Interactions with the pharmaceutical industry: experiences and attitudes of psychiatry residents,interns and clerks.

OBJECTIVE: To examine the type and number of interactions of psychiatry residents, interns and clerks with sales representatives of pharmaceutical companies and the attitudes of physicians-in-training toward these interactions. DESIGN: Survey conducted with the use of a self-report questionnaire. SETTING: Seven teaching hospitals affiliated with the Department of Psychiatry, University of Toronto. PARTICIPANTS: All 105 residents, interns and clerks training in psychiatry at the seven teaching hospitals between October 1993 and February 1994 were eligible; 74 completed questionnaires, for a response rate of 70%. One respondent was excluded from the analysis. OUTCOME MEASURES: Number of personal meetings and "drug lunches" attended, number of drug samples and promotional items received and estimated value of gifts received by each physician-in-training during a 1-year period as well as attitudes of residents, interns and clerks about interactions with pharmaceutical representatives. RESULTS: Median number of personal meetings reported was 1 (range 0 to 35), of drug lunches attended was 10 (range 0 to 70), of promotional items received was 2 (range 0 to 75) and of drug samples received was 1 (range 0 to 20). Trainees'' median estimate of the value of gifts received was $20 (range $0 to $800 Fewer than one third felt that pharmaceutical representatives were a source of accurate information about drugs; however, 71% (52/73) disagreed with the statement that representatives should be banned from making presentations. Although only 15% (11/73) felt they had sufficient training about meeting with pharmaceutical representatives, 34% (25/73) felt that discussions with representatives would have no impact on their prescribing practices, and 56% (41/73) felt that receiving gifts would have no impact on prescribing. Fewer than half said they would maintain the same degree of contact with representatives if they did not receive promotional gifts. The more money and promotional items a physician-in-training had received, the more likely he or she was to believe that discussions with representatives did not affect prescribing (p < 0.05). Clerks, interns and junior (first-year and second-year) residents attended two to three times more drug lunches than senior (third-year and fourth-year) residents, and significantly more junior than senior residents felt that pharmaceutical representatives have a valuable teaching role. Junior residents were three times more likely than senior residents to have received drug samples. CONCLUSIONS: Interactions between pharmaceutical representatives and psychiatry residents, interns and clerks are common. The physicians-in-training perceive little educational value in these contacts and many, especially clerks, interns and junior residents, disavow the potential of these interactions to influence prescribing. Therefore, supervisors of postgraduate medical training programs may wish to provide instruction concerning potential conflicts of interest inherent in these types of interactions.     

Knowledge of genetics among residents in obstetrics and gynecology.

A supervised genetics examination was administered to 76 obstetrics and gynecology (ob/gyn) residents from 15 different institutions in the Philadelphia area. The questions were specifically designed to be applicable to obstetrical practice. Overall, the mean score was 69% (range 32%-88%). Using the nonparametric Mann-Whitney rank sum test, we found that the 25 residents from institutions with an obstetrics-gynecology-genetics (OGG) program, coordinated by an obstetrician/gynecologist board certified in clinical genetics, had statistically significant higher scores than the remaining 51 residents from institutions without an OGG program (77% vs. 65%, respectively; P < .001). This study demonstrates that knowledge of genetics among residents in ob/gyn is deficient, especially among residents at institutions without OGG programs. Special efforts should be made to provide genetics education to these individuals. We propose that more obstetricians be encouraged to pursue postgraduate training in genetics in light of the rapid development of medical genetics; its application to prenatal screening, diagnosis, and counseling; the anticipated utilization of genetics services; and the need for educational initiatives geared toward ob/gyn patients.     

Medical staffing in Ontario neonatal intensive care units.

Advances in technology have improved the survival rates of infants of low birth weight. Increasing service commitments together with cutbacks in Canadian training positions have caused concerns about medical staffing in neonatal intensive care units (NICUs) in Ontario. To determine whether an imbalance exists between the supply of medical personnel and the demand for health care services, in July 1985 we surveyed the medical directors, head nurses and staff physicians of nine tertiary level NICUs and the directors of five postgraduate pediatric residency programs. On the basis of current guidelines recommending an ideal neonatologist:patient ratio of 1:6 (assuming an adequate number of support personnel) most of the NICUs were understaffed. Concern about the heavy work pattern and resulting lifestyle implications has made Canadian graduates reluctant to enter this subspecialty. We propose strategies to correct staffing shortages in the context of rapidly increasing workloads resulting from a continuing cutback of pediatric residency positions and restrictions on immigration of foreign trainees.     

Use of vitamin B12 injections among elderly patients by primary care practitioners in Ontario

BACKGROUND: Excess use of parenteral vitamin B12 has been reported from audits of clinical practices. The authors assessed the use of vitamin B12 injections in patients aged 65 years and over in Ontario. METHODS: A cross-sectional analysis was conducted that included all elderly people covered by the Ontario Health Insurance Plan who received insured services from general practitioners or family physicians (GP/FPs). For each practice the proportion of elderly patients who received regular vitamin B12 injections between July 1996 and June 1997 was calculated. The frequency of injections was determined for each patient receiving regular B12 replacement. RESULTS: Of the 1,196,748 elderly patients (mean age 74.8 [standard deviation 6.8], 58.0% female) treated by 14,177 GP/FPs, 23,651 (2.0%) received regular B12 injections. The rate of B12 injections per patient, standardized for age and sex, varied between practices (range 0%-48.6%). Although no authoritative sources support the practice, 3303 (19.8%) of the 16,707 patients receiving long-term parenteral therapy had, on average, overly frequent injections (more than 1 injection every 4 weeks). For 76 (12.3%) of the 617 practices with 10 or more patients receiving regular vitamin B12 injections, the mean injection frequency was greater than once every 4 weeks. The proportion of patients in these 617 practices who received overly frequent injections varied extensively (0%-100%). INTERPRETATION: Our findings indicate that some primary care physicians in Ontario administer unnecessary vitamin B12 injections to elderly patients.     

A survey of medical quality assurance programs in Ontario hospitals.

OBJECTIVE: To determine the prevalence and types of medical quality assurance practices in Ontario hospitals. DESIGN: Survey. SETTING: All teaching, community, chronic care, rehabilitation and psychiatric hospitals that were members of the Ontario Hospital Association as of May 1990. PARTICIPANTS: The person deemed by the chief executive officer of each hospital to be most responsible for medical administration. INTERVENTION: A questionnaire to obtain information on each hospital''s use of criteria audit, indicators inventory, occurrence screening and reporting, and utilization review and management (URM) activities. OUTCOME MEASURES: Prevalence of the use of the quality assurance activities, the people responsible for the activities and the relative success of the URM program in modifying physicians'' performance. RESULTS: Of the 245 member hospitals participants from 179 (73%) responded. Criteria audits were performed in 136 (76%), indicators inventory in 43 (24%), occurrence screening in 44 (25%), occurrence reporting in 61 (34%) and URM in 123 (69%). In-hospital deaths were reviewed in 157 (88%) of the hospitals. In all, 87 (55%) of the respondents from hospitals that had a URM program or were developing one indicated that their program was successful in modifying physicians'' practices, and 29 (18%) reported that it was not successful; 26 (16%) stated that the effect was still unknown, and 16 (10%) did not respond. Seventy (40%) stated that results of tissue reviews were reported at least 10 times per year and 94 (83%) that medical record reviews were reported at least as often. The differences in the prevalence of the quality assurance activities between the hospitals were not found to be significant. CONCLUSIONS: Many Ontario hospitals are conducting a wide variety of quality assurance activities. Further study is required to determine whether the differences in prevalence of these activities between hospitals would be significant in a larger, perhaps national, sample. Strategies are needed to ensure universal involvement and participation in the improvement of the quality of care and the assessment of the cost-effectiveness of health care treatments. Recommendations to achieve these objectives are suggested.     

Regional and global concerns over wetlands and water quality

Water quality in many stream catchments and river basins is severely impacted by nutrient enrichment as a result of agriculture. Water-resource managers worldwide are considering the potential role of riparian zones and floodplain wetlands in improving stream-water quality, as there is evidence at the site scale that such wetlands are efficient at removing nutrients from through-flowing water. However, recent studies have highlighted disadvantages of such use of wetlands, including emissions of greenhouse gases and losses of biodiversity that result from prolonged nutrient loading. Here, we discuss the water purification function of wetlands at the site and catchment scale and suggest ways in which these disadvantages could be overcome.