Residents Want Education on Interacting With Drug Industry
A survey conducted by several of the APA/Bristol-Myers Squibb fellows is pointing to the need to educate residents about the ethics of interacting with representatives of the pharmaceutical industry. Although preliminary, the results indicate that responding residents were far more involved with industry than the surveyors had anticipated. In addition, residents across the country expressed a need for more guidance on how to manage those interactions ethically and appropriately.
Daniel Dickstein, M.D.: Nearly 40 percent of the residents said they had received no education on interacting with the pharmaceutical industry.
The survey results were reported in a session at APA’s 2002 Institute on Psychiatric Services in Orlando in October.
Dickstein, a combined pediatric, adult, and child psychiatry fellow at Brown University, teamed with APA/BMS fellows Daralynn Deardorff, D.O., a resident at the University of Texas Southwestern Medical School, and Pamela Swedlow, M.D., a resident at the University of California at San Francisco-Langley Porter Psychiatric Institute, to survey the residents in each of their programs. In addition, the psychiatry residents at the University of Louisville were surveyed. Leah Dickstein, M.D., chair of the APA/BMS Fellowship Selection Committee, is a professor of psychiatry and behavioral sciences at the University of Louisville.
Responses were received from 67 residents, about half of the total number of residents in the four programs. (There are approximately 5,714 psychiatry residents in the United States.) The residents in the four programs not only were convenient, but also offered geographical diversity as well as different types of residencies, including large urban research sites and large clinical sites. The trio of APA/BMS fellows has plans to expand the survey to other residency programs in the future.
“The lucrative market for psychotropic medications has really raised the stakes for companies marketing to psychiatrists,” Swedlow said at the institute session. “Psychiatrists are expected to generate some $8.3 billion in sales this year. As a profession, we are heavily targeted for marketing. Detail-related spending to psychiatrists ranked fourth [among all specialties] in 1999, for an overall total expenditure by drug companies of $375 million.”
Deardorff, who chaired the session, pondered why so many see a conflict in these kinds of numbers and why the topic generates so much affect among physicians.
“We have to remember that industry does not have any ethical obligation to us,” Deardorff said. “They have an obligation to their shareholders. We, as physicians, have an ethical obligation to our patients and to our profession. It is up to us to maintain the integrity of our professional judgment.”
With those thoughts in mind, Dickstein developed the survey “Pharmaceutical and Residents Ethical and Behavioral Evaluation,” which he refers to as “PhREBE.” Residents were allowed to return the completed surveys anonymously. Data presented at the institute included responses returned during September, but responses have continued to be returned and will be included in the final analysis, Dickstein told Psychiatric News.
The survey has four sections, one looking at the demographics of the residents surveyed and the basic nature of their contact with industry representatives, a second looking at what materials those residents receive from industry representatives, a third evaluating residents attitudes toward their interactions with industry, and a fourth section as a performance test in which residents were asked to pair up generic and trade names of some of the 10 highest-selling pharmaceutical products with their advertising slogans.
Dickstein told Psychiatric News that several of the findings impressed the fellows. Nearly half of the respondents indicated they have contact with pharmaceutical industry representatives on a weekly basis, with almost the same number saying they saw a company representative at least once a month.
While slightly over half said that their residency program had at least some education on the ethics of interacting with industry, nearly 40 percent said they had received no education on the issue in their residency programs.
Dickstein told Psychiatric News that of those programs that did offer some education on the issue, there was little consistency in what that education consisted of from program to program. Some programs featured ongoing discussions, while others offered one lecture or a grand rounds.
While about a third of those responding said their residency program had a policy restricting their interactions with pharmaceutical representatives, less than 20 percent said they did not see company representatives during their hours on duty.
“So, if contact is being made during work hours, is it benefiting the patient or taking away from the patient?,” Dickstein asked.
The material benefits of the interactions were reportedly far ranging—anywhere from a pen or two to textbooks and thousands of dollars in free samples. Just over one-third of the respondents indicated they had taken advantage of more than 15 free meals, many with no educational component, over the previous six months.
“Material gifts are quite common,” Dickstein said, “and they are more common than the education received about the ethics involved.”
Most residents surveyed felt that their interactions with industry representatives did not help them learn about new medications, nor did they believe that the interactions influenced their prescribing habits for a new medication. The survey also indicated that the respondents appeared to be marginally familiar with the AMA’s ethical guidelines on the subject of industry gifts to physicians.
The prevalence of resident-industry contact and the apparent lack of education and guidance on the ethics of that interaction trouble Dickstein and his colleagues.
“I think,” Dickstein told Psychiatric News, “that in some ways it could be dangerous in that it doesn’t allow impressionable young physicians to have the chance for formal mentoring and training on the issue before they are subjected to it.”
Deardorff agreed. “We really should be teaching our residents—and actually it should start in medical school—about how to ethically interact with industry. We need to teach them how to maintain their boundaries, how to critically evaluate data on the effectiveness and safety of medications, and how to balance that with the most important needs of their patients.”
The team is preparing the final results of the survey for publication and is in the process of revising the pilot study for use with other residency programs.
The AMA Council on Ethical and Judicial Affairs’ “Clarification of Gifts to Physicians From Industry” is available on the Web at www.ama-assn.org/ama/pub/category/5689.html. ▪
