between physicians and pharmaceutical companies. The outcomes of interest included knowledge, beliefs and attitudes of practicing physicians. The search strategy covered MEDLINE and EMBASE databases. Two reviewers completed in duplicate and independently study selection, data abstraction, and assessment of methodological features. The data synthesis consisted of a narrative summary of the findings stratified by knowledge, beliefs and attitudes.

Results

We included ten reports from nine eligible studies, each of which had a number of methodological limitations. Four studies found that the top perceived benefits of this interaction were receiving information and rewards. In five out of eight studies assessing the perception regarding the impact of the interaction on the behavior of physician prescription, the majority of participants believed it to be minor. In one of these studies, participants perceived that impact to be lesser when asked about their own behavior. The attitudes of physicians towards information and rewards provided by pharmaceutical company representatives (PCRs) (assessed in 5 and 2 studies respectively) varied across studies. In the only study assessing their attitudes towards pharmaceutical-sponsored Continuing Medical Education, physicians considered local conferences to have higher impact. Their attitudes towards developing policies restricting physicians’ interactions with PCRs were positive in two studies. In one study, the majority of participants did not mind the public knowing that physicians were receiving gifts and awards from drug companies.

Conclusions

This review identified few studies conducted in low and middle-income countries. While physicians generally perceived the impact of interactions on their behavior to be minor, their attitudes toward receiving information and rewards varied across studies.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1299-4) contains supplementary material, which is available to authorized users.

Pharmaceutical industry exposure in our hospitals: the final frontier

Despite recent changes in attitudes, most hospitals continue to experience pharmaceutical industry presence. Pharmaceutical industry presence may be necessary and beneficial in the context of sponsorship of clinical trials with appropriate governance. Doctors continue to hold positive attitudes towards market-oriented activities of the pharmaceutical and medical device industries. Despite evidence to the contrary, doctors believe they are able to effectively manage pharmaceutical sales representative interactions such that their own prescribing is not adversely impacted. Doctors also share a belief that small gifts and benefits are harmless. There may be significant financial burden associated with divestment of such sponsorship by hospitals. Change requires education and effective policies to manage pharmaceutical industry relationships and conflicts of interest. We discuss case studies involving students and public hospital doctors to show that divestment is possible without significant financial detriment. Health services need to be proactive in transitioning financial and cultural reliance on pharmaceutical industry sponsorship to other potentially less harmful sources.

Conflicts of interest in dermatology: a medical student and mentor perspective

Conflict of interest (COI) in medicine is well defined, but is seldom discussed in the field of dermatology. This perspective sheds light on this topic in dermatology and provides suggestions on how better to approach COI in medical school and residency.