In our review of studies on interactions between the pharmaceutical industry and physicians in training, several themes emerge. The frequency of resident interaction with the pharmaceutical industry was high, and the majority of residents believed that industry interactions were appropriate. Despite evidence suggesting that pharmaceutical representative interactions can influence prescribing, a majority of residents felt that their own prescribing could not be influenced by interactions or gifts, while allowing that others' prescribing could be influenced. Many programs lacked policies to regulate or inform interactions with industry representatives, and trainees reported insufficient training in how to approach these interactions and other forms of industry promotion, despite a high frequency of contact.
Trainees' self-assured attitudes toward influence and their lack of training in how to interpret pharmaceutical marketing techniques, combined with limited but suggestive evidence that education and policies can change attitudes and practices, suggests a central role for education and policy. The 9 educational interventions reviewed provide a limited set of models by which curricula may be implemented, including lecture-, video-, and seminar-based curricula, as well as evaluations of pharmaceutical representative presentations, both real and staged. The studies reviewed here suggest that these interventions can be effective at raising trainee awareness of influence and increasing their skepticism towards information presented by industry. However, the time to the follow-up survey was short in each of these studies, so the long-term effects on attitudes remain uncertain, as do the effects of these interventions on skills and behavior. While the current data are not sufficient to recommend the inclusion of one particular teaching intervention in residency curricula, larger scale randomized evaluations of educational curricula are warranted.
While these curricula represent an important first step, a more vigorous set of interventions may be necessary to effectively counter the effects of pharmaceutical marketing. In particular, such interventions should focus on problem areas in knowledge, attitudes, and practices that have been documented in the literature. For example, curricular- and practice-based interventions should emphasize training students and residents to critically assess marketing practices and information received from industry, challenging prevailing local beliefs about acceptable levels of interaction with industry, and debunking the common belief among trainees that they are impervious to influence. This might take the form of an ongoing series of seminars to address educational deficiencies in these areas. Simultaneously, interventions that target faculty and chief residents to encourage appropriate role modeling in their daily interactions with trainees are likely to play a critical role in establishing new cultural norms for trainees and promoting alignment of the overt with the “hidden” curriculum. It is important that these interventions incorporate proven methods to change physician behavior, namely, they should be sustained, interactive, and multifaceted, and should use local opinion leaders (e.g. chief residents and respected faculty members) and/or “academic detailers.”54–56
In addition, the widespread absence of policies and high frequency of interactions with industry representatives suggest an important role for regulation. The implementation or modification of residency program policies is likely to be helpful, as some studies suggest that the presence of policies is associated with more skeptical attitudes toward industry and fewer future interactions with representatives. Such policies, when clear and explicit, can not only modify current behavior but can also help establish norms that may remain with trainees into subsequent stages of their careers. Moreover, these policies and norms should guide not only the interactions between trainees and industry representatives but also the interactions that the industry enjoys with program leaders and the training programs they represent. Senior program faculty and chief residents should set an example by moderating their own contact with industry representatives, as well as by minimizing or eliminating industry funding for and involvement with the educational and social components of their programs.
Given the breadth and importance of this issue, a nationwide approach is merited. Curricular recommendations should be established by the Accreditation Council for Graduate Medical Education (ACGME) and the American Association of Medical Colleges (AAMC) as part of their larger efforts to standardize and improve medical education. For example, the ACGME's Practice-based Learning (PBL) core competency addresses residents' skills in evaluating scientific evidence and critically appraising the medical literature in making patient-related decisions.57
Because physicians may adopt practice patterns and attitudes from pharmaceutical marketing, even when they believe they rely on scientific sources,6
evaluating the validity of pharmaceutical marketing information is an important part of mastering this competency. Similarly, educating trainees about the influence and ethics of marketing can contribute to meeting the standards of the ACGME's Professionalism competency,58
as well as providing skill-based training on preferred methods of interacting with industry representatives.
Educational curricula will only be effective if trainees view them as necessary, making it important to understand trainee attitudes so as to tailor curricula to their interests and needs. In addition, it is important to understand the attitudes and practices of supervising faculty, given their central role in developing and implementing curricula and their status as role models for professional behavior. Therefore, while national recommendations may be warranted, local factors are also critical to acknowledge and incorporate into training curricula, as opportunities for change are highly contextual within cultures of medical practice.32
The experience of McMaster University is illustrative, wherein faculty, residents, and pharmaceutical representatives were all involved in the process of creating guidelines, with the result being the successful implementation of policies ending drug-sponsored lunches, industry presence at educational events, and funding of events requiring the inclusion of materials by the sponsor.59
Finally, further high-quality research is needed to evaluate the long-term effectiveness of interventions and thus guide future efforts in this area.
While the literature informs our understanding of this topic, several limitations of the studies we reviewed merit attention. Many of the studies are small, and of limited power. Most of the survey instruments used were not validated; the validated attitude scale introduced by McKinney et al. has been used by other authors, but with few subjects. Also, few studies have used objective measures of actual behavior change in trainees. However, the self-report and knowledge surveys among trainees reviewed here suggest that interactions with pharmaceutical representatives influence prescribing, which is also suggested by studies of behavioral outcomes in practicing physicians as well as the inherent goals of advertising and promotion in a profit-based marketplace.3,7,8
Another limitation is that the potentially charged nature of this subject may have led to bias in assessments of knowledge, attitudes, and behavior. However, the wide variety of studies that produce a generally consistent message about knowledge, attitudes, and behavior suggests that these effects are both real and generalizable.
In summary, the pharmaceutical industry has a significant presence during medical training and has gained the overall acceptance of trainees. Residents acknowledge the potential for industry influence in others, but generally not in themselves, despite evidence that they themselves are influenced as well. Given this state of affairs, it is time for a major shift in the culture of medical training. Serious and sustained interventions have the potential to substantially modify these attitudes and behavior, and to improve the skills of trainees in dealing with industry marketing and information. Such efforts can foster a climate of best practices that is less likely to be compromised by the promotional efforts of individual pharmaceutical companies.