Hodges, Laura E. MD; Arora, Vineet M. MD, MPP; Humphrey, Holly J. MD; Reddy, Shalini T. MD
The pharmaceutical industry interacts, extensively and influentially, with medical trainees and physicians.1–6 In one review, Wazana6 found that physicians interact with the pharmaceutical industry about four times per month. According to Austad et al,7 these interactions start early; 61% to 97% of preclinical students reported having some kind of interaction with the pharmaceutical industry. By the time they have reached their clinical years, 74% to 100% of students report some kind of interaction.
Physicians’ widespread exposure to the pharmaceutical industry’s marketing raises concerns about their ability to make unbiased, evidence-based treatment decisions. Drug marketing starts as early as the first year of medical school, shifting students’ and physicians’ attitudes in favor of the promoted drugs.6–11 Grande et al11 found that students’ overall “implicit attitude” varied with their schools’ institutional policies regarding interactions with the pharmaceutical industry; the more restrictive the policy, the less favorable the attitudes of students toward promoted drugs.
Educational efforts to address these conflicts of interest are directed mainly at trainees in medical school and residency.12–15 We wondered, though, whether the pharmaceutical industry interacts with students even before they enter medical school. Our study, the first to look at drug marketing among medical students before they enter medical school, examines the frequency and context of exposures to such marketing among students matriculating at one midwestern medical school. By understanding the extent and nature of exposure to pharmaceutical marketing among prematriculants, medical educators can better determine the appropriate type and timing of conflict-of-interest education.
In this cross-sectional survey study, designed to characterize the extent and nature of interactions between students and the pharmaceutical industry prior to matriculation in medical school, we distributed questionnaires, either paper or electronic (via Perseus and SurveyMonkey), to all 389 students who matriculated at the University of Chicago Pritzker School of Medicine from 2007 through 2010. The University of Chicago Biological Sciences Division institutional review board exempted the study from review.
Two separate but related questionnaires produced our study data. The first series of questions was part of a larger survey on professionalism, distributed to Pritzker medical students from 2007 to 2010 within six months of their matriculating.16 Students reported on whether they had observed or participated in two interactions with the pharmaceutical industry: “accepting a pen” and “attending a social event or dinner.” If they had, they were asked to judge the professionalism of the interactions, using a five-point Likert scale (1 = unprofessional, 2 = somewhat unprofessional, 3 = neutral, 4 = somewhat professional, 5 = professional).
When we analyzed that first survey, we found that interactions between the pharmaceutical industry and matriculating students happened more often than we had expected. We designed a follow-up survey to help us characterize the source and nature of those pre-medical-school interactions. In 2010, we distributed this cross-sectional survey to students in all four years by e-mail or during class lectures. In this second survey, students reported on the type, context, and frequency of interactions with the pharmaceutical industry and indicated whether they had participated in or merely observed the interaction.
Participation in both surveys was voluntary, and responses were anonymous and not linked to individuals. We used descriptive statistics to summarize the means and standard deviations to survey items. To compare the level of participation in pharmaceutical interactions with the professionalism assessment students gave to each of these behaviors, we used Wilcoxon rank sum tests. We performed data analysis in STATA 11.0 (College Station, Texas) with statistical significance defined as P < .05.
Of the 389 students who matriculated at Pritzker from 2007 to 2010, 282 (72.5%) responded to the first questionnaire. Response rates by year varied significantly, from 60.2% to 95.5% (chi-square = 34.1, P < .001). Of the 282 respondents, not every respondent answered every individual question in the survey. The total number of respondents to each question is indicated in the denominator of each result. A good portion of the students (114/278; 41%) reported that, as premedical students, they had accepted a pen from a pharmaceutical representative. A clear majority (164/276; 59.4%) reported that they had observed others accepting a pen. Almost a quarter of the students (61/266; 22.9%) found accepting a pen to be somewhat professional or professional.
Sixty students (60/277; 21.7%) reported that, as premedical students, they had attended a dinner or social event sponsored by a pharmaceutical representative. A full third of the students (93/279; 33.3%) knew supervisors or colleagues who had attended such a dinner or social event. They considered accepting drug companies’ hospitality somewhat professional or professional at only a slightly smaller rate (54/263; 20.5%) than they considered the professionalism of taking drug company pens.
Table 1 shows the association between students’ participation in an interaction and their perception of its professionalism. For both “accepting a pen” and “attending a social event or dinner,” students who had either participated in or observed these interactions were less likely to view them as unprofessional than those students who had not experienced these interactions. The difference in mean professionalism ratings between students who were exposed and not exposed was statistically significant for students who observed the two interactions (“attending social event or dinner,” P = .003; and “accepting pen,” P = .02), whereas the difference in ratings between students who participated and did not participate in these two interactions, although present, was less statistically significant (“attending social event or dinner,” P = .06; and “accepting pen,” P = .11).
We used our second survey to determine the contexts and locations in which pharmaceutical marketing contact was occurring. Of those same 389 students over the four years, 219 (56.3%) responded. Response rates by year also varied significantly, from 43.6% to 88.6% (chi-square = 51.3, P < .001). Over half of the students (136/219; 62.1%) reported some interaction with the pharmaceutical industry prior to medical school.
Table 2 shows the contexts in which students interacted with the pharmaceutical industry. These behaviors, listed in decreasing order of number of students who reported having engaged in them, were (1) accepting a pen, (2) attending a pharma-sponsored lunch, (3) receiving a small gift from the pharmaceutical industry, (4) attending a pharma-sponsored dinner, and (5) sponsored conference travel. For two interactions, “accepting a pen” and “attending a pharma-sponsored lunch,” students most commonly reported that it had occurred while shadowing. For two others, “receiving a small gift from the pharmaceutical industry” and “attending a pharma-sponsored dinner,” students most commonly reported that the interaction occurred during “other” contexts.
Students who reported interactions in “other” contexts were invited to describe that context in a free-text box. Over a quarter (17/58; 29.3%) of the students who used the free-text box to describe the “other” context described the interaction as taking place through a family member. Another 13 (13/58; 22.4%) described interactions while working in a medical setting. Several students (11/58; 19.0%) also reported that they had observed physicians interacting with pharmaceutical representatives while attending a conference.
To date, the literature has not focused on the exposure of premedical students to pharmaceutical marketing practices. Our single-institution survey showed a positive correlation between exposure to certain interactions with the pharmaceutical industry and the perceived professionalism of these interactions. Students exposed to the pharmaceutical industry before medical school viewed these interactions more positively than did those who had not been so exposed. This is consistent with findings from prior studies on students and professionalism.1 One possible explanation is that students are more likely to engage in behaviors they view as professional. An alternate explanation, based on cognitive dissonance theory, is that students may change previously held attitudes to be more consistent with the behaviors in which they have engaged.17
Our study’s main implication is that most students enter medical school having already had some form of contact with the pharmaceutical industry. Furthermore, students’ opinions about the professionalism of interactions between physicians and the pharmaceutical industry correlate with whether or not they themselves have interacted with this industry. If, in fact, students’ perceptions of professionalism are being altered even before matriculation, medical schools should intervene as early as possible. Our institution, for example, has implemented a first-year session about conflicts of interest associated with interactions with the pharmaceutical industry.
Most educational interventions are implemented during the clinical years or residency; studies have found little impact on trainees’ interactions with and attitudes toward pharmaceutical industry marketing.12–15 Perhaps these interventions come too late, after students have already formed opinions and become less receptive to such interventions. We suggest that future research should focus not only on the educational strategies that would most effectively counteract the influence of the pharmaceutical industry but also on the impact of early curricular interventions.
Our students reported being exposed to pharmaceutical marketing in a variety of contexts. Students are often exposed to the medical profession through relatives before medical school, but our finding that they were exposed to pharmaceutical marketing through family members was unexpected and is cause for further research. The overall percentage of students who reported this type of exposure was low, but we did not ask directly about the role of family members in exposure. Physician role models in the family can substantially affect the attitudes held by physicians in training toward their work.18 According to its most recent data, the Association of American Medical Colleges reports that 17.1% of all students matriculating at U.S. medical schools in 2006 had a father who was a physician, and 4.6% had a mother who was a physician.19 Despite this, we found no literature on the effect of physician parents on medical students’ attitudes toward pharmaceutical marketing, or even professional development in general. Given the high number of medical students with physician parents, the role of familial influence on students’ professional development calls for further study. These results also highlight the need for further research into the impact of premedical exposure to the medical system and the pharmaceutical industry.
Our study has important limitations. We used two questionnaires that—although we based the follow-up questionnaire on the preliminary findings of the first questionnaire—were separate instruments. Follow-up studies should ideally use one survey administered at a uniform time in students’ education. Our results are not fully generalizable because the survey population was limited to one medical school. This limitation is mitigated by the fact that Pritzker students come from all regions of the country, which suggests a wide range of premedical experiences and exposures to pharmaceutical marketing. Still, more fully comparable data may be gathered by surveying medical schools that are diverse in geography, mission statement, and funding.19
Another limitation of this study is the significant variability between years of the survey response rates. The response rates from students matriculating in 2010 were much higher (95.5% for the first survey and 88.6% for the second survey) than those from previous years, likely because, for the first time, we distributed the survey in paper form at a very well-attended orientation lecture. In 2007 through 2009, we distributed the survey by e-mail or in paper form at lectures further along in the academic year, when student attendance was not as high. The possibility of response bias exists in those first three years; students with strong feelings regarding pharmaceutical marketing may have been more likely to complete the survey. Unfortunately, our data on the nonresponders from those years are not good enough to test for bias.
The timing and content of the follow-up survey present other limitations. We distributed it to the students in all four classes at the same time (in 2010). This made it susceptible to recall bias by the upper-level students, who were by then several years removed from their premedical studies. Additionally, the follow-up survey included an “other” category. An intermediary qualitative study might have suggested more specific categories, which could have more fully elucidated the extent and contexts of students’ exposure to pharmaceutical marketing. Finally, we did not collect demographic data, so we are unable to link results to age, gender, race, parents’ education, or parents’ occupation.
The role of pharmaceutical industry marketing in medical education is under pressure to change. According to Brennan et al,20 educational programs are only one of the interventions that will help bring about these changes. Over time, increased restrictions on how the pharmaceutical industry interacts with physicians may also diminish its interactions with premedical students. Kao et al21 suggest investigating how recent changes to institutional conflict-of-interest policies at many academic medical centers affect medical students’ exposure and attitudes. Proposals—such as that of Austad and Kesselheim22—that faculty disclose conflicts of interest could expose students to effective role modeling behaviors early in their medical training. Ultimately, to change the way students view and interact with pharmaceutical industry marketing, medical educators must use a wide spectrum of tools—both institutional changes and the more traditional curricular interventions aimed directly at students.
Acknowledgments: The authors wish to thank Michael McGinty and Morgan Sonderegger.
Other disclosures: None.
Ethical approval: This study received review exemption from the University of Chicago Biological Sciences Division institutional review board.
Previous presentations: Oral presentation, Society for General Internal Medicine Midwest Regional Meeting, September 2010, Chicago, Illinois; poster presentation, Association of American Medical Colleges Annual Meeting, November 2011, Denver, Colorado.
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