August 2014
Results From a National Survey
Kirsten E. Austad, MD
JAMA Intern Med. 2014;174(8):1283-1290. doi:10.1001/jamainternmed.2014.2202
Abstract
Importance In recent years, numerous US medical schools and academic medical centers have enacted policies preventing pharmaceutical sales representatives from interacting directly with students. Little is known about how pharmaceutical sales representatives affect trainees’ knowledge about pharmaceutical prescribing.
Objective To determine whether there is an association between medical trainees’ interactions with pharmaceutical promotion and their preferences in medication use.
Design, Setting, and Participants We surveyed a nationally representative sample of first- and fourth-year medical students and third-year residents by randomly selecting at least 14 trainees at each level per school.
Exposures All trainees were asked how often they used different educational resources to learn about prescription drugs. Among fourth-year students and residents, we posed a series of multiple choice knowledge questions asking about the appropriate initial therapy for clinical scenarios involving patients with diabetes, hyperlipidemia, hypertension, and difficulty sleeping.
Main Outcomes and Measures Evidence-based answers followed widely used clinical guidelines, while marketed-drug answers favored brand-name drugs over generic alternatives. We used survey answers to build an industry relations index assessing each trainee’s level of acceptance of pharmaceutical promotion; we used proportional odds logistic regression models to estimate the association between the index and responses to the knowledge questions.
Results The 1601 student (49.0% response rate) and 735 resident (42.9% response rate) respondents reported common use of unfiltered sources of drug information such as Google (74.2%-88.9%) and Wikipedia (45.2%-84.5%). We found that 48% to 90% of fourth-year students and residents accurately identified evidence-based prescribing choices. A 10-point higher industry relations index was associated with 15% lower odds of selecting an evidence-based prescribing choice (odds ratio [OR], 0.85; 95% CI, 0.79-0.92) (P < .001). There was also a significant association between the industry relations index and greater odds of choosing to prescribe brand-name drugs (OR, 1.08; 95% CI, 1.00-1.16) (P = .04).
Conclusions and Relevance Among physician trainees, our survey showed an association between positive attitudes toward industry-physician interactions and less knowledge about evidence-based prescribing and greater inclination to recommend brand-name drugs. Policies intended to insulate trainees from pharmaceutical marketing may promote better educational outcomes.
The pharmaceutical industry spends nearly $60 billion per year on marketing its products to the medical community, with the largest share going to personal interactions with physicians, usually mediated by sales representatives.1 These interactions affect physicians’ medication choices: an early study of primary care physicians found that physicians’ knowledge of drug properties was more consistent with sales information than with the medical literature.2 Marketing tools such as gifts and free meals also influence clinical decision making.3
Recently, policy changes by academic medical centers,4 government,5 and the drug industry6 have sought to reduce undue influence of pharmaceutical marketing on physicians. Particular attention has been paid to trainees because the medical school and residency learning environment may influence subsequent professional development and behavior, including openness to pharmaceutical promotional messages.7-11 For example, Stanford prohibits faculty and students from receiving gifts, meals, financial support, or other education directly from pharmaceutical companies.12
Policies limiting access of pharmaceutical sales representatives to medical schools have been controversial, with some faculty members and students arguing that they waste resources and prevent positive educational outcomes that might result from these interactions. Frequency of students’ contact with pharmaceutical marketing activities predicts favorable attitudes toward industry interactions.13 But not enough is known about how interactions with pharmaceutical sales representatives affect trainees’ knowledge about evidence-based drug use.
In 2013, we reported the results of a large, random-sample national survey of medical students and residents to determine how their interactions with sales representatives affect attitudes and behavior.14 The survey included objective questions testing students’ knowledge about evidence-based prescribing in common clinical scenarios. We now report on the association between trainees’ interactions with pharmaceutical promotion and their medication-use preferences.