One need only walk into a hospital or clinic to be struck by the pervasiveness of pharmaceutical marketing to physicians to the tune of an estimated $6.3 billion dollars annually.1 Pens and notepads bearing product brand names are commonplace. Nearly 90% of physicians have been exposed to pharmaceutical industry marketing on the average of four times per month.2,3 Most physicians have received gifts from the pharmaceutical industry, mainly small trinkets, books, and free meals, but also more expensive tributes such as travel to a conference, tickets to entertainment events, and even cash.4 These pharmaceutical industry–physician interactions often begin in medical school and continue into residency and practice.3
Pharmaceutical marketing is prominent in teaching hospitals and residency programs.5–7 Most residents consider gifts from pharmaceutical representatives appropriate, particularly if the gifts are of minimal value.8,9 Although interactions with pharmaceutical representatives often begin in medical school, research into the exposure and attitudes of medical students toward pharmaceutical marketing is sparse.10,11
Accepting gifts from the pharmaceutical industry is controversial as such gifts establish an implicit relationship between the pharmaceutical representative and physician with a “vague, but real” obligation.12 Interestingly, most residents and physicians deny that these gifts influence their prescribing behavior.4,8,13 Only rarely do physicians admit that their prescribing habits have been affected by interactions with pharmaceutical representatives.6,7 Substantial evidence exists, though, that gifts do influence both prescribing behaviors and requests for formulary additions of drugs made by the sponsor's company.2,3,14
Despite the prominence and potential impact of pharmaceutical marketing, most students and residents receive little or no education regarding pharmaceutical marketing techniques or the ethics of gift acceptance.5,9 A minority of residents are satisfied with their training for dealing with pharmaceutical marketing during medical school or residency.8 Even when written guidelines governing interactions between residents and pharmaceutical companies exist, such guidelines are more likely to concern the distribution of drug samples, displays, and working-hours contact between residents and pharmaceutical representatives than to address the ethics of gift giving.15
Given the substantial impact of pharmaceutical marketing in the health care industry, we propose that the interactions between pharmaceutical representatives and medical students warrant further investigation. In this study, our objective was to better characterize the nature of the student–industry interaction. We sought to compare the differences in number and forms of exposures between preclinical and clinical students. We further determined how many students had received formal or informal education from a faculty member or advisor regarding interactions with the pharmaceutical industry.
We administered questionnaires to 281 second-, third-, and fourth-year medical students at the University of Minnesota Medical School—Twin Cities, from December 2001 through May 2002. Questionnaires were distributed to all 165 second-year students prior to an examination at University of Minnesota's Minneapolis campus. We personally distributed questionnaires to 82 third- and fourth-year medical students during clinical clerkships in obstetrics–gynecology, psychiatry, internal medicine, surgery, and primary care at various hospitals in the Twin Cities area. Additionally, 34 questionnaires were mailed to third-year students participating in the Rural Physicians Associate Program (RPAP) in various small towns in Minnesota. All surveyed students attended years one and two of medical school at University of Minnesota's Duluth or Minneapolis campus.
On an anonymous 17-item questionnaire, we asked participants for demographic information including gender, year of birth, work history, whether the first two years of medical school were spent at the Duluth or Minneapolis campus, whether the student was a participant in RPAP, and medical practice goals.
We asked students to classify the number of times they were exposed to pharmaceutical marketing during medical school as none, a few (one to five exposures), some (six to ten exposures), quite a few (11–20 exposures), or many (>20 exposures). Participants were asked to identify which of the following gifts they had received: meal at a lecture, fine dining, tickets to an event (sports or cultural), textbook, pocket text, medical journal subscription, and/or trinket (including pens, notepads, penlights, and stethoscopes). Participants were asked to rate their experiences as positive or negative on a scale of 1 to 5, where 1 = most positive, 3 = neutral, and 5 = the most negative. We additionally asked students whether the donor was readily identifiable during these exposures, in what rotations and settings pharmaceutical marketing most often occurred, if they knew or could guess the cost of the gifts they received, and which gifts they valued most. Participants were asked if an instructor or advisor had ever discussed the issue of pharmaceutical marketing with them.
We classified students in their second year of medical school as “preclinical” students. Students in their third and fourth years were designated as “clinical” students. We compared clinical and preclinical students using a χ2 analysis with a p value of < .05 considered to be significant.
One-hundred fourteen preclinical students (69.1%) and 107 clinical students (92.2%) responded to the questionnaire (see Table 1). Preclinical students had an average age of 25.5 years and 65 (57.5%) were women. Clinical students had an average age of 26.9 years and 58 (54.7%) were women.
Nearly all students surveyed had been exposed to pharmaceutical industry marketing during their medical school career (see Figure 1), with only three students (1.4%) recalling no exposures. Clinical students reported a significantly greater number of exposures than did preclinical students (p < .005). Among preclinical students, three (2.6%) reported no exposures to pharmaceutical industry marketing, and 15 (13.2%) reported more than 20 exposures. All clinical students had at least one exposure to pharmaceutical marketing. Among clinical students, 76 (71.7%) reported more than 20 exposures.
The most common gifts medical students received from the pharmaceutical industry were free meals, trinkets, and pocket texts (see Figure 2). Clinical students were statistically significantly more likely than were preclinical students to have received a free meal (98.1% of clinical students versus. 89.5% of preclinical students, p < .01), textbook (26.2% versus 10.5%, p < .005), pocket text (78.5% versus 29.8%, p < .005), or trinket (91.6% versus 63.2%, p < .005) from a pharmaceutical representative. Clinical and preclinical students (14%, respectively) were equally as likely to have received a journal courtesy of the pharmaceutical industry.
Clinical and preclinical students both viewed interactions with the pharmaceutical industry as slightly positive, with clinical students giving such exposures an average rating of 2.58 and preclinical students giving such encounters an average rating of 2.67. Students could identify the donor of the gifts more often than not (82.4% of clinical students and 73.3% of preclinical students). For the most common gift, a free meal, 77 (73.5%) clinical students and 84 (82.4%) preclinical students said they could identify the donor. For the receipt of trinkets, 75 (76.5%) clinical and 62 (86.1%) preclinical students said they could identify the donor.
Institutional settings, including school, hospitals, and clinics, were the most common setting of these interactions. Of clinical students, 37 (34.6%) identified internal medicine and 29 (17.8%) identified the primary care clerkship as the rotations during which they were most frequently exposed to pharmaceutical marketing. Virtually all clerkships exposed clinical students to pharmaceutical marketing. The majority of students (96.1%) did not know the value of gifts they had received, but students’ estimates for individual gifts ranged from $0.25 – $200. Of clinical students, 41 (38.3%) named pocket texts, 25 (23.4%) named trinkets, and 23 (21.5%) named free food as the gifts they valued most. Of preclinical students, 24 (21.5%) identified trinkets, 20 (17.5%) identified food, and 6 (5.3%) identified pocket texts as the gifts they valued most.
The majority of students had not discussed the issue of pharmaceutical marketing with an advisor or instructor. Fifty-nine (55.7%) clinical students and 87 (80.6%) preclinical students reported that they had not discussed the issue with an advisor or instructor (p < .005). Forty-seven (44.3%) clinical students and 21 (19.4%) preclinical students had discussed the issue with an advisor or instructor. One clinical and six preclinical students did not answer this question.
Pharmaceutical marketing is prominent within the health care industry, often beginning in medical school. Our study indicates that medical students are frequently presented with free meals, pocket texts, and small gifts such as pens, penlights, and notepads. Exposure to the pharmaceutical industry increases as students progress from the preclinical to the clinical curricula. Even items of nominal value captured the attention of students, with students indicating small trinkets, free meals, and pocket texts as the gifts they prized.
Given what is already known about the effects of such exposures on the prescribing patterns of physicians and residents, these early interactions of pharmaceutical representatives with physicians-to-be warrant the attention of both the medical school and the medical community. Physicians who participate in meetings with pharmaceutical representatives are more likely to request formulary additions for drugs marketed by that representative's company and less likely to prescribe generic formulations.3 Although physicians generally acknowledge this influence of pharmaceutical marketing over other physicians’ prescribing behaviors, many of these same physicians do not believe that their own prescribing behaviors are affected by the gifts they accept.9 Early student–pharmaceutical industry interactions establish a foundation for later pharmaceutical industry influence.
Over the past two decades, professional organizations have observed the growth of the pharmaceutical industry and have registered concern over the ethical dilemmas surrounding physician–industry interactions. Several professional organizations including the American Medical Association (AMA) have established written guidelines regarding the appropriateness of accepting gifts from pharmaceutical representatives. The AMA deems gifts to physicians acceptable so long as they are of minimal value and entail a benefit to patients.16 Recently, however, some medical students have rallied for a more rigorous code of ethics. In March, 2002, the American Medical Student Association (AMSA) established a set of guidelines urging all medical students and physicians to refuse all gifts and a policy prohibiting pharmaceutical advertisements in AMSA publications.17
Residency programs are beginning to adopt guidelines regarding residents’ interactions with pharmaceutical representatives. Physicians trained at programs that restrict industry–resident contact tend to view pharmaceutical representatives and the acceptance of gifts less favorably.18,19 Only a minority of residency programs, though, provide formal education to guide residents in dealing with pharmaceutical marketing. Most residents feel ill-prepared by residency programs or medical school curricula to deal with such interactions,8 and many have never received any formal education in this matter in medical school or residency.9
Little research has been done into the prevalence of guidelines and formal curricula in medical school programs and the effect of such teaching. Indeed, a minority of our participants had received any education from an instructor or advisor regarding interactions with the pharmaceutical industry. With the substantial exposure of medical students to the pharmaceutical industry and the potential impact of such exposures, we urge medical schools to develop formal instruction to address this topic and better prepare students for industry interactions.
Our study had some limitations. We surveyed students at one university-based medical school. Our results may be limited by recall bias, given the self-reported nature of the data. This limitation could have affected our results regarding the types and numbers of students’ exposures to pharmaceutical industry marketing, and whether they could recall receiving any gifts during these exposures. Additionally, interpretations of what constituted informal education on pharmaceutical marketing may have differed from student to student.
The aim of our study was to determine the character and scope of interactions between the pharmaceutical industry and medical students. The preliminary evidence suggests that medical students are not immune to gift giving by pharmaceutical representatives. Even the U.S. Department of Health and Human Services has recognized the potential influence of such pharmaceutical marketing over health professionals.20 Future research into this subject should consider studying whether these early medical school exposures influence later practice and prescribing patterns. Formalized education of medical students about pharmaceutical marketing has the potential to train students to reasonably evaluate contacts made by pharmaceutical representatives. As medical schools begin to incorporate this subject into their curricula, studies will be necessary to assess the effectiveness of this education. With ever increasing attention on clinical outcome measurements and cost containment within the medical profession, the impact of a better informed base of medical students on pharmaceutical marketing could be substantial, especially given the focus of today's multibillion dollar pharmaceutical industry on physicians and physicians-to-be.
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