The results of this survey provide a first ‘environmental scan’ of the aims and extent of education about drug promotion within medical and pharmacy faculties. The survey results cannot be assumed to be representative of global education but do provide a range of experience across many countries and regions.
For most faculties that responded, education on promotion was included within the required curriculum but usually students had less than a day’s worth of education about this topic during their professional training. In nearly one-third of cases, medical faculties devoted only 1-2 hours, often within a broader course on pharmacology, clinical pharmacology or therapeutics. Electives followed a similar pattern. Those with total educational time in all courses combined of one-half day or less, were less likely to judge this education to be at least somewhat successful (41% vs. 68% of those with at least four hours of teaching). Those with educational sessions lasting one-half day or less were also less likely than others to use interactive educational techniques, such as small group discussions or exercises involving critical analysis of sample advertisements. Similarly, more than half of those reporting at least 4 hours of education also included questions on drug promotion in student examinations, as compared to just one-quarter of those who spent less than half a day on education about drug promotion. Inclusion of a topic in examinations provides a message to students about educators’ perception of the importance of the topic, as well as influencing retention of knowledge.
On the one hand, the outcome of this survey was extremely positive. There are few published studies describing initiatives to educate medical or pharmacy students about drug promotion. Zipkin and colleagues identified 11 article published between 1960 and 2004 that involve educational interventions targeting doctors in training, and addressing interactions with pharmaceutical sales representatives (Zipkin, 2005). One additional article describes use of an educational video to stimulate discussion among medical students and faculty members (Shashindran, 1995). Suryawati and Santoso (1997) evaluated an educational session on critical evaluation of drug advertisements, and Harvey and Black describe the use of an educational video, brochures and therapeutic guidelines as educational tools (Harvey, 1994).
In comparison to these 14 published descriptions of educational initiatives, all targeting medical students or residents, the volume of responses to this survey was both encouraging and unexpected. We received descriptions of over 200 educational initiatives in 64 countries, most of which are part of the required curriculum in pharmacy and medical schools. The responses also included many innovative and interesting examples of curricula, assignments and educational materials. Educators in many countries are clearly aware of the influence of pharmaceutical promotion on the health professions and wish to prepare students for this aspect of their professional lives. As a physician educator from India said, “…Whatever rational things we want to inculcate in them, that should be done in the student period itself. Once they taste big money then habits develop and later die hard.”
Medical school respondents generally tended to spend less time in education about drug promotion than pharmacy respondents. Medical students already face a heavy workload and educators may be loathe to add additional content. On the other hand, most spending on pharmaceutical promotion is in categories targeting physicians (IMS Health 2002), and empirical studies evaluating the effects of promotion on physicians’ behaviours and knowledge have found that influence to be largely negative (Avorn, 1992; Wazana, 2000; Steinman, 2001; Boltri, 2002; Caamano, 2002). Thus many students may be graduating with little preparation to deal with commercial influences on an important aspect of their professional practice after graduation.
A national survey of U.S. 3rd year medical students at 8 medical schools highlights the extent of exposure to promotion during students’ training: 97% of the 826 respondents had eaten lunches provided by drug companies; 94% had received small gifts such as pens or coffee mugs, and 87% had attended Grand Rounds sponsored by a drug company (Sierles, 2005). The authors call promotion ‘the hidden curriculum’ during medical school. Two of the 8 medical schools provided education on drug promotion, but this was only a single 2-hour session. Students who had attended these sessions were no more sceptical than others who had not. This is consistent with the opinions of educators in this survey, in that they were less positive about the success of education that was limited to 4 hours or less.
We found that the content of coursework on drug promotion was remarkably similar by health profession and region, with most educators focussing primarily on critical appraisal skills, followed by sales representatives. Pharmacy faculty respondents were more likely than medical respondents to include education related to patient-directed promotion: patient requests for advertised drugs and the use of the Internet to promote drugs. This difference may reflect the larger role of pharmacists in counselling patients about drug treatment decisions.
Direct-to-consumer advertising of prescription drugs is legal in the USA and New Zealand. Even in these countries, few medical faculty respondents reported educating students about how to respond to patient requests for advertised drugs. A recent randomized controlled trial using model patients found that patient requests for advertised drugs were a stronger determinant of prescribing decisions than whether or not the patient had the condition the drug aimed to treat (Kravitz, 2005). A previous study of prescribing decisions in response to patient requests found that if a patient asked for an advertised brand, they usually received it, although the physician was more likely to be ambivalent about these prescribing decisions (Mintzes, 2003). These studies suggest a need for physicians and pharmacists to receive adequate training on how to respond to patient requests.
In jurisdictions where prescription drug advertising is illegal, the public is exposed to over-the-counter drug promotion. Additionally, effects of Internet promotion remain a concern, and in many countries, prescription-only status is poorly enforced. One pharmacist educator from Iraq characterized the situation as involving, “Uninformed patient use and their demands for the latest medicines,” adding that, “…the current pharmaceutical situation is lamentable; since the national drug policy is (if present) fragile, the drug market is open and not controlled, coupled with the lack of quality assurance measures; all result in the propagation of the possible counterfeit and substandard pharmaceutical products…In fact a case of pharmaceutical chaos is presented here.”
Most educators were aiming to enable students to critically appraise drug promotion and to increase students’ use of independent information sources. Most medical school respondents also aimed to improve prescribing behaviours after graduation, whereas pharmacy school respondents were more likely to aim more generally to expose students to a different perspective or to increase students’ ability to extract beneficial information from drug promotion.
One US pharmacist educator commented that: “We are unique in that while we recognize the problems that may arise out of promotional efforts in the pharmaceutical industry, we also recognize the tremendous benefits of these activities. The trick is in the balance…” On the other hand, a German medical faculty respondent stated that their main aim was, “to inform students about conflicts of interest: pharmaceutical company plus shareholders versus public health, society, stakeholders.”
Many observational studies have found correlations between lower quality of prescribing and more exposure to drug promotion and/or positive beliefs about drug promotion (Haayer, 1982; Berings, 1994; Caudill, 1996; Caamano, 2002; Watkins, 2003). It is therefore noteworthy that fewer respondents aimed to change students’ attitudes towards promotion than to improve dispensing or prescribing behaviour, and that only 10% of pharmacy and 24% of medical schools aimed to decrease students’ use of drug promotion. It is possible that many pharmacy and medical schools hoped to improve the quality of prescribing via education about critical appraisal of drug promotion and/or increasing the use of independent information. We are not aware of any studies that investigate whether skills in critical appraisal of drug promotion are associated with better prescribing. There is controlled trial and observational evidence that use of independent information sometimes improves the quality of prescribing but often makes little or no difference. (Jamtvedt, 2003; Thomson O’Brien, 1997; Thomson O’Brien 2001; Freemantle, 1997)
The most frequent barriers to success mentioned were lack of integration into the curriculum and inadequate time allocation. In several cases, the influence of the pharmaceutical industry on educational facilities was mentioned. Educators in a variety of regions and economies mentioned barriers related to the influence of the pharmaceutical industry on student activities at their institution. One Zimbabwean pharmacy respondent attributed, “lack of placed [sic] value on the importance of this subject.” A Belgian medical faculty respondent similarly identified the, “attitude of opinion leaders in the faculty,” as a barrier. A Kenyan medical educator described, “Threats from big pharma, big pharma funding… thus making it difficult to ‘restrict’ their activities.” A Canadian medical respondent said that, “the medical school, especially post-graduate, actively undermines objective education by promoting opportunities for drug companies to subsidize morning Grand Rounds (coffee and donuts) noon rounds (‘sponsored’ lunches with drug reps in attendance) etc.” At a Turkish medical school, a respondent mentions as a barrier, “Drug companies financing the activities of students and giving gifts after they graduate.” Although there are no doubt differences between experiences in these different regions, all mention some degree of pharmaceutical industry influence on their institution or students as a barrier to effective education about drug promotion.
One of the aims of this survey was to collect information on educational initiatives that had been systematically evaluated. Few respondents overall (19%) were carrying out any programmatic evaluation of education on drug promotion. The proportion increased with increasing time spent educating students about drug promotion, with 30% of those who reported more than 10 hours of education reporting some form of evaluation.
Most often, the evaluation was in the form of written or oral course appraisals (e.g. student evaluation forms). This provides useful feedback on students’ opinions of coursework for future planning. However, it cannot evaluate effects on knowledge, skills, beliefs or behaviour. Nearly half of those who reported some form of evaluation of educational initiatives relied only on student course appraisals (19/41 or 46%). In total, 20 (9%) of respondents were carrying out some form of evaluation other than student evaluations or counts of numbers of students attending courses; this was most often before and after comparisons of students attending sessions. Seven respondents (3%) included some form of control group of students who had not participated in sessions on drug promotion in their evaluation. These educational initiatives are being followed up for further details on curriculum, methods and results of evaluations.