Hyman, Paul L. MD; Hochman, Michael E. MD; Shaw, Jonathan G. MD; Steinman, Michael A. MD
Defining the appropriate relationship between the pharmaceutical industry and the medical profession continues to be a highly contentious issue. Many have raised concerns that gifts to physicians from pharmaceutical companies, as well as pharmaceutical-sponsored educational activities, represent a conflict of interest.1–6 These issues are particularly germane to medical students because medical school is a time when physicians in training learn the principles that will guide them throughout their careers.
Few medical schools have policies guiding student–pharmaceutical industry interactions,7 although several schools have created stricter policies for their faculty.8,9 Previous studies at U.S. and Canadian medical schools have found that students receive numerous gifts from pharmaceutical companies and interact frequently with pharmaceutical representatives.7,10–14 These studies have suggested that most students support such interactions7,10–11,13–15 and feel that the pharmaceutical industry has an important role in medical education,7,10,15 yet students consider themselves inadequately educated on how to interact with the pharmaceutical industry.7,10,11,14 Limited data suggest that students generally believe that medical schools should not develop policies to limit pharmaceutical involvement in medical education.14 However, few studies have examined how students’ opinions differ between medical school class years. Understanding these differences is important because it can reflect how the medical school experience influences students’ attitudes toward interactions with industry.
After our class had received a free textbook from a pharmaceutical company during a second-year musculoskeletal course at HMS, we surveyed our student body to determine their opinions about the role of the pharmaceutical industry in medical education. In particular, we focused on differences in students’ opinions across class years, specifically, between the preclinical (first and second) and clinical (third and fourth) years. We also looked for correlations between students’ opinions and their self-reported level of education about the pharmaceutical industry.
After the free textbooks were given as gifts to the second-year class (through distribution to student mailboxes, with a letter in the front cover explaining which pharmaceutical firm had made their distribution possible), several students expressed concerns about the appropriateness of the gift, generating classwide discussion about the appropriateness of interactions between students and industry. In a class of approximately 150 students, about 10 students chose to return their textbooks, citing ethical concerns.
At the time, HMS did not have an explicit policy on pharmaceutical industry gift- giving to students, but Harvard University policy did state that “educational activities of the university, including student services, should be free from intrusive commercial aspects.” There was no required course at the medical school that discussed pharmaceutical industry gift-giving, although some students discussed these issues in an elective ethics class. On the wards, there was a large amount of variability in how much interaction students had with pharmaceutical representatives. Some departments had daily drug company lunches, whereas others did not permit direct interaction with pharmaceutical representatives.
Several students proposed that the medical school should develop a policy to regulate industry interaction with students. The dean of medical education at the time suggested that the student body should be surveyed to determine their opinions about pharmaceutical involvement in medical education.
From November 2003 through January 2004, we distributed an anonymous six-question survey to the student body of our medical school. The questionnaire presented six opinion statements related to pharmaceutical companies’ interactions with medical students. Using a five-point Likert scale (1 = strongly agree, 2 = agree, 3 = neutral, 4 = disagree, and 5 = strongly disagree), participants were asked to express their opinions about the following statements:
1. It is appropriate for medical students to accept gifts from pharmaceutical companies.
2. It is appropriate for medical students, during their formal education (i.e., while in class or clerkships), to be presented with promotional gifts from pharmaceutical companies.
3. The medical school curricula (classroom or clerkship) should include events sponsored by pharmaceutical companies.
4. HMS should take a role in guiding students’ interactions with the pharmaceutical industry.
5. I feel adequately educated on the issue of pharmaceutical industry–medical professional interactions.
6. I believe there is adequate separation between Harvard affiliated hospitals/faculty and the pharmaceutical industry.
Participants were also asked their year in medical school. Respondents had the opportunity to give additional qualitative comments.
A paper questionnaire was initially distributed during a course required for most students during their clinical years. Subsequently, an e-mail link to an electronic version of the questionnaire was sent to the entire medical student body, requesting that it be completed only by those who had not already submitted the paper version. The questionnaire was made available for two weeks, and a reminder e-mail was sent halfway through the survey period.
For each question, we calculated the percentage of students responding in each category and the mean Likert scale responses, excluding “I don’t know” responses when calculating means. Comparisons of Likert scale responses between preclinical (first and second year) and clinical (third, fourth, and fifth year) medical school classes were done using the Mann-Whitney test. Additional analyses comparing individual class years were conducted using the Kruskal-Wallis test for equality of populations. Finally, correlations between responses to these questions and self-reported education on medical professional–industry interactions were analyzed using Pearson’s correlation test. In all analyses, students who reported being in their fifth year of medical school were counted as fourth-year students because both sets of students were typically at or near the end of their medical school experience. Students who reported being in a class year other than first, second, third, fourth, or fifth were excluded from the analyses. A P value of < .05 was considered significant. All analyses were performed using STATA version 8.0 (Stata Corp; College Station, TX).
The survey was initially conducted solely for the purpose of generating internal discussion. We subsequently obtained permission to publish the results from the Committee on Human Studies at HMS and from the Research and Development Committee at the San Francisco VA Medical Center and the Committee on Human Research at the University of California, San Francisco.
A total of 418 questionnaires were returned from a student body of 723—an overall response rate of 58%. Of the respondents, 103 (25%) reported being first-year students, 89 (21%) were second-year students, 132 (32%) were third-year students, 82 (20%) were fourth- or fifth-year students, and 12 (3%) were others (e.g., MD–PhD or other dual-degree students beyond their fifth year).
Overall, the majority of students were skeptical of pharmaceutical involvement in their education. More than half of the students did not agree (checking “strongly disagree” or “disagree”) that it is appropriate for medical students to be presented with promotional gifts from pharmaceutical companies during their formal education or that the medical school curriculum should include events sponsored by the pharmaceutical industry (Table 1). Student opinion was divided about whether the Harvard- affiliated hospitals and faculty were adequately independent from the pharmaceutical industry, with 125 (30%) students answering “I don’t know” when asked whether the relationship was appropriate. The majority of the responding students—253 (61%)—reported that they did not feel adequately educated about interacting with the pharmaceutical industry.
Responses were divided into preclinical and clinical students to determine whether there were differences between these groups (Table 2). For most questions, attitudes were similar for preclinical and clinical medical students, with students tending to feel that it is not appropriate for students to accept gifts from the industry, that it is not appropriate for students to be presented with gifts during the formal curriculum, and that the medical school should take a role guiding students’ interactions with the industry. Both clinical and preclinical students were, on average, neutral when asked whether they thought there was appropriate separation between the Harvard hospitals and the pharmaceutical industry.
Statistically significant differences in some responses according to students’ self-reported levels of education were observed: clinical students felt better educated about interacting with the pharmaceutical industry than did preclinical students (mean Likert scale responses 3.3 and 3.8, respectively; P < .001). In addition, clinical students were slightly less accepting of industry-sponsored events than were preclinical students: the mean response of clinical students was 3.8 compared with a mean response of 3.6 in preclinical students (P = .04).
To determine whether differences between individual classes might have affected these results, we repeated the analyses, comparing each class individually. Results were generally similar, with two exceptions. Regarding the medical school’s role in guiding students’ interactions with industry, there were substantial differences between third- and fourth-year students (mean Likert score 2.3 for first-year students, 2.4 for second-year students, 2.6 for third-year students, and 2.0 for fourth-year students; P = .04). Also, the greater perception among clinical students of being adequately educated on industry–medical professional interactions was largely driven by third-year students (mean Likert score 3.8 for first-year students, 3.7 for second-year students, 3.1 for third-year students, and 3.6 for fourth-year students; P < .001).
Students’ responses to the question about how well educated they felt regarding interactions with the pharmaceutical industry were correlated with their responses to the other five statements (Table 3). Students’ self-perceived levels of education on the topic were inversely correlated with their desire for an academic policy controlling their interactions with the pharmaceutical industry (i.e., students who felt better educated were less likely to believe that the medical school should take a role in guiding students’ interactions, and vice versa). All other statements correlated positively (e.g., students who reported feeling well educated on the topic were more likely to agree that student–pharmaceutical industry interactions were appropriate). All correlations were statistically significant. However, the magnitude of the correlations was small for all questions.
Discussion and Conclusion
In this study, we found that the majority of students at HMS were skeptical about the role of the pharmaceutical industry in their education. Many students felt inadequately educated about interaction with the pharmaceutical industry, and students’ opinions about pharmaceutical industry–medical school interactions did not generally differ between the preclinical and clinical class years. In addition, we found that students who felt they were better educated about interaction with the pharmaceutical industry tended to be less skeptical of industry involvement in medical education.
The similarity in opinions throughout the class years was surprising. Given the significant acculturation that takes place as students transition to the wards and clinic, where they have greater contact with the pharmaceutical industry and its representatives and where they observe how practicing physicians handle such interactions, it might be expected that preclinical and clinical students’ opinions would be different. The lack of difference we observed between the opinions of students in these two groups suggests that the medical school experience may have minimally impacted students’ opinions regarding pharmaceutical industry–medical student interactions. In our view, a possible implication of this result is that the opinions that graduating students carry into residency and that guide their physician–industry interactions may largely be the same opinions that they carried into medical school. However, because the students in our study were not followed longitudinally, this hypothesis is speculative.
The similarity in responses between preclinical and clinical students is consistent with results from a study at the University of Western Ontario, which showed that students’ opinions of pharmaceutical gifts do not differ among the class years.15 It is also consistent with a published abstract from Georgetown Medical School, which found no significant differences among the different classes in response to several questions about the pharmaceutical industry.14 In contrast, a recent study of medical residents at the University of Chicago found modest changes during the training period in attitudes toward several specific activities, with less acceptance of activities such as tickets to sporting events or complimentary rounds of golf, but increasing tolerance of sales representatives’ activities at noon conferences and of gifts of pens, notepads, and pocket antibiotic guides.16
In our study, preclinical and clinical students did respond differently to two of the six questions. Clinical-year students were less likely to agree that the medical school curriculum should include events sponsored by the pharmaceutical industry, although the magnitude of this difference was small. It is possible that third- and fourth-year students, who often have more interactions with industry representatives, tend to be more skeptical of the industry. However, this is not consistent with studies of medical residents by Brotzman and Mark,17 Hodges,11 and McCormick et al,18 which found that medical students and residents who have fewer interactions with pharmaceutical representatives tend to be less accepting of pharmaceutical gifts.
Additionally, clinical-year students were more likely to feel adequately educated on the issue of pharmaceutical industry–medical professional interactions than first- and second-year students. Most of the difference was attributable to the fact that the members of our class (we were third-year medical students at the time of the survey) felt considerably more educated than did those in all other classes, including those in their fourth year, whose reported levels of education were similar to those of preclinical students. We posit that higher levels of perceived education among third-year students may be the result of class discussion and ad hoc educational efforts directed at our class that closely preceded our survey and arose from the same textbook-gift controversy that had precipitated that survey. Although this explanation is speculative, it would be consistent with the findings of Vinson et al.19 and Wilkes and Hoffman,20 who found that even short educational activities about the pharmaceutical industry can increase students’ knowledge about industry marketing practices, although the long-term effect of such interventions may not be robust.16
Our findings suggest that many students may graduate from medical school without feeling adequately educated about what constitutes appropriate pharmaceutical industry–medical professional interactions. Specifically, we found that one quarter of students felt adequately educated about such interactions and that fourth-year students in our survey did not feel significantly better educated on the topic than did the first- or second-year students. Thus, our survey adds support to the growing literature that has suggested the need for increased attention to this topic in medical education. Monaghan et al10 found that a considerable percentage of fourth-year students at Creighton University did not believe they had been given “sufficient training during education regarding how one should interact with pharmaceutical sales representatives.” Fischer et al14 found that 33% of fourth-year medical students at Georgetown felt “they had been given sufficient training to interact with pharmaceutical company representatives.” Sierles et al7 found that 78% of students at eight medical schools felt “their school should teach them more about the drug company–physician relationship,” and a survey of residents by Steinman et al21 reported that 14% of those surveyed had received “moderate” or “a lot” of training about the pharmaceutical industry during medical school, with 44% reporting no education during medical school on this topic.
Another notable finding of our survey is that students’ responses about their levels of education on physician–industry interactions correlated with their responses to all other questions, although the magnitude of these correlations was small. The students who reported being better educated on the topic were more likely to favor involvement of the pharmaceutical industry in their education and to disfavor guidance from their medical school. The reasons for this are not clear. One explanation is that students who have received more education about the industry have a better understanding of the industry’s agenda and, therefore, feel more comfortable interacting with the industry. Alternatively, students who interact more with industry may consider themselves better educated and (by virtue of predilection or experience) desire less regulation of these interactions, a hypothesis consistent with previous research showing less skepticism among trainees with greater experience of industry activities.11,17,18 Finally, students who are less skeptical of the pharmaceutical industry may not feel that they require as much education about the industry and may, therefore, be more likely to judge themselves adequately educated. Because the correlation is small and opinions about physician–industry interactions may have been influenced by the textbook gift, these results require confirmation. Further investigation into this question, with an objective means of measuring levels of student education on this topic, would be necessary to elucidate this finding.
Finally, it is important to mention that the majority of students favored only limited involvement of the pharmaceutical industry in their education. These results differ, to some degree, from those of other studies. As previously noted, prior studies have found that the majority of students support involvement of the pharmaceutical industry in medical education. The reasons for the discrepancy between our results and those of prior studies are not clear. Students’ opinions may differ from school to school or from region to region, or they may change with time and changes in the political climate. In addition, there is a lack of standardization of survey methods in the literature surveying attitudes towards the pharmaceutical industry.22 These differences may be responsible for some of the discrepancies.
We acknowledge several limitations to this survey. First, because participation was voluntary, our results are susceptible to selection bias. The survey instrument was distributed after the discussions that had been generated by the free textbook gift. These discussions may have affected the responses of the third-year students, the group most involved in these discussions. Other classes may have been influenced as well, though likely to a lesser extent. In addition, the cross-sectional nature of this survey does not clarify whether individual opinions change during the medical school experience; rather, the results only indicate that there were no differences between class years at a single point in time. The survey questions we used have not been formally validated, and using a Likert scale to assess students’ opinions has limitations; most notably, it does not reflect the full complexity of those opinions. Nonetheless, we feel the survey gives useful insight into the general opinions of our student body and reaffirms the need for greater educational attention to the subject of pharmaceutical interactions during medical school.
It seems clear that as the relationship between the pharmaceutical industry and physicians becomes increasingly complex, medical schools will need to devote more attention to helping their students develop appropriate ethical standards for interacting with pharmaceutical companies. It does not appear, at least at our medical school, that the curriculum or medical school experience is having much systematic impact on students’ opinions regarding pharmaceutical interactions. This suggests the need for greater efforts to educate students on this topic. Medical schools should evaluate their curricula to determine how best to assist students in developing informed opinions and ethical standards for their interactions with the pharmaceutical industry. Although some have advocated training students and residents through the use of structured interactions with sales representatives,23 this may implicitly condone such interactions as normative. Rather, we believe medical students may be better served by vigorous education on this topic, combined with policies (such as those proposed by the American Medical Student Association24) that markedly restrict or eliminate students’ contact with industry representatives and activities.
The authors are indebted to Dr. William Taylor, MD, Harvard University, for his advising role, and to Saunak Sen, PhD, and Daniel Bertenthal, MPH for their assistance with statistical and data management issues. Dr. Steinman was supported by a Research Career Development Award from the Health Services Research and Development Service of the Department of Veterans Affairs.
The views expressed in this manuscript are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs.
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