gms | German Medical Science

GMS Journal for Medical Education

Gesellschaft für Medizinische Ausbildung (GMA)

ISSN 2366-5017

German medical students´ exposure and attitudes toward pharmaceutical promotion: A cross-sectional survey

research article medicine

  • corresponding author Kristine Jahnke - Universitätsmedizin Greifswald, Institut für Community Medicine, Abteilung Allgemeinmedizin, Greifswald, Deuschland
  • corresponding author Marcel Stephan Kremer - Universitätsmedizin Greifswald, Institut für Community Medicine, Abteilung Allgemeinmedizin, Greifswald, Deuschland
  • corresponding author Carsten Oliver Schmidt - Universitätsmedizin Greifswald, Institut für Community Medicine, Abteilung Study of Health in Pomerania - Klinisch-epidemiologische Forschung (SHIP-KEF), Greifswald, Deuschland
  • corresponding author Michael M. Kochen - Universitätsmedizin Göttingen, Institut für Allgemeinmedizin, Göttingen, Deutschland
  • author Jean-François Chenot - Universitätsmedizin Greifswald, Institut für Community Medicine, Abteilung Allgemeinmedizin, Greifswald, Deuschland

GMS Z Med Ausbild 2014;31(3):Doc32

doi: 10.3205/zma000924, urn:nbn:de:0183-zma0009245

This is the original version of the article.
The translated version can be found at: http://www.egms.de/de/journals/zma/2014-31/zma000924.shtml

Received: January 21, 2014
Revised: April 21, 2014
Accepted: June 5, 2014
Published: August 15, 2014

© 2014 Jahnke et al.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by-nc-nd/3.0/deed.en). You are free: to Share – to copy, distribute and transmit the work, provided the original author and source are credited.


Abstract

Objective: Early contact of medical students with pharmaceutical promotion has been shown in many international studies. We assessed the frequency and places of contact of German medical students to pharmaceutical promotion and examined their attitudes toward pharmaceutical promotional activities.

Methods: This cross-sectional survey was based on a self-developed questionnaire. It was distributed to all clinical students at the University of Goettingen Medical School in 2010. A 4-point rating scale was used to assess the attitudes toward different statements regarding pharmaceutical promotion.

Results: The overall response rate was 55% (702/1287). The proportion of students with direct contact to pharmaceutical sales representatives increased from 21% in the first clinical year up to 77% in the final year. 60% were contacted during their elective clerkship. 80% had accepted promotional gifts. 86% stated their prescribing behavior to be unsusceptible to the influence of accepting promotional gifts. However, 35% of the unsusceptible students assumed doctors to be susceptible. Almost all (90%) reported that dealing with pharmaceutical promotion was never addressed during lectures and 65% did not feel well prepared for interactions with the pharmaceutical industry. 19% agreed to prohibit contacts between medical students and the pharmaceutical industry.

Conclusions: German medical students get in contact with pharmaceutical promotion early and frequently. There is limited awareness for associated conflicts of interests. Medical schools need to regulate contacts and incorporate the topic in their curriculum to prepare students for interactions with the pharmaceutical industry.

Keywords: Pharmaceutical promotion, medical students, medical education, Germany, cross sectional survey


Introduction

First contact to pharmaceutical industry occurs early in medical education [1], [2], [3]. Frequency of exposure to pharmaceutical promotion increases with each additional academic year [2], [4], [5]. In the final clinical year up to 90 percent of medical students reported indirect or direct contact to pharmaceutical promotion or sales representatives as well as participating in sponsored events [2], [3]. Accepting small gifts, free meals and educational material sponsored by the pharmaceutical industry is considered to be normal, appropriate and ethically unobjectionable by most students [2], [3], [4], [6]. Frequent exposure of medical students to pharmaceutical promotion was associated with a general positive attitude toward the pharmaceutical industry [4], [7] and confidence in dealing with pharmaceutical marketing strategies [4]. Exposure to small branded promotional items of the pharmaceutical industry is associated with a more favorable implicit preference of medical students toward the promoted products [8]. Early strengthening of positive associations toward pharmaceutical industry on various levels, including small gifts, free meals, sponsored educational and social events and contacts to sales representatives, has the potential to form an implicit brand awareness leading to brand choices over other alternatives [9]. Therefore a risk of future conflicts of interests exists. Physicians’ exposure to pharmaceutical promotion is associated with biased treatment decisions and non-rational prescribing behavior [10], [11], [12], [13], [14].

Past studies focusing on medical students’ exposure and attitudes toward the pharmaceutical industry were mostly conducted in the U.S.. Only few European studies examined medical students` relation to the pharmaceutical industry [4], [15], [16], [17], [18], [19]. The aim of our study was to assess the frequency of exposure of German medical students to pharmaceutical promotion as wells as to explore their attitudes toward pharmaceutical promotion, their perceived influence on future describing behavior and their need for educational support for dealing with pharmaceutical marketing.


Methods

This was a cross sectional survey based on a self-developed questionnaire which was distributed to all clinical students at the University of Goettingen Medical School in 2010. Students were asked to complete paper pencil versions before or after lectures and courses. Final year students on rotation in external hospitals were contacted up to three times per mail using an electronic version of the questionnaire. Participation was voluntary and responses anonymous. The ethic committee of the University of Goettingen Medical School deemed a formal approval unnecessary (January 2010).

The 29-item questionnaire was developed based on literature review of previous studies with similar research questions [3], [15] and pilot tested. Times of completing the questionnaire, response issues (e.g. vagueness, applicableness, ambiguity) as well as recommendations of improvement were assessed using the think aloud method [20]. At first students and teachers of a seminar in family medicine evaluated the first version of the questionnaire. Further evaluation was done by students of the second preclinical year and students of the third clinical year before a final version was developed. After pilot testing, preclinical students were excluded from the original target sample, since they reported almost no contact to pharmaceutical promotion. Items on advertisement of drugs and treatments in medical journals were excluded as well, since students rarely reported reading medical journals. International editions of core medical journals in Germany are free of advertisement unlike in the US. Pharmaceutical promotion was defined as any kind of contact (e.g. meetings with sales representatives, educational and informational material, gifts) between medical students and the pharmaceutical industry.

The questionnaire assessed three issues related to pharmaceutical promotion: exposure, attitudes toward pharmaceutical promotion and educational activities. We collected data on age, gender, clinical semester and number of weeks of clerkships of all respondents. Items on exposure comprised questions about the frequency and places of contact to pharmaceutical sales representatives, the frequency of accepting small gifts as well as the frequency of accepting gifts of higher value. Small gifts included e.g. pencils, sweets, paper pads and gifts of higher value included e.g. books and medical equipment. Whether clinical teachers used the substance name or the trade name of a drug more frequently was assessed as well as whether the doctoral thesis was financially or materially supported by the pharmaceutical industry. Data on various attitudes including the appropriateness of accepting promotional gifts, the agreement with material support of medical faculties by pharmaceutical industry, the usefulness of informational material provided by the pharmaceutical industry and the assumed impact of pharmaceutical gifts on describing behavior was collected. A 4-point rating scale, ranging from 1=strongly agree, 2=agree, 3=disagree, 4=strongly disagree, was used to assess the attitudes toward different statements regarding the relation between medical students and pharmaceutical industry. Questions concerning educational activities included participation on topic related lectures, the perceived need for specific educational activities and the attitude toward prohibiting contact between students and pharmaceutical industry in medical school.

Data analysis was performed in STATA 12.0. It included descriptive statistics and between-group statistical comparisons using Chi-Square tests (and Fisher-Exact-tests respectively). Results are presented as p-values or relative risks. Because of differences in the response rate between the clinical years an adjustment using statistical weights as reciprocal value of the probability of participation was carried out. Therefore we used robust variance estimates (Taylor series linearization). In case of missing data we report the number of subjects analyzed (n).


Results

Sample

A total of 702 (55%) out of 1287 medical students returned a questionnaire. Response rates among the clinical years ranged from 78% for the first clinical year to 17% for the final year. Age and sex of medical students and response rates are reported in table 1 [Tab. 1].

Exposure to pharmaceutical promotion

Direct contact with pharmaceutical sales representatives was reported by 44% (CI 39.2–48.2, n=697) of the students. The proportion of students reporting direct contact increased from 21% (CI 15.4–26.1) in the first clinical year up to 77% (CI 66.2–87.9) in the final year (see Figure 1 [Fig. 1]).

Among the respondents 12% reported more than ten contacts by a pharmaceutical sales representative. More than half of the students (60%) were contacted during their elective clerkships. A small proportion of students´ (13%) was contacted directly outside of lectures. The majority of students (80%, CI 77.7–83.7) reported accepting gifts sponsored by the pharmaceutical industry. Four fifths of the students (79%, CI 75.8–82.0, n=698) accepted a small gift and 23% (CI 19.6–27.1, n=699) of the students accepted gifts of higher value. The proportion of students´ accepting gifts increased each academic year. More than half of the students (70%, CI 64.3–75.9) of the first clinical year versus almost all students of the final year (96.8%, CI 92.3–101.3) accepted gifts. Small gifts had been accepted one to five times by 53% and more than twenty times by 15% of the respondents. A small fraction of the students (7%) accepted smaller gifts more than twenty times. Most commonly distributed gifts were pens (72%, CI 68.3–75.8, n=700) and paper pads (52%, CI 48.1–56.9, n=698) with logos of pharmaceutical companies. Nearly half of the medical students (42%, CI 37.5–46.3, n=698) accepted free meals offered by the pharmaceutical industry (see Figure 2 [Fig. 2]).

Gifts were not only distributed by pharmaceutical sales representatives. More than two-third of the students (73%, CI 69.8–77.1, n=698) reported that they received learning material with logos of pharmaceutical companies by clinical teachers. About half of the students (59%, CI54.8–63.3, n=696) reported that most clinical teachers used substance names of a drug more frequently than trade names. An evenly use of substance name and trade names of drugs was reported by 36% (CI 31.6–39.9, n=696) of the students. Material or financial support of the doctoral thesis by the pharmaceutical industry was stated by 5% (CI 3.5–7.2, n=636) of the students. However, almost half of the respondents (42%, CI 38.0–45.9, n=636) were unsure whether their doctoral thesis was supported by the pharmaceutical industry.

Attitudes toward pharmaceutical advertising

Medical students´ agreements with statements regarding pharmaceutical industry are shown in Figure 3 [Fig. 3].

Almost all medical students (92%) found it appropriate to accept small gifts and 78% had no objection to accept promotional gifts of higher value. There were no significant differences between clinical semesters or gender. Although there was a statistical significant difference in the proportion of students´ reporting contact and students´ reporting no contact to pharmaceutical representatives regarding the appropriateness of accepting promotional gifts, the observed difference was small (95% vs. 89% for accepting small gifts, 80% vs. 77% for accepting gifts of higher value). Almost half of the medical students (48%) agreed with the statement that pharmaceutical industry should provide material support to medical faculties. Information obtained from the pharmaceutical industry sources was considered a useful way of learning about drugs and treatments by 49% of the students. The majority of students (92%) did not agree that information about drugs and treatments provided by the pharmaceutical industry present advantages and disadvantages evenly. Almost every one (98%) agreed that promotional gifts are part of a marketing strategy to early ingrain brands in the minds of future doctors. Nearly half of the students (42%) agreed that accepting promotional gifts influences the prescribing behavior of doctors in general. Only 14% of the students assumed their own prescribing behavior will be influenced by the acceptance of promotional gifts. However, 35% of the students who considered themselves immune to the influence of promotional gifts versus 79% of the students who considered themselves influence able assumed doctors to be susceptible (p<0.0001, n=682). Students who have accepted gifts tended to be more likely to believe their own prescribing behavior could be influenced by promotional gifts (RR 1.4, CI 0.96–2.13, n=693).

Educational activities

Most medical students (90%, CI 87.2–92.9, n=699) stated that dealing with the pharmaceutical industry was never addressed during lectures and courses. Two-third of the respondents (65%, CI 60.5–69.1, n=698) did to not feel well prepared for possible interactions with the pharmaceutical industry. More than half of the students (60%, CI 55.6–64.2, n=699) wished for educational activity on the topic. One fifth of the students (19%, CI 15.9–22.4, n=679) agreed that contact between medical students and the pharmaceutical industry should be prohibited.


Discussion

Summary of the main results

Nearly half of the surveyed medical students reported direct interactions with pharmaceutical sales representatives. The majority accepted promotional gifts. Exposure to pharmaceutical promotion increased with every academic year, being the highest during final year. Although most students were aware that the aim of pharmaceutical promotion is to influence prescribing behavior, the majority of the students assumed themselves to be immune to pharmaceutical promotion. However, they suspected that doctors are susceptible. Dealing with pharmaceutical promotion was virtually never addressed during lectures and students did not feel well prepared in that regard. Anyway only a minority of the students agreed that contact between pharmaceutical industry and medical students should be prohibited.

Meaning of the results and comparison with existing literature

Exposure of medical students to pharmaceutical promotion was observed in many other countries [1], [2], [4], [15], [17]. In comparison to the U.S. first contact of German medical students to pharmaceutical promotion seems to occur later in the educational process and less frequently directly on campus [1], [2], [21]. Only a few students reported having been contacted directly by pharmaceutical sales representatives on campus. Most contacts to sales representatives occurred during elective and mandatory clerkships or in the final year. We have no evidence that German students are directly targeted by pharmaceutical sales representatives or pharmaceutical promotional activities. We speculate that they are unintentionally or mistakenly addressed as doctors.

Similarly to other existing surveys the majority of students reported to have accepted gifts sponsored by the pharmaceutical industry [2], [3], [4], [15], [19]. Most common gifts were pens, notepads and meals as well as learning material such as pocket cards. Not only pharmaceutical sales representatives distributed gifts. Students reported about clinical teachers offering learning material with logos of pharmaceutical companies. These findings are in line with similar data of other studies [3], [19]. The acceptance of meals, educational material or assisting in lectures sponsored by the pharmaceutical industry could be also a by-product of accompanying clinical teachers. This is important since students learn by role models.

There are less critical voices of German medical students concerning the appropriateness of accepting small or even higher valued gifts compared to results of previous studies [2], [3], [4], [6]. Consistent with results of other studies students agreed to accept funding by the pharmaceutical industry for decreased tuition fees [2], [3]. Financial support or gifts were considered to be a kind of compensation for the financial burden of medical education [8], [21]. In accordance with other surveys informational material received by the pharmaceutical industry was considered to be a useful way of learning about drugs and treatment options by half of the students [2], [3], [6]. Nonetheless informational material distributed by the pharmaceutical industry was recognized to be biased and not objective by almost all students [3], [19]. Although German medical students seem to recognize promotional gifts to be a marketing strategy to anchor brands in mind of future doctors and to influence prescribing behavior, they do believe themselves to be unsusceptible just like their foreign fellow students [2], [3], [4], [15], [17]. Early contact to the pharmaceutical industry was rarely viewed critically by students. Potential future conflicts of interests were seldom presumed [2], [4], [6]. Previous studies found a positive association between the frequency of exposure to pharmaceutical promotion and a general positive attitude toward the pharmaceutical industry [4], [5]. Existing data suggests early exposure to pharmaceutical promotion to bear the potential of anchoring pharmaceutical brands in mind, leading to an easy recall of promoted products in situations of treatment decisions without considering alternatives [8], [10], [11], [13]. Especially gifts evoking positive emotions bear the risk of choosing the promoted product just because of the association to the emotion [22]. Motives of reciprocity have been discussed as well to cause non-rational prescribing behavior and biased treatment decisions [22], [23]. A contradiction between students´ and doctors´ awareness of the potential influence of promotional gifts on prescribing behavior and their belief to be unsusceptible themselves was evident. This discrepancy could be explained by the self-serving-bias as well as within the theory of cognitive dissonance by Festinger [24], [25]. Disclosing this contradiction and developing an awareness for pharmaceutical promotion`s possible impact on professional behavior should be part of educational interventions to prepare future doctors for interactions with the pharmaceutical industry.

As in our survey students participating in other studies did not feel well prepared for interactions with the pharmaceutical industry and asked for educational support [2], [3], [26]. Prohibiting any kind of contact between pharmaceutical industry and medical students could be one solution, favored only by 19% of the students in our survey. This finding is in line with findings of a survey at eight German medical faculties [19]. Controlling exposure of medical students to pharmaceutical promotion especially during their clerkship, internship or final year will require a great effort or is even impossible to implement. Medical schools have a conflict of interest too, since they cooperate with and depend partly on grants from the pharmaceutical industry. Limiting any contact to the pharmaceutical industry could therefore lead to significant losses in medical education and research. Furthermore many teaching activities take place outside the jurisdiction of the faculties. One might argue that medical students should not be artificially protected from contact with promotional activities. It could even be used as a teachable moment.

Educational workshops and lectures, developing guidelines and policies dealing with the issues of interactions with the pharmaceutical industry could be first steps to create awareness for problems of entanglement of medicine and the pharmaceutical industry. Although little data on the impact of educational workshops and medical school policies exist small effects for changes in attitudes have been demonstrated [16], [27], [28], [29], [30]. Lectures on pharmaceutical promotion and teaching staff as role models [22], [31], [32] could lead to a critical perception of pharmaceutical promotion activities and the selection of objective informational material. More transparency and awareness for pharmaceutical interactions could be also reached through guidelines and policies of medical schools ensuring the integrity of the medical profession [16], [27].

Strengths and limitations

To our knowledge this is one of the largest studies in Germany assessing the frequency of exposure to and attitudes toward pharmaceutical industry of medical students at one medical school, thus allowing us to investigate the effects across the academic years of medical education. A similar survey was conducted at the same time at eight German medical schools with a total of 1151 participants [19]. Unlike this study which has sampled a small proportion of clinical students at each medical school we attempted a survey of all clinical students at one medical school. Additionally we assessed places and frequency of contact to pharmaceutical sales representatives, participation in educational activities and the need for educational support. In comparison with international studies it is one of the largest studies with a high response rate.

Our study has several limitations. The cross-sectional design limits conclusions concerning the course of attitudes over time. Statistical weights were used to account for differential response rates between the academic years, but bias may still be present. Our results might not be generalizable to all medical schools in Germany. However, medical schools in Germany follow a similar curriculum and exposure to pharmaceutical promotion occurs in many institutions outside of direct control of the faculty. We cannot exclude the presence of social-desirability-bias, but our results show that students had little awareness of ethical implications of interactions with the pharmaceutical industry.


Conclusions

Early contact of medical students with pharmaceutical promotion paves the way for future doctor pharmaceutical industry relationships. We have no evidence that medical students are intentionally targeted by promotional activity of the pharmaceutical industry. However, exposure to pharmaceutical promotion and acceptance of gifts with little awareness of associated problems is common. Medical schools need to develop a policy regarding medical students´ exposure and prepare them to understand pharmaceutical marketing strategies as well as associated conflicts of interests and ethical problems. Next steps are a national survey of policies of medical schools regarding students´ exposure and preparation for dealing with pharmaceutical promotion activities. The topic should be incorporated in the curriculum and effectiveness of educational interventions needs to be assessed.


Acknowledgements

We are grateful to Prof. Dr. disc. pol. Wolfgang Himmel for advice and all medical students participating in the survey.


Competing interests

The authors declare that they have no competing interests.


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