Medical students' exposure to and attitudes about the pharmaceutical industry: a systematic review

Background

The relationship between health professionals and the pharmaceutical industry has become a source of controversy. Physicians'' attitudes towards the industry can form early in their careers, but little is known about this key stage of development.

Methods and Findings

We performed a systematic review reported according to PRISMA guidelines to determine the frequency and nature of medical students'' exposure to the drug industry, as well as students'' attitudes concerning pharmaceutical policy issues. We searched MEDLINE, EMBASE, Web of Science, and ERIC from the earliest available dates through May 2010, as well as bibliographies of selected studies. We sought original studies that reported quantitative or qualitative data about medical students'' exposure to pharmaceutical marketing, their attitudes about marketing practices, relationships with industry, and related pharmaceutical policy issues. Studies were separated, where possible, into those that addressed preclinical versus clinical training, and were quality rated using a standard methodology. Thirty-two studies met inclusion criteria. We found that 40%–100% of medical students reported interacting with the pharmaceutical industry. A substantial proportion of students (13%–69%) were reported as believing that gifts from industry influence prescribing. Eight studies reported a correlation between frequency of contact and favorable attitudes toward industry interactions. Students were more approving of gifts to physicians or medical students than to government officials. Certain attitudes appeared to change during medical school, though a time trend was not performed; for example, clinical students (53%–71%) were more likely than preclinical students (29%–62%) to report that promotional information helps educate about new drugs.

Conclusions

Undergraduate medical education provides substantial contact with pharmaceutical marketing, and the extent of such contact is associated with positive attitudes about marketing and skepticism about negative implications of these interactions. These results support future research into the association between exposure and attitudes, as well as any modifiable factors that contribute to attitudinal changes during medical education. Please see later in the article for the Editors'' Summary     

2015年度中国医药市场发展蓝皮书——产业经济部分 （ Ⅰ ）

从产业经济角度,包括医药工业总产值、医药工业销售收入、医药工业盈利水平、医药流通行业销售规模、医药商业效益水平、     

Association of Medical Students' Reports of Interactions with the Pharmaceutical and Medical Device Industries and Medical School Policies and Characteristics: A Cross-Sectional Study

Background

Professional societies use metrics to evaluate medical schools'' policies regarding interactions of students and faculty with the pharmaceutical and medical device industries. We compared these metrics and determined which US medical schools'' industry interaction policies were associated with student behaviors.

Methods and Findings

Using survey responses from a national sample of 1,610 US medical students, we compared their reported industry interactions with their schools'' American Medical Student Association (AMSA) PharmFree Scorecard and average Institute on Medicine as a Profession (IMAP) Conflicts of Interest Policy Database score. We used hierarchical logistic regression models to determine the association between policies and students'' gift acceptance, interactions with marketing representatives, and perceived adequacy of faculty–industry separation. We adjusted for year in training, medical school size, and level of US National Institutes of Health (NIH) funding. We used LASSO regression models to identify specific policies associated with the outcomes. We found that IMAP and AMSA scores had similar median values (1.75 [interquartile range 1.50–2.00] versus 1.77 [1.50–2.18], adjusted to compare scores on the same scale). Scores on AMSA and IMAP shared policy dimensions were not closely correlated (gift policies, r = 0.28, 95% CI 0.11–0.44; marketing representative access policies, r = 0.51, 95% CI 0.36–0.63). Students from schools with the most stringent industry interaction policies were less likely to report receiving gifts (AMSA score, odds ratio [OR]: 0.37, 95% CI 0.19–0.72; IMAP score, OR 0.45, 95% CI 0.19–1.04) and less likely to interact with marketing representatives (AMSA score, OR 0.33, 95% CI 0.15–0.69; IMAP score, OR 0.37, 95% CI 0.14–0.95) than students from schools with the lowest ranked policy scores. The association became nonsignificant when fully adjusted for NIH funding level, whereas adjusting for year of education, size of school, and publicly versus privately funded school did not alter the association. Policies limiting gifts, meals, and speaking bureaus were associated with students reporting having not received gifts and having not interacted with marketing representatives. Policy dimensions reflecting the regulation of industry involvement in educational activities (e.g., continuing medical education, travel compensation, and scholarships) were associated with perceived separation between faculty and industry. The study is limited by potential for recall bias and the cross-sectional nature of the survey, as school curricula and industry interaction policies may have changed since the time of the survey administration and study analysis.

Conclusions

As medical schools review policies regulating medical students'' industry interactions, limitations on receipt of gifts and meals and participation of faculty in speaking bureaus should be emphasized, and policy makers should pay greater attention to less research-intensive institutions. Please see later in the article for the Editors'' Summary     

From Evidence-based Medicine to Marketing-based Medicine: Evidence from Internal Industry Documents

While much excitement has been generated surrounding evidence-based medicine, internal documents from the pharmaceutical industry suggest that the publicly available evidence base may not accurately represent the underlying data regarding its products. The industry and its associated medical communication firms state that publications in the medical literature primarily serve marketing interests. Suppression and spinning of negative data and ghostwriting have emerged as tools to help manage medical journal publications to best suit product sales, while disease mongering and market segmentation of physicians are also used to efficiently maximize profits. We propose that while evidence-based medicine is a noble ideal, marketing-based medicine is the current reality.     

PUBLICATION ETHICS AND THE GHOST MANAGEMENT OF MEDICAL PUBLICATION

It is by now no secret that some scientific articles are ghost authored – that is, written by someone other than the person whose name appears at the top of the article. Ghost authorship, however, is only one sort of ghosting. In this article, we present evidence that pharmaceutical companies engage in the ghost management of the scientific literature, by controlling or shaping several crucial steps in the research, writing, and publication of scientific articles. Ghost management allows the pharmaceutical industry to shape the literature in ways that serve its interests. This article aims to reinforce and expand publication ethics as an important area of concern for bioethics. Since ghost‐managed research is primarily undertaken in the interests of marketing, large quantities of medical research violate not just publication norms but also research ethics. Much of this research involves human subjects, and yet is performed not primarily to increase knowledge for broad human benefit, but to disseminate results in the service of profits. Those who sponsor, manage, conduct, and publish such research therefore behave unethically, since they put patients at risk without justification. This leads us to a strong conclusion: if medical journals want to ensure that the research they publish is ethically sound, they should not publish articles that are commercially sponsored.     

Physicians and the pharmaceutical industry: a dysfunctional relationship

The pharmaceutical industry is one of the largest and most profitable industries in the world, and in the United States, the industry has a particularly privileged economic position. Yet the cost of drugs in the United States is higher than anywhere else, due largely to the fact that the industry is focusing increasingly on marketing rather than on the development of meaningful new medications: available evidence does not support claims of great expense for the development of new drugs. Because of its vast resources, the pharmaceutical industry has assumed an increasing influence in medicine, which, given the differences in values and priorities between medicine and the drug companies, is a cause for concern. The pharmaceutical industry has acted to maximize its profits in ways that frequently conflict with medicine's need for truth and full disclosure. Indeed, the industry has arguably worked to compromise physicians' judgments, as well as academic standards. As a result, despite government regulation there have been unnecessary adverse effects from drugs. The experience with butorphanol (Stadol) exemplifies problems in the current system and the harm that can result. Changes are suggested to make the pharmaceutical industry more responsive to the needs of patients and physicians.     

Market Affections: Moral Encounters with Kenyan Fairtrade Flowers

This paper explores commodity exchange as a morally inflected practice, one that mediates competing tensions of greed and generosity, the sacred and profane, and affection and estrangement through the fairtrade flower. Using the UK–Kenya fairtrade flower commodity chain to examine the cultural economy of fairtrade, I suggest that like the charity business and the international development industry, fairtrade complicates the distinction between the sacred and secular and the gift and commodity as Northern consumers and NGOs weave webs of obligation through the medium of the market. Further, I argue that while fairtrade is predicated on values of partnership and interdependence, it also operates within commodity chains that advance liberal ethics as a mode of ‘governmentality’ over African producers, translating consumers' sympathy-based humanism into new technologies of regulation and surveillance.     

Survey on Ethical Conduct Thresholds in Cardiologal Medical Practice in Argentina

The purpose of this study was to analyze the attitude of a group of cardiologists on the ethical conducts they would accept or adopt when encountered with different hypothetical situations of medical practice. Between August and September of 2011, 700 Argentine cardiologists were surveyed in situations which posed ethical dilemmas in the patient‐physician relationship, among colleagues or involving financial agreements with employers or the pharmaceutical industry. Ethical conflicts were evidenced in a series of inappropriate conducts such as differential fees, trips and meals sponsored by laboratories, splitting fees, overbilling, self‐referral, charging for patient referral, financial compensation for ordering medical procedures, and various situations derived from the relationship with employers. In general, financial compensation from the pharmaceutical industry was more accepted than the conflictive situations which directly involved patients, colleagues or employers. The rejection of these conducts, the physicians' deontological education and the improvement of financial and organizational conditions in medical practice will help to encourage better medical professionalism and avoid unseemly behaviors.     

Art and the Twenty-First Century Gift: Corporate Philanthropy and Government Funding in the Cultural Sector

Marcel Mauss's work on the archaic gift contributes to understandings of corporate and government support of arts organisations, or ‘institutional funding’. His approach allows us to see institutional funding as a gift that is embedded in a system of exchange wherein gifts come with a variety of obligations, and self-interest and disinterestedness are inseparable. The institutional gift operates through money and contracts; nevertheless, it entails obligations to give, to receive, and to reciprocate. This system of obligations has been joined, in the contemporary institutional gift, by another obligation: the obligation to ask.

Institutional funding of the arts has acquired additional twenty-first-century elements. The article elaborates these, using the UK as an example. It also argues that the ambivalence felt by some members of the arts world about institutional funding stems, in large part, from the obligations inherent in the gift. The recent imposition of the neo-liberal model into the arts is an intrinsic part of the exchange between institutional funders and arts organisations. Given that Mauss's work is strongly anti-liberal and anti-utilitarian, it is ironic that his ideas should prove so useful for understanding a form of twenty-first-century gift in which neo-liberalism plays such a crucial role.     

品管圈在PIVAS降低不合理医嘱中的应用

为提高医院PIVAS的医嘱合理性，保证患者用药安全，我院引入品质管理概念，运用品管圈活动的十大步骤，进行计划、执行、确认和处置，完成PDCA循环。结果表明，品管圈活动能显著降低PIVAS不合理用药医嘱数，提升药学服务内涵，有利于药学服务质量的持续改进，值得推广。     

Nuptial Feeding in Insects: Theoretical Models of Male and Female Interests

We present a series of prospective models of nuptial feeding, mainly for insects. The models examine various optimal male and female strategies, but do not include any element of mate choice in which the female chooses males in relation to the gift he provides. We find that the female should use the gift to enhance egg size and/or clutch size when gifts represent a relatively large component of the energy resources for the gametes, or when the gift occurs at a relatively late stage in her reproductive cycle. However, if the female receives a single, relatively small gift during her reproductive cycle, she should show a reduced gametic output at the next oviposition. A literature survey revealed several studies that show increases in egg and clutch sizes following gift donation, but we found no instances in which there was a reduction in gametic output. We also find that if gifts are infrequent, there can be significant sexual conflict over the pattern of allocation of donated resources to future offspring. Male interests will generally be best served by a more immediate use of the resources than will be optimal for the female. This may result in selection for male ability to influence vitellogenesis and/or oviposition. Evidence is available which shows that male-derived substances influence female physiology; this might reflect an outcome towards male interests as a result of an arms race in sexual conflict. Some studies have demonstrated an effect of gift donation on survivorship. We examine models in which gift donation reduces male survival but increases female survival. These suggest that gift donation is most likely to evolve when (1) giving a gift has little effect on male, but a significant effect on female survival, (2) when the male is more likely to father eggs in a later batch, rather than the next batch, and (3) when random mortality is high.     

The spirit of the gift,the price of potency: a Maussian model of the Southeast Asian state of Luwu

This rereading of Mauss's The gift shifts the focus of discussion from the Maori hau to another example: tanoana (potency) among the Toraja (To Pamona) of Central Sulawesi. This potency animates an exchange with (human) gods that is at once gift and purchase (maoli). By tracing the intersection of this Maussian literature with that on the animist foundation of the Southeast Asian state, I analyse the nature of potent gifts that serve as a form of social currency in a ‘spiritual economy’ tying centre with (Toraja) periphery in the kingdom of Luwu. This ‘money’, imbued with royal potency, is a medium for the payment of debt only and not a medium of exchange, which gives ‘purchases’ made with it the characteristics of a ‘gift’ and also an opportunity to extract tribute. The Maussian analysis of the blurring of person and thing, and of persons and spirits, thus offers new insight into the nature of political power in the Southeast Asian state.     

Bride‐service and the absent gift

Building on a previous experiment to apply Strathern's discussions of Melanesian gift exchange to ethnography relating to Tukanoan societies in Northwest Amazonia, this essay asks why other authors should repeatedly affirm that the gift has no relevance in the Amazonian context. Two answers are proposed. Firstly, the authors concerned tend to assume that a particular type of social formation is characteristic of Amazonia as a whole. The Tukanoans, who engage in ceremonial exchange of food and goods, do not fit this rubric. Secondly, despite their differences, these authors assume that Amazonian societies are bride‐service societies where, axiomatically, there can be no gift. The Tukanoans are not bride‐service societies and, if anything, tend towards the bride‐wealth alternative. This Tukanoan exception serves to re‐emphasize the diversity of Amazonian social formations, one that would have been even greater in the archaeological past. It also warns against the dangers of over‐hasty theoretical closure.     

Food-Pharma Convergence in Medical Nutrition– Best of Both Worlds?

At present, industries within the health and life science sector are moving towards one another resulting in new industries such as the medical nutrition industry. Medical nutrition products are specific nutritional compositions for intervention in disease progression and symptom alleviation. Industry convergence, described as the blurring of boundaries between industries, plays a crucial role in the shaping of new markets and industries. Assuming that the medical nutrition industry has emerged from the convergence between the food and pharma industries, it is crucial to research how and which distinct industry domains have contributed to establish this relatively new industry. The first two stages of industry convergence (knowledge diffusion and consolidation) are measured by means of patent analysis. First, the extent of knowledge diffusion within the medical nutrition industry is graphed in a patent citation interrelations network. Subsequently the consolidation based on technological convergence is determined by means of patent co-classification. Furthermore, the medical nutrition core domain and technology interrelations are measured by means of a cross impact analysis. This study proves that the medical nutrition industry is a result of food and pharma convergence. It is therefore crucial for medical nutrition companies to effectively monitor technological developments within as well as across industry boundaries. This study further reveals that although the medical nutrition industry’s core technology domain is food, technological development is mainly driven by pharmaceutical/pharmacological technologies Additionally, the results indicate that the industry has surpassed the knowledge diffusion stage of convergence, and is currently in the consolidation phase of industry convergence. Nevertheless, while the medical nutrition can be classified as an industry in an advanced phase of convergence, one cannot predict that the pharma and food industry segments will completely converge or whether the medical industry will become an individual successful industry.     

Regulatory affairs and biotechnology in Europe. I. Introduction into good regulatory practice

The high cost and risks associated with the research and development of new drugs demand an alert as well as realistic legislative policy at both national and international levels. Registration of a new drug required before a marketing license is granted, is important for all branches of the pharmaceutical industry but is crucial for success in the innovative biotechnological sector. Innovation as such is no guarantee to be profitable. Increasing government demands have introduced uncertainty on whether new products will secure registration and have led to a disproportionate increase in the economical risks for innovative industry. Preparation and submission of an application for registration should be undertaken seriously and professionally since it has significantly more consequences than simply obtaining a marketing licence. It will influence marketing strategies and results. It is proposed--since dealing with regulatory affairs can be considered as an essential specialism--to apply a Quality Assurance approach. Activities in this context should comply with the same performance standards as developed for GMP, GLP and GCP leading to Good Regulatory Practice (GRP). By acknowledging regulatory affairs as a quality assurance means one can define a set of standard procedures within an organization to ensure that decisions are made on current and future regulations. In such a setup regulatory affairs becomes a marketing tool. This paper illustrates the complex problems found in registration activities. It underlines the necessity of introducing a GRP-approach of performance resulting in substantive evidence of regulatory efficacy.     

Commodifying Development Experience: Deconstructing Development as Gift in the Development Blockbuster

This paper discusses the recent rise of popular ‘blockbuster’ books written by international development industry insiders and produced by commercial publishers. The paper explores a set of common stylistic devices found within this emerging genre. Though each book is different, a key trope is the story of an author's earlier professional life—the hard lessons and gritty insights that have supposedly emerged from it—that normally underpins each narrative. By living the challenges involved in development work at first hand, and by making mistakes and experiencing epiphanies along the way, these author-professionals want readers to know that they have found out the hard way that long-cherished beliefs about development now need to be questioned. Readers are invited to relive these lessons and epiphanies, and to think and act differently about development by upholding a highly pragmatic form of development professionalism. Combining elements of research monograph, self-help book and personal memoir, these development blockbuster books can be understood not only as commodities, but also as part of the development gift. The authors promise a gift of experience but, in reality, these books are mundane commodities enmeshed in capitalist exchange relations.     

How Pharmaceutical Industry Employees Manage Competing Commitments in the Face of Public Criticism

The pharmaceutical industry has been criticised for pervasive misconduct. These concerns have generally resulted in increasing regulation. While such regulation is no doubt necessary, it tends to assume that everyone working for pharmaceutical companies is equally motivated by commerce, without much understanding of the specific views and experiences of those who work in different parts of the industry. In order to gain a more nuanced picture of the work that goes on in the “medical affairs” departments of pharmaceutical companies, we conducted 15 semi-structured interviews with professionals working in medical departments of companies in Sydney, Australia. We show that this group of pharmaceutical professionals are committed to their responsibilities both to patients, research participants, and the public and to their companies. Despite the discrepancies between these commitments, our participants did not express much cognitive dissonance, and this appeared to stem from their use of two dialectically related strategies, one of which embraces commerce and the other of which resists the commercial imperative. We interpret these findings through the lens of institutional theory and consider their implications for pharmaceutical ethics and governance.     

Manufacturing Consensus

The Food and Drug Administration (FDA) has declared that it would be illegal to advertise as or in any way claim your drug to be superior to competitors on the market, which are up to 30 times cheaper. How does a pharmaceutical company market such a product? The answer is to enlist academics to form expert panels to construct guidelines and algorithms, or participate in Delphi panels and other exercises, which can be expected to prove that newer, more costly drugs produce cost savings. These academics do so on the basis of the existing clinical trial evidence—which supposedly the FDA has used to come to its verdict that the newer compound is no better than its competitors. However, where the FDA has seen the raw data, academics later see the published data. In between intervenes a medical writing exercise, which produces the first and most important piece of advertising for any pharmaceutical product—the randomized controlled trial infomercial. This paper explores how pharmaceutical companies manufacture an apparent academic consensus and, in so doing, gives a case study of the recent controversies surrounding the marketing of selective serotonin reuptake inhibitor (SSRI) drugs for adolescent depression.     

BEYOND ALTRUISTIC AND COMMERCIAL CONTRACT MOTHERHOOD: THE PROFESSIONAL MODEL

It has become common to distinguish between altruistic and commercial contract motherhood (or ‘surrogacy’). Altruistic arrangements are based on the ‘gift relationship’: a woman is motivated by altruism to have a baby for an infertile couple, who are free to reciprocate as they see fit. By contrast, in commercial arrangements both parties are motivated by personal gain to enter a legally enforceable agreement, which stipulates that the contract mother or ‘surrogate’ is to bear a child for the intending parents in exchange for a fee. She is required to undergo medical examinations and to refrain from behaviour that could harm the foetus. The intending parents are the child's legal parents from the outset. The parties to the contract can, but are not expected to, maintain contact after the transaction is completed. We argue that contract motherhood should not be organized according to the norms of the gift relationship, and that contract mothers should be compensated for their labour. However, we accept that there are good reasons for rejecting the commercial model as a suitable framework for contract pregnancy, and argue, instead, in favour of viewing it as a profession.