For the past few years, one of the more contentious controversies has been the close financial ties between drugmakers and some doctors. But why have some docs embraced the pharmaceutical industry? Were their attitudes formed early in their careers? If so, would there be virtue in educating medical students and residents about the downside to industry interactions?
That is the conclusion reached in a report issued last week in PLoS Medicine, which analyzed 32 studies that looked at industry interactions with medical students and whether these influenced student views (this amounted to reviewing data concerning some 9,850 students at 76 med schools or hospitals). They found that most had some interaction with drugmakers, but contact increased in the clinical years, with up to 90 percent of all clinical students receiving some form of educational material.
What else did they find? In most studies, the majority of students in clinical training believed there was nothing wrong with taking gifts; a smaller percentage of preclinical students felt the same way. Why? They cited financial hardship or claimed other students did so anyway. While acknowledging education provided by industry is biased, most found the info to be useful. Almost two-thirds insisted they were not swayed by goodies or interaction with reps, but maintained others were not immune.
They were also divided on whether interactions should be regulated by med schools or the government. But 86 percent of American medical students reported that during their residencies they would like to interact with sales reps. At the same time, between 69 percent and 77 percent endorsed the idea that faculty should disclose any conflicts prior to lecturing.
Interestingly, most students reported they did not feel adequately educated about interactions with industry; between 62 percent and 86 percent wanted more instruction about this issue, the authors wrtie. Although 39 percent of the clinical students reported being adequately educated on the topic, only 11 percent of preclinical students reported the amount of instruction they received was sufficient.
Consequently, the authors write there is a "significant hole in the existing research, most notably the need for studies that can determine whether changes in student attitudes" toward drugmakers are caused by contact with "industry, the influence of role models, institutional policies, or other factors." And while a recent survey by the American Medical Student Association found that med schools have strong conflict policies (see here), they argue for developing strategies to educate students on industry interactions to address "misconceptions about the effects of marketing and other biases that can emerge from industry interactions."
"Given the pervasiveness of interactions between practicing physicians and drug, device, and other health care-related industries, it seems reasonable to formally teach medical students about the positive and negative issues surrounding these interactions," Aaron Kesselheim, a co-author and an assistant professor of pharmacoepidemiology and pharmaeconomics at Harvard Medical School, writes us.
One route he suggests is for schools to create mentors. "Mentoring definitely has an impact on professionalism development during medical school. It is part of what is classically called the 'hidden curriculum' of professional schools that impacts students' development," he continues. "Medical schools need to pay closer attention to how institutional policies (such as COI disclosure, attitudes towards consulting arrangements, etc.) affect the social context in which their medical students learn."
31 Comments
There will be a two day series panels, all allowing CME credit for the programs, on these very same general topics, at Georgetown's Med School, on June 16-17, 2011. Should be very interesting -- I may pop in.
See this -- for the details.
Namaste
Same crap as always I am more worried about how managed care plans affect prescribing. They don't give a crap about outcomes and only worry about cost.
It's a little troubling to see medical journals publishing articles about how to best re-educate medical students who form "incorrect" attitudes, e.g., attitudes that are different from those of the authors.
Maybe we could recruit some informants from each class, so as to identify those with incorrect attitudes early on. A couple of years in a re-education camp should be sufficient to fix them right up.
"Almost two-thirds insisted they were not swayed by goodies or interaction with reps, but maintained others were not immune."
The classic MD response, all those other docs are influenced but not me. The industry spends billions of dollars each year to influence prescribers, it works - whether they think it does or not.
Hence the argument that off-label promotion, etc will not influence a doctor from what is best for their patients is bogus.
Doctors are smart, know more about medicine than company reps, but are human beings, open to the same tendencies of people.
Doc,
You are very wrong in your thinking that Dr.'s know more about the medicine than the company representatives. With the majority of the Dr.'s I deal with on a daily basis-at two of the most prestigious teaching institutions in the Midwest- Northwestern and University of Chicago- I'm an integral part of patient care. I educate the Dr.'s on not just my medicine but also the disease state. Dr.'s are just normal human beings they don't know everything- and I find often are ill informed about my drug and the patients that its best for. I educate them to help them provide better outcomes for patients. Without my education many patients would not be getting the BEST treatment out there- and it isn't always the drug I sell.
If this is going on at arguably two of the best medical schools in the nation- how bad is it at the 2nd tier schools?
This study demonstrates to me that medical students not only have the great robotic ability to regurgitate large quantities of memorized information, we also are pragmatic enough to accept gifts like the Lilly bag and the Welch Allyn ophthalmoscope I received as a second year student for financial hardship reasons, we are also discerning enough to recognize marketing propaganda when we see it or hear it.
What a breakthrough!. Medical students are actually able to hold two different types of thought patterns in our heads! What's next? The sky's the limit.
@ Marketing Maniac - I do believe there are reps like you that really do put the patient first and take your role as an educator very seriously. Frankly, I also think you are in the minority of sales reps out there. And I agree with your opinion that it is a rare doc that is as educated about the nuances of all the medications they prescribe as they would like to believe. They just can't be....especially those that are in general medicine. Many of the docs are vulnerable to drug company marketing due to a myriad of reasons. Yes, kick-backs and illegal influence catch their attention - but sometimes, I believe they want to try out a different drug - and so, their patients become "clinical trial subjects". And finally, we cannot discount the significance of the influence of other high prescribers. There is a "herd effect" in medicine that can't be ignored and pharma companies know this - that is why thought leader development continues to be the cornerstone of marketing in our industry.
Doc-You're right. These & other surveys seem to provide a classic "out" by first asking if a student feels that he himself is influenced, presumably as a yes/no, & then asking about his fellow students.
A more illuminating way to do it would be to use a scale, ie, "How much influence, if any, does the industry have on a scale of 0-4?" This enables the student to admit to some influence without essentially saying that he's become biased. It would also be good to ask about the influence on students in general first, then on himself. This way, he doesn't have the opportunity to pin a trait onto his cohorts in compensation for himself.
Perhaps, as law students do, med students should study "case med"...for example, there could be the "Biederman" study. Or Nemeroff. Then they could have a section on large fines paid back to the feds and what these were for. The final could include questions such as "If a rep tells you a drug is 'perfectly safe', should you believe the opposite? Yes, no, and explain your answer..."
Wouldn't it be more interesting and telling to do a study that determined which med students have a higher rate of prescribing medication errors (right drug, at correct dose for right patient)... pharma-influenced vs pharma-shielded (you'd have to include journal and conference influence, any pharma sponsored education programs and clinical trial involvement of the med school). The premise would be there is no need for pharma because medical schools alone teach the students everything they need to know about drug treatment. www.PharmaReform.com
I teach an undergrad course that includes a number of pre-meds as well as students in Nursing, Pharmacy, Chem Engineering, Business, Law, Policy, and more.
Many of these issues are taken up, debated, etc. There are speakers from industry, journalism, medicine, pharmacology, etc.
So far, virtually all students have felt the course changed their lives, and anticipated professional lives, for the better. And none complain it is one-sided.
I think waiting until students are already in professional school may be too late for many students. The demands of their education and responsibilties make this kind of reflection cognitively dissonant by then.
This article is truly ego gratifying. A simple pharma rep with a 4 year college digree can influence and sway the elite at the top of the IQ scale (the medical students). It is a shame that pharma companies only pay these reps around $45K-$85K base salary (based on experience) if this is how effective they are in discussions with people of much higher intellect and knowledge base.
Justice, I respect your approach, but when you teach theswe things to undergrads without any of the real life exposure to pharma marketinge receive in med school aren't you just teaching concepts in the abstract?
Jim, these days med school teaching is largely by the PBL (problem based learning)method, different from the heavy lecture approach we had. In that regard, they may actually be doing somewhat akin to the case method you mention for the law students.
Good question, Insider. Actually the Nursing and Pharmacy students have a fair amount of real life experience, which they share with others. So also the folks who come in, including med students, senior docs, et. al. As far as the impact of marketing on docs' rx'ing, there is, as you know, a ton of empirical studies. So it is certainly not concepts without data.
Re: Pharma Gal's comments, I would with all respect, not necessarily put med students at the top of the intellectual pyramid, love 'em as I do. But it's really beside the point. Excuse the analogy (even though I make it deliberately), but my guess is that the folks with whom Elliot Spitzer did business probably had a less impressive resume than his. But that did not impact their "influence" (admittedly, I'm sure they were much better paid than the average detailer).
In fairness, I should have also said that a number of the students who take this course hope to be reps. Some change their mind. Most don't. I have the highest respect for both (despite some of the implications of my last comment). I would like to believe, and have a little supporting data, that those who do go on to become reps will do so differently than they might have otherwise. Some have returned to tell the tale.
The core premise of the PLoS Medicine article is that we need to study how medical students develop attitudes toward industry, and take measures to correct the process. Besides the Orwellian undertones of this line of inquiry, don't we simply have many more urgent priorities in medicine than that?
Physicians are inarguably the most educated major profession, and arguably the most generally intelligent. Yet they require someone to educate them on how to interact with sales reps? That's nonsense. If physicians have spare classroom time, let them use it to keep up with science and be better doctors - it's a constant challenge.
Marketing Maniac, your moniker says it all, the very idea that you know more about your medicines than physicians is laughable in 99% of cases.
Do you know your PI and product specific clinical studies better than some docs? Let's hope so, you "sell" these drugs - but that is a whole different thing than actual treatment of patients with multiple concommitant disease states.
What the average physician knows after 4 years of med school, even before internship & residency, would bowl you over.
Keep it real marketing dude, put down the kool aid.
Doc- again you show your ignorance and arrogance. I have the benefit of talking to hundreds of physicians some that have great results with my drug and others that don't have such great results. I hear first hand about the experiences that they have with my product. Where it is working, where it isn't working, what side effects patients are reporting, how they handled a side effect, etc. I hear more about my drug in a given week then what any given Dr. will hear in a year. And the amount I know about my drug- outside of the PI and Clinical studies, plus what I know about my competitors, plus what I know about the complex disease state I sell in- is way more then what the average physician knows and will ever know. You are the one that is underestimating the knowledge that a drug representative has. I can easily talk over the head of most specialist in my disease state. And in regards to my knowledge over that of a resident.... your making me laugh.
And of course I use my knowledge to my benefit and consistently lead my company in sales year after year. And the funny thing is I don't make that much less then the Dr.'s I'm calling on- and I didn't have to spend 4 years in med school! If you really are a Dr.- you are a laughable one. One that for sure isn't offering the best care for your patients because you dismiss the knowledge of your drug reps. I see Dr.'s like you all the time- and trust me you aren't nearly as smart as you think you are. Trust me when I tell you that your arrogance and closed mindedness is helping your patients. My advice may seem harsh but think about it and help your patients get better outcomes- we are all on the same team!
Marketing Maniac, I don't doubt that you know a ton more about your drug than what's in the PI or the clinical trials, but unless you are an MSL, at the end of the day you must stick to the script and be "on message".
Additional knowledge is a good thing. Unfortunately the regs and your company's policies do not, or at least should not allow you to share it.
You seem to have a real chip on your shoulder. Were you rejected by one of those for-profit Caribbean Medical Schools? You would definitely know more than your teachers down there.
No chip on my shoulder. I just think its ridiculous when Dr.'s discredit drug reps. And as far as a "script" and "on message"- I've never followed that nor will I ever follow that. Interactions can't be scripted. I haven't utilized a "detail piece" in over 4 years- although I think they have there place when a product is new to the market. If something comes up in the conversation that is or could be considered "off label" then I acknowledge it. I think "off label" promotion gets to much attention- I don't think that to many physicians are going to be swayed by a drug rep to prescribe a drug completely off label. And if they do prescribe something off label and something bad happens to the patient it should be on the Dr. not the drug company- at the end of the day they decide to write the script.
haha rejected from medical school....to be honest I was an average student at best. I excelled at sports not school. In college I took an easy major because I knew it wouldn't matter in the end- just having the degree is what counts 99% of the time. Whats wrong with a Caribbean Medical School- I think its funny that they get looked down upon. Not all the best Dr.'s have to go to US Medical Schools.
I am a long time hospital selling stud (30+years) and from my experience, marketing maniac is spot on. In reality, there are very clever, very smart reps inside the academic medical centers who are very educated in narrow areas and they know more than all medical students, most residents, EVERY hospitalist, and most attendings and fellows in specific disease states. They are rare. They are almost always 50+ year old men ( sorry, pharma hag).
What makes me suspicious about the article is that I have never, nor have I ever met anyone who calls on med school students. They can't write. I seldom even called on residents unless they were chiefs. Certainly fellows and above, but not students. The article reads like it starts with an agenda.
Marketing Maniac (appropriately self described)
"You are the one that is underestimating the knowledge that a drug representative has."
HA! Arrogance and ignorance? I have been involved with pharma marketing, sales and medical for over 35 years.
I have run across many reps like you who: "And the amount I know about my drug- outside of the PI and Clinical studies, plus what I know about my competitors, plus what I know about the complex disease state I sell in- is way more then what the average physician knows and will ever know."
You are sadly mistaken. The real question, which can never be adequately answered is; If you had to treat a seriously ill oncology patient, with diabetes, CAD, pulmonary disease, etc, etc and YOUR knowledge was on the line for the patient's life and YOUR personal financial liability - how sure would you be with your grandious knowledge?
You wouldn't be treating my friends or family.
Your smugness is killing this industry. No wonder more medical schools and offices are closing to pharma reps.(But not you, I'm sure).
Actually Doc- if my specialty was Oncology- the answer to your question would most likely be yes. Why- glad you asked. Because I more then likely would have heard of other Dr.'s that have treated similar tough to treat patients and I know what they did and what the outcome was. Rather it was with my drug or not. That is why I consistently do dinner programs- to listen to case studies. As far as to "how sure I would be"- well when treating a tough to treat patient its always a crap shoot- not all patients have good outcomes- of course if you really are a Dr. you would know that. But I would be confident that I was doing the best possible treatment plan for the patient based on previous/similar patients and outcomes.
And my "smugness" is what is killing this industry. What is killing the industry is the fact that companies- like my own- are coming out with crap me-to drugs or extended release products to replace drugs that are going off patent. We are coming out with these because back in the 90's pharmaceutical companies were making money hand over fist and didn't worry about research and development as much- or had faulty strategies to get drugs to market. Arrogance on our part. In the past we priced these me-to or patent extending drugs competitively or heavily discounted them to PBM's to get on formulary. No innovation. On top of that pharmaceutical companies has loads of data showing that reach and frequency is the key to selling- so we increased the size of our sales forces again and again. Lastly the price of drugs that aren't that innovative get in the news and the industry backs down with these stupid "Pharma guidelines" which stipulates how and what we can do when "selling" which really took sales out of the equation.
And your right I don't have problem getting access. I'm a sales guy at heart. And if I'm not selling you I'm moving on to the next guy that values our relationship and what I can bring to patient outcomes. At the end of the day its actually more of a partnership then selling. These "pharma guidelines" don't apply to me- or any rep worth his salt.
And TRX producer- your right most of the time it is guys that get it done. Although I have to disagree I'm 38 years old and if I'm doing this when I'm 50+ I'll be on depression meds!
Appreciated the last part of Maniac's reflections. I would stil take issue with poster who claimed, "Physicians are inarguably the most educated major profession, and arguably the most generally intelligent."
I guess everything is "arguable," but plenty of Ph.D.'s spend 7-8 years in professional training, and it is not obvious to me that med school plus internship/residencey is "more education" than grad school plus doctoral dissertation plus clinical training (if you're going into a clinical field).
But the larger point is that study after study, including those done by MDs, show that docs do _not_ rightly estimate the impact of pharma marketing on prescribing behavior (much as they often claim it applies to other docs, not themselves). In any event, the "other docs" presumably had the same overall education and are otherwise also smart cookies.
Point is--education is specific. As we all know, specialists and subspecialists often know very little about tx and dx relevant to other subspecialities. The best docs know their limits, which is part of being a best doc.
Justice is right, BUT having been on both ends of a stethoscope, physicians' presecribing habits, no matter what the source, are every bit as imprinted on him or her as are a child's first memory of her mother and father. Studies like these are great; getting doctors to read them, much less change their prescribing habits is like trying to climb Mt Everest in a swimsuit, i.e. you can try it but you won't get very far.
The Master Marketeers in Pharma are far more sophisticated in influencing doctor's prescribing habits than can be captured on a survey. For example, I know of some highly technically sophisticated subliminal advertising methodolgies under development that far outweigh the abilty of any survey to assess them in one or two survey questions. Why, because a good subliminal ad is soon forgotten by the conscious memory, i.e. when answering a survey, but is called up by the unconscious memory when needed, which is the part of the doctor's brain in which the subliminal message has been planted by Master Marketeer. Almost like having a chip in your brain without the actual silicon. VERY scary, yet is part of the wave of the future in pharma marketeering. Also is light years ahead of the social scientists who design such mundane surveys or the regulators who try to control them.
Do you know what they call the person who finishes at the bottom of their medical class????? Doctor. Just as any profession, you have very intelligent doctors and a few who shouldn't be allowed to prescribe an aspirin, let alone anything else.......... Read through a few malpractice law suits and you'll see my point.
Marketing Maniac, your educational attainments and those of George W Bush reinforce the idea that the world is unfortunately run by "C" students.
Agree with Insider. And I'll bet those subliminal techniques were created by Ph.D.s!
Anyway, I've learned a lot by reading "scripts" for telemarketers, drug reps, and others who want to win friends and influence people. Understand that speech is just one, relatively superficial level, of all this. Still, it provides a sense of how much study has gone into the "science of persuasion."
If truly imprinted, then I suppose the best strategy would be for pharma marketeers to identify potential docs at birth (perhaps by interviewing their mothers). Then they could all be led around like Lorenz's swans.
Reality Check, you should be familiar with another adage, whichturns out to be pretty accurate:
- Doctors in the top third of their class make the best teachers - Doctors in the middle third make the best clinicians -Doctors in the bottom third make the most money.
Seems like undergrad med students are telling us they have a need for education on this topic. Wondering if mid-career professionals feel the same way? Perhaps could be the topic of a CME needs assessment with education carried out under new ACCME criteria.
Not clear to me, however, where study authors got data from med students saying they wanted education on this topic. As I read PLoS article, seemed like a meta-analysis of many other studies.
I plan to retweet link to this article on Twitter, perhaps discuss there underhashtag #CMEchat or #SoMeCME? My Twitter handle is @grantsmeister.
Don, receiving and reading material by a med student in the clinical years is way different. For example, when I was on third year surgery rotation I had to report to the hospital at 5:30 AM to pre-round on my patients before the residents arrrived at 6:00AM. I then rounded with them until 6:45 AM when we then proceeded to get ready for surgery. Operations usually went until noon, at which time I had a mandatory lecture every day. After a 10 minute lunch break we went back to the wards to check on the patients we had operated on earlier that day, followed by seeing my other post-op patients. The rest of the afternoon was spent writing notes on our patients, followed by Attending rounds at 5PM and residents sign-out rounds at 6PM. We then made one final check to see that our written orders made it on to the chart for the next day, then went home for the evening IF we not on call that night. We repeated the same process the next day, all the while trying to stay awake enough at night to read up on our patients and eventually study for the final exam.
During that grueling time period I did not read anything that I was not absolutely required to read, and that certainly included pharmaceutical marketing materials. I doubt that things have changed all that much, except that now they do surveys on this stuff.