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Examining Professional Behavior

The Hidden Curriculum: Medical Students’ Changing Opinions toward the Pharmaceutical Industry

Fitz, Matthew M.; Homan, David; Reddy, Shalini; Griffith, Charles H. III; Baker, Elizabeth; Simpson, Kevin P.

Editor(s): Cook, David MD; Hemmer, Paul MD

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doi: 10.1097/ACM.0b013e31813e7f02
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Recent articles in medical education have documented the exposure of medical students to pharmaceutical representatives during the clinical clerkships.1–3 As recently as this year, surveys of medical students’ attitudes towards accepting pharmaceutical gifts have failed to demonstrate any difference in the opinions of preclinical versus clinical medical students.4 Nevertheless, ongoing debate has suggested that academic medical centers, the primary location for medical student training, should take a more active role in eliminating conflicts of interest from the health care industry that compromise a physicians’ professionalism.5 Specifically, the challenge to the medical education community is to restrict the presence of pharmaceutical representatives on medical campuses, especially in areas of education. Nevertheless, little formal education is given for medical students in addressing attitudes toward and knowledge of the pharmaceutical industry.6 Our study aimed to better define these prevailing themes while seeking to uncover unique dynamics in medical students’ formative years. We wanted to determine how much exposure medical students are having with representatives of the pharmaceutical industry. We also wanted to evaluate medical students’ opinions regarding pharmaceutical industry gifts to government officials, physicians, themselves, and their colleagues, and whether students felt those gifts influence prescribing behavior. Uniquely, we also wanted to identify whether medical students’ attitudes changed during medical school, with the hypothesis that medical students became more favorable toward accepting gifts from the pharmaceutical industry without a change in their knowledge of the pharmaceutical industry’s influence.

Before initiating the survey, all the institutions administering the survey acknowledged that there were no formal curricula regarding the pharmaceutical industry at our respective schools.


The IRB at our institution approved the following research design. Our study used an anonymous 20-item questionnaire administered to medical students from four different medical schools: Loyola University Chicago Stritch School of Medicine, Rush Medical College, Pritzker School of Medicine at the University of Chicago, and the University of Kentucky College of Medicine, at all levels of training at the beginning of the 2005–2006 academic year. This survey was developed at the home institution during a six-month period, with input from our bioethics and biostatistics divisions. We piloted the survey with 42 graduate students in pharmacology, physiology, and pathology before administering it to medical students at our institutions. The first 15 items addressed medical students’ opinions. These questions used a Likert scale (1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree).

We used three questions addressing students’ opinions toward accepting gifts. Gifts were defined as any material item given without charge. This included pens, informational brochures, meals, drug samples, and clothing, among others. The last five items on the survey were free-response questions addressing knowledge:

  1. What percentage of all drugs that begin preclinical testing ultimately meet FDA approval?
  2. What percentage of the pharmaceutical industry’s funding is federally supported?
  3. What percentage (average) of a pharmaceutical company’s budget is spent on advertising?
  4. How much money (in dollars) is spent by pharmaceutical companies on direct-to-consumer advertising per year?
  5. How much money (in dollars) is spent by pharmaceutical companies on advertising directed at physicians per year?

Questionnaires could be completed online or on a paper copy, depending on the institution surveying. In distinguishing the two groups, students were labeled as preclinical if they were beginning medical school or had completed the first or second year of medical school, whereas students were labeled as clinical if they had completed their third of fourth year of medical school. Results for preclinical versus clinical students were analyzed by Fisher exact test. In analyzing the opinions of medical students from the Likert scale, a response of agree or strongly agree was labeled as favorable, whereas a response of disagree or strongly disagree was labeled as unfavorable for the Fisher exact test.


We received 667 responses from the four schools. Whereas the response rate at the home institution was 80%, the response rate at the three additional institutions ranged from 20% to 40%. Our study found that medical students’ exposure to the pharmaceutical industry increases dramatically during their clinical years. Approximately 90% of students in the preclinical years had either one (30%) or no exposure (60%) to a pharmaceutical representative, whereas 80% of students in the clinical years had more than one exposure to pharmaceutical representatives (P < .001). In addition, more than 80% of students in the clinical years had accepted gifts from pharmaceutical representatives, whereas <40% of students in the preclinical years had accepted gifts (P < .001). Preclinical and clinical students (85% versus 84%) felt it was inappropriate for government officials to receive gifts from pharmaceutical representatives; however, 65% of clinical students felt it was appropriate for medical students to accept gifts, whereas only 28% of preclinical students felt it was appropriate for medical students to accept gifts (P < .001). Additionally, more than 50% of clinical students felt it was appropriate for physicians to accept gifts from the pharmaceutical industry, whereas 30% of preclinical students felt it was appropriate for physicians to accept gifts (P < .001). Medical students from both the preclinical (70%) and the clinical years (72%) felt that acceptance of gifts from the pharmaceutical industry had no influence on the practicing physician. Data collection from the five questions addressing knowledge of the pharmaceutical industry revealed no difference between the preclinical and clinical medical students. Specifically, preclinical and clinical students reported similar answers to questions regarding funding for direct-to-consumer and direct-to-physician advertising.


Our study has several limitations. Like many designs in the medical education literature attempting to assess students’ attitudes, our survey was voluntary and, thus, subject to selection bias. Secondly, the survey was conducted as a snapshot in time, and the individual opinion of any medical student was not analyzed over his or her progression throughout medical school. Encounters with the pharmaceutical industry were analyzed as a dichotomous variable. This limits the ability of our study to extrapolate more meaningful relationships between levels of exposure and potential difference and influence. In this sense, we cannot identify which students received individual attention from pharmaceutical representatives and for how long each encounter was.

Interestingly, however, our study surveyed students from various institutions, both public and private, and noted a difference in opinions between preclinical and clinical students. This is in contrast to previous studies attempting to identify attitudes of medical students from single institutions.4,8,9 When compared with the existing body of literature regarding student and resident physician attitudes, our study raises the question of how much influence any interaction with the pharmaceutical industry has on medical students.

It seems that increasing exposure to the pharmaceutical industry leads to more favorable opinions toward accepting gifts from these companies without an accompanying increase in understanding of the pharmaceutical industry. It is not clear, however, how these attitudes are shaped and how much formal and informal education will impact attitudes and behaviors of students and resident physicians. Linking a study of how students and physicians learn within the culture of medicine is a natural next step to identify the most meaningful interventions in this arena.


As in the paper by Bellin et al,1 this study reveals that medical students have extensive exposure to the pharmaceutical industry. We have expanded on the results from Bellin et al1 by demonstrating that medical students in the clinical years become more favorable toward accepting gifts from pharmaceutical representatives without recognizing that these gifts influence decision making. This is in contrast to the findings from Hyman’s4 article, which reveals no statistical difference in opinions toward accepting gifts from the pharmaceutical industry between the preclinical and clinical medical students. Equally noteworthy, medical students’ knowledge of the pharmaceutical industry does not increase throughout their formal medical training. Because substantial evidence suggests that resident physicians are directly influenced by gifts, one could reasonably argue that medical students are likely to be influenced by their interactions with pharmaceutical representatives in a similar manner.11

We agree with Bellin et al1 and others that more formal education regarding the pharmaceutical industry should be used and can have significant effects during the clinical years to provide perspective to future physicians.12 Medical schools, however, need to be cognizant and proactive to place medical students in the best clinical environments that foster open discussion regarding pressures and demands that may not be formally addressed. Recognizing that medical students receive a significant percentage of their clinical experience and training away from academic medical centers, such as private physician offices and community hospitals, it is not enough for academic medical centers to eliminate pharmaceutical representatives and expect that medical students’ training will be free of influence from outside pressures. We have provided increasing evidence to a growing body of literature that medical schools must exercise increased vigilance in determining who is teaching and, ultimately, shaping our future physicians.13–15


The authors would like to thank Dr. Mark Kuczewski, PhD, director of the Neiswanger Institute for Bioethics and Health Policy at Loyola University Stritch School of Medicine, for his support of this research endeavor. They would also like to thank Dr. Ramon Durazo-Arvizu for his help in statistical analysis with the data.


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      © 2007 Association of American Medical Colleges