Medical students are extensively exposed to drug company marketing (1–3). In our previous study of 826 third-year students at eight medical schools, students either received a gift or attended a sponsored lunch once weekly on average (1). This is problematic for several reasons. First, extensive exposure will likely continue after graduation (1–5). Second, drug company-physician interaction presents information favoring the sponsor’s product (1–3, 6–13) and increases the likelihood of prescribing that product (14–17). Third, the resulting prescribing may be inconsistent with evidence-based guidelines (16, 18) or—when samples are available or patients make requests based on direct-to-consumer advertising—against the physician’s better judgment (19, 20). Fourth, physicians who interact with industry are more likely than their counterparts to make formulary requests for drugs with no clear advantage over existing ones (21), prescribe nonrationally (i.e., not appropriate or effective for the patient’s symptom or disease, not safe, or not in the right dose or duration), and prescribe costlier drugs and fewer generic drugs (1–3). Contributing to the problem is the fact that most medical students and physicians deny they could be influenced by drug company promotions (1–3). Most students perceive that they have not been taught sufficiently about drug company-physician interaction (1).

Concerned about these situations, numerous authors and organizations (1, 3, 22–29) have published positions or guidelines about drug company and physician or student interactions. These range from statements of general principles, specific modest limitations on these interactions, to recommendations that students and doctors accept no gifts. As Geppert (25) writes, “These guidelines have particular importance for psychiatric education where the clinical and ethical influence of the pharmaceutical industry is especially intense, extensive, and subtle.” Brodkey (3) comments, “Psychiatrists are pursued particularly vigorously, because CNS drugs account for the largest category of U.S. pharmaceutical sales (over 22%) and include some of the most profitable agents.”

Nationally, there is still no consensus about, or verification of compliance with, guidelines for medical students or psychiatric residents, but progress toward consensus has begun. In 2006, the Association of American Medical Colleges (AAMC) established a task force to examine health industry influence on medical education (26). In June 2008, this task force published its report (27) and followed it up by presenting 15 schools’ policies (28). In 2009 the Institute of Medicine (IOM) published its recommendations (29). In 2002 the Accreditation Council for Graduate Medical Education (ACGME) specified that “programs and sponsoring institutions must have policies which specify whether and what type of contact between residents and pharmaceutical representatives is suitable” (25, 30), but as of May 2009, the Psychiatry Residency Review Committee Program Information Form site visitor’s checklist still had not incorporated this ACGME expectation (31).

There is evidence that, compared with residents in programs that do not restrict residents’ exposure to pharmaceutical representatives, those in restricting programs are more likely to develop healthy skepticism about these interactions and interact less frequently (1–3). Most medical students are unaware of their organization’s guidelines on interactions with pharmaceutical representatives (1). Even if medical students were familiar with the guidelines, this would not ensure attitudinal or behavioral change if their physician role models do not adhere to the guidelines. In one study, 93% of students were asked or required by physicians to attend sponsored lunches (1).

Until around 2007, medical school administrations have had relatively little to say about student relationships with drug companies. In 2005 only 9% of medical schools had policies about student interactions with drug companies (1). In 2007 an American Medical Student Association survey found that only 10% had policies (32). By 2009, this situation had changed dramatically. The American Medical Student Association’s richly detailed 2009 PharmFree Scorecard (33) of policies of U.S. medical schools graded nine schools with an A (exemplary or close to it), 19 with a B, eight with a C, 25 with a D, 43 with an F (failing), and 43 with an I (insufficient data).

To our knowledge, no published studies exist concerning student affairs deans’ views regarding medical students’ interactions with industry. Because medical schools, deans, and student affairs deans are well positioned to influence medical students’ attitudes and behaviors, and because student affairs deans are intensively and continually involved with students’ development as important role models and contributors to setting policy, we decided to study those 10 schools that had formal policies in 2005 and to examine student affairs deans’ attitudes about these interactions.

This study was conducted through the multispecialty Alliance for Clinical Education, which consists of leaders of seven national clerkship directors’ organizations, including the Association of Directors of Medical Student Education in Psychiatry. The Alliance for Clinical Education’s mission is to foster collaboration across specialties to promote excellence in medical student clinical education. We obtained institutional review board exemption at the first author’s (FSS) school. In April 2005, we sent a one-page questionnaire to each of the 126 U.S. medical school deans and another one-page questionnaire to each of the 126 student affairs deans, using survey methods discussed by Sierles (34). We sent surveys to both categories of deans for two reasons. First, our consultants (the medical school dean/vice-president, the university’s vice-president for academic affairs, and the medical school associate dean for student affairs and curriculum at the first author’s medical school) told us that deans and student affairs deans are inundated with surveys, so to ensure excellent response rates when the surveyors are a nonauthoritative source, we should keep the surveys extremely short. Second, to demonstrate concurrent validity regarding the proportion of schools with a policy, we sought out two independent authoritative sources at each school and compared proportions. Because responses were anonymous, we could not make within-school comparisons between deans’ and student affairs deans’ responses. To increase the response rate, we mailed the survey three times. Because the surveys were anonymous, all recipients received three mailings, and the second and third mailing included the statement “If you responded to this survey previously, please disregard this mailing.” Mailing labels were obtained from AAMC. The surveys were sent in different envelopes, with different cover letters on different-colored paper, to avoid each respondent (e.g., dean) confusing his or her questionnaire with that of the school’s other recipient (e.g., student affairs dean).

Deans’ Survey

Each of the 126 deans received an individually addressed cover letter and a three-item anonymous survey. The survey questions were as follows: Does your medical school have a formal written school-wide policy or guideline about interactions between drug company representatives and medical students? (Choices were yes, no, and not sure.) If the answer to #1 is yes, did your school have this policy or guideline during calendar year 2003? If the answer to #1 is yes, please write what that policy or guideline is and (if it is convenient) send me a copy in the enclosed stamped envelope along with the survey.

Student Affairs Deans’ Survey

Each of the 126 student affairs deans received an individually addressed cover letter and a 10-item anonymous survey. The survey questions were as follows: Does your medical school have a formal written school-wide policy or guideline about interactions between drug company representatives and medical students? (Choices were no, yes, and not sure.) If the answer to #1 is yes, did your school have this policy or guideline during calendar year 2003? Please rate your view of the appropriateness of a student at your medical school receiving the following from a drug company representative: a gift <$50 in value; a gift >$50 in value; a personal drug sample; a meal; a textbook; a social/recreational outing; travel to a conference; a vacation. Each of these items was followed by a 5-point Likert scale from 1 (very appropriate) to 5 (very inappropriate), as used in our medical student study (1).

Statistical Analysis

Data were entered into SPSS 15.0.1.1 (SPSS Inc., Chicago). Pearson χ² (df=4) was used for the comparison of student affairs deans’ attitudes about the appropriateness of each of the items with attitudes of the 826 third-year medical students at eight schools in our previous national study (1). Because responses from the deans, student affairs deans, and students were anonymous, we could not make within-school comparisons of deans and students at the eight schools. We compared total deans’ responses with total student affairs deans’ responses in terms of proportions of schools with policies using chi-square.

One hundred fourteen of 126 deans (90.5%) and 114 of 126 student affairs deans (also 90.5%) responded. Table 1 summarizes reports of deans and student affairs deans about whether their schools have a policy. Although we could not ascertain within-school agreement between the deans concerning whether the school had a policy, the proportion of deans (10/114) and student affairs deans (11/114) reporting their school had a policy was extremely similar (difference=0.8790%, 95% CI=−6.9522 to 8.7420, χ²=0, df=1, p=0.999). Significantly more deans than student affairs deans (χ²=10.29, df=2, p<0.005) were familiar with whether their school had a policy.

Table 2 summarizes responses of the 10 deans who reported a policy. In Table 2, we numbered the schools based on the apparent specificity of the reported guideline.

Figure 1 compares responses of student affairs deans and third-year students regarding the proportions perceiving each item was appropriate. Using 5-point Likert scales, for each of the eight items, the student affairs deans were significantly (p<0.001) less likely than medical students to perceive that receipt of each of the items by a medical student would be appropriate (p<0.001 for all comparisons: gift <$50, χ²=127.1; gift >$50, χ²=111.4; personal drug sample, χ²=42.4; meal, χ²=153.0; textbook, χ²=69.8; social outing, χ²=86.1; travel to a conference, χ²=90.7; vacation, χ²=74.8).

The extremely high response rate (90.5%) indicates that the samples generalize well to schools, deans, and student affairs deans nationally. The two deans’ samples’ concordance regarding policies validates that in 2005 (the time of this study) only about 10 schools had policies about drug company-student interactions.

Characteristics of Policies

Among the 10 schools with policies in 2005, several trends appear. For schools 2–4 and 7 in Table 2, policies refer to university medical centers where large proportions of students have clerkships. Students at school 2 responded on university stationery, so they are not anonymous, and we are familiar with school 2 from our previous study (1). In that study, school 2’s students were less exposed to drug company interactions and more likely to have healthy skeptical attitudes about these interactions than students at most schools. The fact that these four schools’ policies focus on medical centers, and that school 2’s policy apparently succeeded, suggest that schools developing student policies should take medical centers’ policies into account.

At schools 4, 5, and 10, policies address departments and associate deans as intermediaries and limit-setters between industry and students, highlighting the importance of associate deans’ views.

Eleven percent of student affairs deans did not know whether their school had a policy, which suggests inattentiveness to the topic. It calls to mind the high proportions of physicians (35) and students (1) unaware of departmental, school, and national organizational policies, which increases the likelihood of policy nonadherence.

Limitations

One study limitation is that we did not query whether or how policies are enforced. Another limitation is that in the present study we report on attitudes of student affairs deans in 2005 and compare it with attitudes of medical students in 2003 from our previous study (1). The student affairs deans’ attitudes could have been influenced by intervening events, such as the increasing national publicity about drug company-physician relationships.

This study’s findings about attitudes and policies in 2005 might contribute to current medical schools’ deliberations about how to comply with the AAMC’s expectations that all schools have policies by June 2009.

*For display purposes, we combined Likert scale responses of “very appropriate” and “appropriate” into “appropriate,” and we combined “inappropriate” and “very inappropriate” into “inappropriate.”

We thank Arthur Ross III, M.D., Timothy Hansen, Ph.D., and Cathy Lazarus, M.D., for their advice about the survey’s design and John Calamari, Ph.D., for his advice about the statistical analysis.

Dr. Lynn has provided full disclosure from several public and private sources that are available upon request. At the time of submission, Drs. Sierles, Frank, Shore, Woodard, McCurdy, Morgenstern, Chao, and Mintz disclosed no competing interests.