As noted before, much North American research has been on trainee doctors. Many studies have looked at codes of practice that regulate the contact between trainee doctors and the industry.

Mahood et al.²²⁷ surveyed all 16 Canadian family medicine training programmes about their policies and practices about contact with the pharmaceutical industry, and what they taught in their curriculum about relationships with the industry. Four programmes had formal policies about interaction with the industry, and one had a policy on research involvement only. Thirteen of the programmes taught critical appraisal of industry products and claims. One programme did not allow sales representatives in training units, and one only allowed contact with sales representatives if faculty members or pharmacists were present. All programmes had some degree of industry sponsorship. Keim et al.¹⁰ surveyed 80 directors of US emergency medicine training programmes. They found 61% of programmes had specific guidelines to limit interaction between trainees and students. In 34% such interaction was not allowed in the clinical department. Only 17% of programmes allowed unrestricted group presentations by sales representatives to students. Bucci and Frey¹⁷ surveyed directors of family practice residency programmes in the US in 1989. They found 20.5% of their respondents included methods to evaluate material provided by sales representatives in their curricula, 79% limited contact between sales representatives and faculty and residents, and about 30% had printed guidelines for sales representatives. In 1991, US family medicine residency programmes were again surveyed, by Brotzman and Mark²²⁸. They examined a range of promotional activities and found that for each, most programmes allowed it within informal guidelines. Fifty-eight per cent of programmes had a written policy about at least one aspect of promotion. They concluded that programmes were more concerned with regulating access to and information from sales representatives, rather than gifts.

In two articles^229,330 Thomas describes a survey of pharmacy directors from 446 US hospitals about their hospitals’ policies towards drug sales representatives. Sixty-seven per cent of hospitals had written policies about drug representatives. Policies included the need for representatives to make appointments, to sign in at each visit, limitations on the areas in which they could detail their products and controls on samples. Some hospitals used fines or loss of exhibit privileges as penalties for those who broke guidelines. Between late 1983 and 1986 about a fifth of hospitals increased their restrictions and many anticipated more restrictions. Most appeared to be motivated by a desire to contain costs. Small hospitals were less likely to have increased their restrictions, but changes were planned across all sizes and types of hospitals. These were most often restrictions on the products which sales representatives could detail and sample, and the people who they could have business contact with.

Jewesson and Herer²³¹ describe the Vancouver Hospital and Health Science Centre’s (VHHSC) policy to restrict and monitor the activities of sales representatives at the hospital. Representatives are required to register on arrival and departure, wear an identification badge throughout their visit; and record the purpose of their visit, who they will contact at the hospital, which company they represent, and copies of any literature they distribute.

CONCLUSION: Guidelines for regulating contacts between companies and medical trainees vary greatly between institutions. Further research into this area would be relatively straightforward to do when changes are instituted.