Contacts between residents and the pharmaceutical industry are common in postgraduate medical training (1). A number of groups, including the American Medical Association (AMA), Canadian Medical Association (CMA), Accreditation Council on Graduate Medical Education (ACGME), Association of American Medical Colleges (AAMC), Pharmaceutical Research Manufacturers’ Association (PhRMA), and many medical specialty organizations, have proposed guidelines to assist medical educators, trainees, and industry representatives in managing these interactions. Their recommendations differ significantly, however, in direction and specificity, leaving much to the discretion of training programs and their parent institutions.
The AMA, for example, has specific guidelines focusing narrowly on the issue of gifts to physicians (2), with little attention to the quality of information presented, sponsorship of educational and research activities, and physicians’ contract services to industry as speakers, consultants, and researchers. Recently, the AMA launched a Web-based tutorial program on gifts from industry aimed primarily at practicing physicians (3). Neither the guidelines nor the Website is intended specifically for trainees.
Of more direct concern to educators, the ACGME has recently issued a draft position paper noting that five of their six core competencies bear directly on this topic and asserting that there are inherent conflicts between industry and medical education (4). The paper recommended that policies be implemented by training programs and sponsoring institutions, but the nature of those policies and how best to teach residents about the topic were left to be worked out by individual programs. Similarly, in April 2003 the AAMC endorsed a position paper by the Organization of Resident Representatives outlining guiding principles for interactions between resident physicians and the medical industry (5, 6). The paper suggested that current practice is inconsistent with AAMC "domains of knowledge" and with ACGME general competencies. Specific recommendations were that residents should look for guidance to professional organizations, that institutions should have explicit guidelines, and that residency curriculums should include formal teaching on the topic.
It is not clear, however, that these measures have had a significant impact on physician behavior (7) or if physicians are even aware that these recommendations and guidelines exist (5). There is scant evidence that they are taught within residency programs (8, 9). They are also without broad support within the profession. The American Psychiatric Association (APA) Ethics Committee, for example, has not endorsed the AMA guidelines or issued an alternative statement.
Ironically, the recommendations with the greatest direct effect on physician-industry interaction may be those proposed by the pharmaceutical industry itself, in response to public and regulatory pressures for reform. On July 1, 2002, PhRMA, an organization of pharmaceutical companies engaged in drug research and development, offered its own voluntary guidelines, which closely parallel those of the AMA (10). The target of these regulations was industry, rather than physicians, placing pharmaceutical representatives in the curious position of educating clinicians about the ethical limits of their interactions with industry. Not surprisingly, individual companies adhere to the PhRMA guidelines with varying degrees of fidelity, ranging from strict compliance to flagrant violation, and not all pharmaceutical companies are members of PhRMA.
Some residency programs have responded to these concerns with policies and curriculum additions, but many have not, and no standard of training seems to exist. A review of the literature in this regard is revealing. Among family practice programs, less than half have policies in place or restrictions on resident interactions with industry representatives (11, 12). Separate surveys of internal medicine residents found that more than two-thirds agreed that it was appropriate for a medical institution to have rules on industry interactions (13), but only one-third were in programs with formal policies regulating such activities, and only one-fourth had received formal instruction on marketing issues (14). In contrast, 38% of residents had been the recipients of industry-sponsored travel (14). Although 90% of chief residents in emergency medicine reported the involvement of pharmaceutical representatives in their programs, less than half were aware of program or institutional guidelines regulating such interactions (15). Meanwhile, 75% of emergency medicine residents reported that industry representatives sometimes crossed ethical boundaries (16). A small "preliminary" survey by APA/Bristol-Myers Squibb fellows found that psychiatry residents have significant contacts with representatives of the pharmaceutical industry, but feel that they lack training in how to manage these interactions (17). Less than 40% said that the residency program provided any education on the ethics of their interactions with industry.
In March 2001, the American Association of Directors of Psychiatry Residency Training (AADPRT) appointed a Task Force on the Relationship between the Pharmaceutical Industry and Psychiatry to study the issue of industry relations with psychiatry residency education and make recommendations to the membership on this topic. We here report the results of a survey of AADPRT membership conducted by the Task Force regarding policies and practices currently in place among psychiatry residency training programs and make specific recommendations based on those findings.
A survey of program policies and practices and of educator attitudes and concerns regarding interactions with industry was distributed confidentially to AADPRT membership on three separate occasions: twice to all AADPRT members by electronic mail in September 2001 and December 2001 and once in hard copy to attendees at the AADPRT annual meeting in March 2002. The survey requested specific descriptions of practices and policies within individual programs, rather than respondents’ perceptions of trends within the field as a whole. To preserve confidentiality, programs were identified by region only. No attempt was made to track individual responses to the survey. Data from the three distributions were combined for the final results. All results were reported as percentages of available responses to individual questions.
The 127 responses received represented 27% of AADPRT’s membership of 460. The respondents were mostly general psychiatry residency training directors (52%). Others included child and adolescent psychiatry residency program directors (21%), assistant or associate training directors (15%), and department chairs (2%). About one-half of the respondents (53%) had been in their current position for 5 years or less, 21% for 6—10 years, 14% for 11—15 years, and 11% in their positions more than 15 years. The responses to the three survey distributions were generally consistent with one another. Responses came from all seven national regions of the organization, with percentages of total responses from each region ranging from 9%—24%. In addition to the structured questions, 43% of respondents included narrative comments.
The extent of specific practices, including provision of meals, sponsorship of retreats, and support for resident travel, is summarized in t1. The large majority of programs permit direct, unsupervised interactions between residents and pharmaceutical representatives both during and after work hours, usually involving meals. In contrast, less than half of respondents reported residents’ involvement in other types of industry sponsored activities.
The prevalence of formal, written policies regulating resident contacts with industry is summarized in t2. Less than a quarter of residents receive a copy of written program policies, either because the policies do not exist or because they are not distributed. The number of respondents who did not know about institutional or program policies was high.
t3 summarizes teaching practices on this topic. Although two-thirds of programs provide some instruction in resident-industry interactions, most of this is informal, with less than half of programs providing specific didactic instruction. Interest in having more information available was almost universal.
Respondents’ opinions on their programs’ policies and practices showed a modest preponderance of concern that there was too much industry involvement in their programs (56%) and in medical education generally (57%). About half of respondents (53%) were aware of some inappropriate overtures to residents by pharmaceutical representatives, but a majority (79%) reported that most interactions were reasonable. Most respondents (61%) thought that their programs’ interactions were similar to those of other institutions. Fifty-seven percent of respondents wanted more institutional direction regarding their interactions, and 86% expressed a preference for AADPRT to issue a comment on the AMA guidelines.
Narrative comments varied widely, both in position and tone, ranging from the opinion that interactions with the pharmaceutical industry were inevitable and beneficial to strongly stated views that these interactions should be curbed or eliminated. Most comments were moderate, noting both positive and negative aspects to industry involvement in their programs.
The response rate to the survey was low, raising the possibility that these data are not representative of all programs or program directors, particularly on a topic with potential to generate strong feelings and extreme opinions. There are, however, several indications that this sample is a valid representation of the field. First, these data are comparable to those previously published from other medical specialties. Second, responses from two different settings (e-mail to home programs and paper distribution at an annual meeting) generated similar responses. Third, the geographic distribution of responses was good. Fourth, the duration of respondents’ service was comparable to that of all psychiatry program directors (18). Fifth, most of the information requested was objective data on individual programs, rather than subjective opinions, limiting the impact of a possible selection bias toward respondents with strong opinions. It should be noted, however, that training directors concerned with this issue and involved in the creation and dissemination of policies and educational activities may have responded at a higher rate. Finally, most of the opinions expressed were not extreme but clustered in the moderate range, suggesting that those with the strongest opinions were not over-represented.
The extent of involvement of the pharmaceutical industry with psychiatry residents and residency programs was similar to that reported for other specialties. The large majority of contacts occurred in the context of lunches provided to residents at which pharmaceutical representatives were in attendance. These data would suggest that residents can find an industry-sponsored lunch nearly every day, lending credence to the argument that industry largesse has become an entitlement for residents. The number of programs requiring faculty to be present at these lunches was small, although the survey did not ascertain the percentage of luncheons at which faculty were actually in attendance. The widespread distribution of literature and gifts at these lunches suggests a high level of input from industry in residents’ training experience. The presence of faculty appears to have been more common at industry-sponsored dinners at restaurants, providing an important source of modeling of professional behavior for residents.
Other contacts were more limited. A minority of programs received significant financial support for retreats, and few of these allowed formal presentations by pharmaceutical representatives. Nevertheless, the mingling of sales representatives with residents in an informal, half or all day retreat sets the stage for the development of the type of familiarity and personal relationships that marketing professionals crave.
Travel funds were widely sought through formal fellowship and scholarship programs, funded by industry but administered by professional organizations. These fellowships are endorsed by the AMA guidelines. In contrast, direct funding of resident travel by industry is specifically prohibited by the guidelines, yet was reported in a third of training programs.
The trend toward increasing interactions represented the period between 1998 and early 2002, and thus did not capture the impact of the PhRMA guidelines introduced in July 2002 or the AMA Website launched in 2003. It is possible that resident travel and the availability of gifts, both addressed in those guidelines, have since changed, but no data are yet available.
Overall, a small majority of respondents judged the extent of involvement of industry with their programs to be excessive, but a significant minority disagreed. Most respondents thought the interactions within their own programs were both typical of all programs and usually stayed within appropriate boundaries.
Evidence suggests that institutional policies and even modest efforts at education strongly affect medical student (19, 20) and resident (21, 22) attitudes toward pharmaceutical marketing and their behavior after completion of training (23). Yet the current findings suggest that formal policies have had little impact on the field as a whole. Few programs had such policies, not all of those programs taught residents about them, and many faculty members appeared to be equally uninformed on the topic. The trend toward less awareness among faculty of policies originating at higher levels of administration was striking. It did not appear that most programs looked to their parent institutions for guidance. There was strong support for the development of clear-cut policies that would guide interactions with the pharmaceutical industry. A majority of respondents expressed a preference for more institutional oversight and guidance from professional organizations, in keeping with the recommendations of the AAMC.
Interest in more information about this topic was nearly universal, but it is not clear how this would be taught. The majority of programs provided no formal didactic instruction but instead depended on informal meetings with the training director to educate residents on the topic. Even with more information available, most respondents expected to limit resident instruction to written information and informal discussions.
These findings make clear that resident contacts with the pharmaceutical industry in psychiatry programs are widespread and largely unregulated. Residents receive little formal education on how to deal with these interactions and are ill-prepared to respond to the ethical and practical issues they involve.
The AADPRT Task Force sought to provide information and to make specific recommendations, but not to dictate prescriptive or proscriptive policy regarding how individual programs should manage this complex and evolving issue. We offer several recommendations based on the above findings.
The Task Force strongly recommends that residents receive formal education regarding their interactions with the pharmaceutical industry, including both written information and discussions with informed faculty. We recommend that programs consider establishing a set of didactic presentations, a reading list, and discussion sessions with appropriate faculty to cover this topic.
The Task Force recommends several specific educational resources to assist in this effort. Although there is not uniform endorsement within the field of the AMA Ethical Guidelines for Gifts to Physicians from Industry, these guidelines should be made available to residents and should be discussed by appropriate faculty. The AMA’s website provides a tutorial covering this issue as well as the guidelines themselves (www.ama-assn.org/go/ethicalgifts). Several curricula from other specialties have been published and are readily adaptable to psychiatry (19, 20, 22, 24, 25). A curriculum has also been developed by one of the Task Force members (M.D.J.) that is specifically directed to psychiatry residents and addresses the full range of industry-physician interactions, rather than just the issue of gifts. The curriculum is available to association members on the AADPRT website (www.aadprt.org/public/educators.html).
The Task Force recommends that departments of psychiatry and their affiliated medical schools or hospitals establish clear policies regarding this topic, that these policies be distributed to faculty and residents, and that they be discussed with residents by informed faculty. We recommend that these policies be made available for review at other sites.
Finally, we propose that this topic be the subject of further research and discussion as policies and practices develop and evolve.