Academic Psychiatry 29:222-229, June 2005
© 2005 Academic Psychiatry
The Role of the Pharmaceutical Industry in Teaching Psychopharmacology: A Growing Problem
Amy C. Brodkey, M.D.
Dr. Brodkey is Clinical Associate Professor of Psychiatry at the University of Pennsylvania Medical School, Philadelphia, Pennsylvania. Address correspondence to Dr. Brodkey, brodkeya{at}verizon.net (E-mail). Copyright © 2005 Academic Psychiatry.
|
ABSTRACT
|
OBJECTIVE: To describe and examine the role of the pharmaceutical industry in the teaching of psychopharmacology to residents and medical students and to make recommendations for changes in curriculum and policy based on these findings. METHODS: Literature reviews and discussions with experts, educators, and trainees. RESULTS: The pharmaceutical industry currently plays an extensive role in teaching psychopharmacology to trainees, both directly and indirectly. Attendance at industry-sponsored lectures and drug lunches, meetings with pharmaceutical representatives, and interactions involving the acceptance of various gifts are the most obvious venues. Less apparent but equally pervasive are the influence of industry-sponsored faculty and research and industry’s effect on the climate of practice and the profession as a whole. Replacing medical education with industry promotion in the guise of scholarship causes demonstrable harm to trainees, the public, and the profession. CONCLUSIONS: In light of these findings, the medical profession must reassert control of medical education and draw a firm barrier between commercial and professional pursuits. These issues must be actively, explicitly, and rigorously discussed with our colleagues and students.
|
INTRODUCTION
|
In this article I will describe and examine the role the pharmaceutical industry currently plays in teaching psychopharmacology to the medical profession, discuss the consequences, and conclude with ideas about how we, as educators and medical citizens, can best respond.
|
The Existing Role of Industry in Teaching Psychopharmacology
|
It is crucial to understand that industry currently plays a dominating role in psychopharmacology education, both in and outside of medical schools. A snapshot of the academic landscape reveals that it is littered with branded pens and cups, posters and clocks, drug samples, literature, bagels (and the detailers who bring them), drug lunches, industry sponsored continuing medical education (CME), named workshops (e.g., Glaxo Pathway), social events, and honoraria (1). In addition, industry sponsored research and other types of partnerships with individual faculty members, departments, and medical schools provide increasing financial support to academic medical centers (2, 3, 4).
The educational/promotional activities of pharmaceutical companies are financed by their marketing and administration budgets, which comprised 30%–35% of their total revenues (approximately $21 billion) in 2002 (4, 5, 6). Promotional activities account for most of that figure, and some of the research and development budget is also dedicated to marketing research. By far, the largest portion (86%) of this marketing is targeted to physicians (6), whose shifts in choices among similar drugs can cause shifts of millions of dollars in market share (7). Psychiatrists are pursued particularly vigorously, because central nervous system (CNS) drugs account for the largest category of U.S. pharmaceutical sales (over 22%) and include some of the most profitable agents (8). To put these figures in perspective, what industry spends on marketing and administration is at least twice the amount spent on research and development and one-half again the amount spent on materials and production (4, 9). Most strikingly, the amount spent by industry on promotion to physicians far surpasses total expenditures on the education of residents and medical students (10).
There is now one pharmaceutical representative (PR) for every 4.7 office-based physicians in the U.S., and marketing staffs are the largest and fastest growing segment of industry employees (39%). Approximately 60,000,000 PR visits were made to physicians in 2000 alone (11). In both money and manpower, industry’s resources eclipse those of medical educators.
Moreover, over 60% of the $1.2 billion costs of CME are now underwritten by drug firms, usually through specialized for-profit medical education communications Companies (MECCs), a billion dollar industry largely owned by ad agencies whose clearly stated purpose is to increase pharmaceutical sales (12–15). The Accreditation Council for Continuing Medical Education (ACCME), about one-half of whose members are representatives of industry, has accredited not only MECCs, but at least one pharmaceutical company, many industry-affiliated foundations, and three advertising agencies to deliver CME. These commercial concerns are given independent authority over the content of "medical education" programs (12, 14, 15).
The immensity of this promotional effort has substantially overpowered and transformed traditional academic educational endeavors and values. Studies of physicians in and outside of academia show that industry promotion is more effective than the scientific literature or collegial consultation in influencing their prescription choices, and physicians select heavily promoted agents despite an absence of scientific support for such selections (16, 17). Even when physicians and CME providers express conviction that they will not be influenced by industry inducements, studies show that they are (18–20). For an example close to home, we need only look at the underutilization of lithium in recent years, despite studies demonstrating its continuing usefulness and unique attributes (21). Due largely to marketing efforts by the makers of sodium valproate, today’s residency graduates may be relatively unfamiliar with lithium’s use. Commenting on this, Frederick Goodwin stated, that "the fact that the choice for physicians will be settled by the biggest CME budget is unfortunate" (22). Similar questions have been raised regarding the enthusiastic adoption of atypical neuroleptics and serotonin reuptake inhibitors to the exclusion of older generic agents (23, 24). In sum, industry is remarkably successful in "manufacturing consensus" in psychiatric practices (17, 25).
|
Education or Promotion?
|
A review of the literature on the quality and objectivity of information provided in journal advertisements (26, 27), by PRs (28–30) and during industry sponsored lectures and CME (12, 31), contradicts the idea that industry is merely subsidizing the education of physicians. Studies uniformly demonstrate selective reporting as well as inaccuracy and bias in the information presented, always favoring the industry’s product.
Continuing medical education requires specific comment since it is less likely to be appreciated as advertising than are other marketing venues. Typically, industry funds CME through "unrestricted educational grants" to a MECC, and together they create "educational programs" presented by paid influential academic "key opinion leaders" (12, 14, 32). Doubtless, some useful information may be imparted in these presentations. However, content control by industry in the form of ghostwritten scripts, slide programs given to speakers in read-only formats, and pressure on speakers to present the company’s product in the best light result in slanted presentations. Accreditation Council for Continuing Medical Education guidelines for CME content and for disclosure parameters are voluntary, unregulated, difficult to interpret, and frequently violated (12, 14). In a recent issue of Pharmaceutical Marketing, a chief executive officer for an MECC wrote, "[T]he broad distinction between health care PR and medical education is becoming obsolete" (14). Even CME funded through unrestricted educational grants directly to academic institutions (who also take a cut) has been shown to be biased in favor of the funder’s products (31).
|
The Research Enterprise
|
More disturbing to some is the rapidly increasing evidence of bias in sponsored research. Several recent reviews and metaanalyses of published literature on the relationship between funding source and outcome demonstrate systematic bias favoring agents made by the company funding the research, although such bias is not associated with other personal, academic, or political competing interests (33–36). These findings hold true across a wide range of specialties, disease states, and drug classes. They are true not only for papers published in journal supplements paid by industry and often lacking peer review (37–39), but for pharmacoeconomical analyses and clinical trials published in regular peer reviewed journals (35, 40). The mechanisms of such outcome biases include the selection of inappropriate comparators, delay or suppression of publication of negative studies, and duplicate publication of positive results (35, 38, 41, 42). Safer (43) reviewed industry-sponsored psychopharmacology trials and described common modifications of design and reporting that have been used to favor the sponsors’ products.
Moreover, what appear to be studies reported by scientists are commonly ghostwritten articles by MECCs, onto which academic authors sign for a fee (2, 14, 15, 32, 45, 46). A comparison of agency-authored and traditionally authored publications on sertraline showed that, although the former omitted or greatly minimized its side effects, ghostwritten studies outnumbered traditional studies, were published in more prestigious journals by more published authors, and were cited by other researchers at a much higher rate (47). Such practices enable industry to formulate the appearance of "scientific consensus" (25). The nondeclaration of industry sponsorship among writers of clinical practice guidelines (25, 48), the often relaxed regulation of financial ties between faculty members and industry by medical schools (49, 50), and the withholding of unfavorable clinical trial data by industry (25, 51) are other examples where financial interest potentially contravenes scientific objectivity.
Industry funds over 60% of clinical trials through for-profit contract research organizations (CROs), whose quality control and ethical practices have been questioned (2, 4, 40) and with whom academic medical centers compete for business. Some large advertising agencies help select potential blockbuster drugs, oversee clinical trials in the agency’s own CRO, ghostwrite literature through their own MECC, and, finally, market the drugs (15).
|
Industry Interactions With Residents and Medical Students
|
Pharmaceutical marketers know that lasting habits and attitudes are formed early in physicians’ training (52–54). They therefore make resolute efforts to cultivate frequent contact with trainees, hoping to establish PRs as sources of both information and gratification. A lifetime of good will toward industry may be more important than the preference for any company’s particular product. In Sandberg’s study, medical students believed that gift-bearing PRs were helpful and provided good information, but they were skeptical of the information they received from PRs who brought no gifts (52).
Surveys confirm trainees’ frequent exposure to sponsored grand rounds, drug lunches, PRs, gifts, promotional materials, sample medications, awards, meeting travel, and social events beginning early in medical school. The overwhelming majority accept gifts and attend industry sponsored educational events as part of their clinical training (53, 55–58). They may feel entitled to gifts because of the expense and rigor of their education.
Trainees exhibit greater acceptance of gifts than do practicing physicians but are even more likely to underestimate or deny their influence (53, 55, 56, 58). They will, however, more readily attest to the possible impact on their peers (55, 56, 58). In fact, several studies have demonstrated a positive correlation between the frequency of exposure to PRs and quantity of gifts received from industry and the belief that such interactions have no impact on prescribing (56, 58). Exposure to PRs is also highly associated with a perception of the benefits and appropriateness of these and other interactions, such as the acceptance of gifts and industry-sponsored promotion (53).
Trainees are taught by faculty who may have multiple relationships with industry, including research funding, paid consultancies, representation on speakers’ bureaus and advisory boards, equity interest, and other partnerships. They may be aware of these connections and may modify their behavior so as not to offend a faculty member. It is not far-fetched to presume that these relationships may also reflect what trainees are taught by those faculty members.
Many residency directors express concern about the potential effects of marketing on residents. Although some programs have instituted policies restricting contact with PRs, many do not distribute or give instruction on them (53, 58, 62). Competition to fill residency positions with the best candidates and concern over jeopardizing industry funding for other activities may play a role in the acceptance of industry largesse or access to trainees (62).
|
What is the Harm?
|
Harm to Trainees
The environment experienced by today’s residents and medical students is very different from the one in which most of their teachers trained. Academic medical centers possess greatly reduced financial and human resources necessary for good teaching (63, 64). Faculty members may earn far more money than their salaries by working for industry, and they may be distracted from their commitment to the school’s educational mission (4). The pharmaceutical industry, with its surpassing resources and motivation, has stepped into this educational vacuum (4, 65). Their messages are neither scientifically objective nor particularly addressed to the needs of trainees who, as former New England Journal of Medicine Editor Marcia Angell put it, "learn that for every problem there is a pill (and a drug rep to explain it)"(3).
In addition to these educational harms, trainees may experience distress and confusion in their adoption of professional identities, for which they depend heavily on role models. With the "holding environment" of medicine’s scientific and humanitarian enterprise in question (63), students and residents experiencing difficulty finding such models to idealize and values to incorporate may feel cynical about the motivations of the people and activities they observe. A revealing question I hear from trainees is, "Can you trust a speaker more if they speak for more than one company?"
The studies on trainees’ attitudes and practices summarized above demonstrate outcomes suggesting cynicism and entitlement in their dealings with industry. In Hodges’ study of psychiatry residents, interns, and clerks, fewer than one-half of the respondents said they would maintain the same degree of contact with PRs if they did not receive promotional gifts (56). In another study, most medical students thought it improper for a politician to accept a gift, but less than one-half thought it improper themselves to accept a similar gift (60). Indeed an ethical analysis of accepting industry gifts reveals a dilemma. The norm of reciprocity subscribed to in all societies (and which is well understood by psychiatrists) means trainees must either accept the obligation to reciprocate, becoming consciously or unconsciously indebted and paving the way for future access and influence, or they may feel they have gotten "something for nothing," and have successfully exploited industry, leading to an unwarranted sense of entitlement that impedes their moral development as physicians (66, 67).
Harm to the Public
A large number of studies demonstrate a relationship between obtaining information from industry, as well as other interactions, and less appropriate prescribing patterns (e.g., 53, 68–71). These include increased incorrect prescription of the sponsored drug, formulary addition requests for drugs with no advantage over existing ones, higher prescribing costs, preference for and rapid prescription of new drugs, less effective and safe prescribing practices, and decreased prescribing of generic drugs. For instance, Caudill demonstrated a strong positive correlation between physicians’ prescription drug costs and their perception of the credibility of information from PRs (68). Galt found that medical group practices that limited physician interactions with PRs had lower prescription drug costs for their patients (72).
The harm of escalating prescription drug costs is generally well appreciated. Marketing to physicians constitutes 25%–30% of industry expenditures, which is reflected in drug prices, and it also increases prescribing of newer, more expensive agents. Prescription of new drugs before their safety profile is fully known also leads to more frequent serious adverse drug reactions (73).
Along with managed care, the increased influence of industry on medical practice has also resulted in the more limited use of nonpharmaceutical therapies. A Scottish study confirmed a change in CME course topics as the portion sponsored by industry increased from 1991–1996. Pharmaceutical disease management, rather than health promotion or service management, became the topic of most industry sponsored courses (74). In addition, industry’s research agenda, oriented toward block-buster drugs, may not reflect the public’s needs and priorities (75, 76).
Harm to the Profession
The pharmaceutical industry now defines much of the profession’s practice and research agendas, and threats to the profession from this crumbling barrier have been the subject of recent publications (2–4, 12, 35, 42, 63–65, 74–77). Market forces have constrained and influenced medical schools’ teaching missions. Industry funding of research has resulted in an atmosphere of troubling uncertainty regarding the profession’s scientific database, and has resulted in threats to academic freedom in some cases (78, 79). In addition, professional societies are heavily dependent on industry’s largesse (80).
Three studies of industry gifts to physicians (81–83) show that patients are more critical of these practices, including the gifting of small items, than are physicians. They believe these practices influence doctors’ prescribing habits and increase prescription costs, and many said that knowledge of these relationships negatively altered their perception of the profession. Indeed, as the public has become increasingly cognizant of these practices, depictions of physicians as "pill pushers" whose cozy relationship with industry has caused them to betray their patients have resulted in expressions of outrage (84). The perceived mutual interest of drug firms and physicians in "disease creation" and attendant drug development has reinforced this image (14, 85). Legislation to curb industry gifts to doctors, with potential for fines and imprisonment, has been proposed or passed in a number of states (86), and a federal investigation of pharmaceutical marketing practice that involve a number of academic medical centers is taking place (87). These events confirm an impression that external policing of the activities of the profession is necessary.
|
Why Should Industry Have Any Teaching Role?
|
The pharmaceutical industry is a profit making enterprise whose primary duty is to its stockholders. Medicine, on the other hand, is grounded in altruism, and our primary fiduciary duty is to our patients (66, 88). The issue, then, is not who is "good" or "bad" but the proper separation of our endeavors, which have fundamentally different aims. The best scientific practice of medicine (and the best education) takes place when these boundaries are maintained.
"Unrestricted" educational grants, fellowships, and awards provide resources; but at what price? Remembering that there are always costs for taking these gifts should help in our sometimes difficult deliberations with colleagues and trainees about their ultimate merit. When a company sponsors a resident (otherwise known as a "future opinion leader") to attend a conference, who gains, and who pays? What do good will and academic legitimacy have to do with industry profits? When we take educational grants or allow drug lunches to become an important part of our trainees’ culture, what do trainees learn about the profession’s willingness and responsibility to teach itself (and buy its own pizza)? Conversely, what do they learn about the profession’s need for and entitlement to external benefactors to fund (and shape) its education? And what do they learn about conflict of interest (89)?
Furthermore, why would we spend our limited time on information sources we know are often biased, with a primary promotional aim, when there are better, more objective sources of information available? And, by example, teach our students to do the same?
|
What Should We Do?
|
Our trainees will inherit our profession, and we all must grasp the larger context in which training takes place in order to evaluate our own behavior and advocate for the profession and our patients. Issues of unintended consequences pose complex moral dilemmas that can become a focus for professional development. By encouraging perspective taking and empathy, higher moral reasoning is associated with better clinical judgment (90). Trainees need to discuss these issues openly with thoughtful and available faculty who should be required to disclose any industry sponsorship.
Medical students and residents generally are not very knowledgeable about the pharmaceutical industry, and they strongly endorse the need for education, guidelines, and training about these issues (53–56, 58, 59, 62). Some innovative curricula have been published (60, 91–96), and several demonstrate changes in attitudes, although none have included long-term follow up. Such curricula should not be limited to ethical issues involved in the acceptance of gifts but should minimally include information about the pharmaceutical industry, the process of drug development (clinical trials, the role of the Food and Drug Administration), drug pricing, the impact of marketing on prescribing practices, evaluation of industry generated information, types of nonscientific appeals made by PRs, evidence-based evaluation of the medical literature, utilization of relatively unbiased information sources, and rational choice of therapies. The ACGME has recently mandated curricula and policies to address this issue in graduate medical education (88).
In light of potential harmful effects on trainees (and their future patients) cited above, educators have a positive duty of care toward students to prohibit industry presence in medical schools and places of training (67). The American Medical Student Association has adopted a total ban on students’ acceptance of gifts and favors from industry (61). Some residency programs have adopted policies defining what contact, if any, is allowed between trainees and PRs (97–99). Frequency of meetings with PRs tends to stabilize during residency (53), and physicians who trained in programs with restrictive policies are less likely to meet with PRs, accept their gifts, or find their information useful (100, 101). They are thus at decreased risk for inappropriate prescribing (68–71).
An intriguing national survey of internal medicine residency programs (102) showed that financial support from the pharmaceutical industry was a negative predictor of programs’ average board pass rates for 3 consecutive years. Assuming that receiving pharmaceutical money denoted underfunding, this outcome should serve as a cautionary tale. Good teaching requires substantial investment. Rather than taking what looks like easy money, we should be advocating strongly for necessary resources.
|
Conclusion
|
Ethical people may differ about where to draw the boundary between industry and the profession, but the challenge to all of us is the same: to actively, explicitly, and rigorously engage ourselves and our students in exploring and understanding these tremendously important issues and the consequences of our own decisions in relation to them. To ignore this would be an abrogation of our responsibility as teachers.
|
ACKNOWLEDGMENTS
|
The author thanks Maureen Gibney, Psy. D., Joel Lexchin, M.D., and Frederick Sierles, M.D. for their helpful editorial comments.
|
REFERENCES
|
- Sigworth SK, Cohen GM: Pharmaceutical branding of resident physicians. JAMA 2001; 286:1024–1025[Free Full Text]
- Bodenheimer T: Uneasy alliance- clinical investigators and the pharmaceutical industry. N Engl J Med 2000; 342:1539–1544[Free Full Text]
- Angell M: Is academic medicine for sale? N Engl J Med 2000; 342:1516–1518[Free Full Text]
- Relman A, Angell M: America’s other drug problem. The New Republic, 12/16/02:27–41
- Public Citizen’s Congress Watch. 2002 Drug Industry Profits. Public Citizen, Washington, D.C. 2003
- IMS Health Integrated Promotional Services and CMR, 2002 cited in Canadian Medical Association Journal 2003; 169:699
- Kessler D, Rose J, Temple R, et al: Therapeutic class wars-drug promotion in a competitive marketplace. N Engl J Med 1994; 331:1350–1353[Free Full Text]
- IMS World Pharmaceutical Market Summary http://open.imshealth.com 11/2003
- Profiting from Pain: Where Prescription Drug Dollars Go Families USA Publication No. 02_105 http://www.familiesusa.org 7/17/2002
- Wolfe SM: Why do American drug companies spend more than $12 billion a year pushing drugs? Is it education or promotion? J Gen Intern Med 1996; 11:637–639[Medline]
- Pharmaceutical Research and Manufacturers of America, Pharmaceutical Industry Profile, 2001, Wash: PhRMA, 2001, Appendix: Detailed Results from the Annual Survey, Table 18
- Relman A: Separating continuing medical education from pharmaceutical marketing. JAMA 2001; 285:2009–2014[Free Full Text]
- Public Citizen. Medical Education Services Suppliers: A threat to physician education. http://www.citizen.org/hrg/PUBLICATIONS/1530report.htm 7/19/2000
- Elliott C: Pharma goes to the laundry: public relations and the business of medical education. Hastings Center Rep 2004; 34:18–23
- Peterson M: Madison Ave. has growing role in the business of drug research. The New York Times, 11/22/02 pp A1, C4
- Avorn J, Chen M, Hartley R: Scientific versus commercial sources of influence on the prescribing behavior of physicians. Am J Med 1982; 73:4–8[Medline]
- Prosser H, Almonda S, Walley T: Influence on GPs’ decision to prescribe new drugs-the importance of who says what. Fam Pract 2003; 20:61–68[Abstract/Free Full Text]
- Bowman M, Pearle D: Changes in drug prescribing patterns related to commercial company funding of continuing medical education. J Cont Educ in Health Prof 1988; 8:13–20
- Orlowski J, Wateska L: The effects of pharmaceutical firm enticements on physician prescribing patterns. there’s no such thing as a free lunch. Chest 1992; 102:270–273[Abstract/Free Full Text]
- Chren M, Landefeld S: Physicians’ behavior and their interactions with drug companies: A controlled study of physicians who requested additions to a hospital drug formulary. JAMA 1994; 271:684–689[Abstract/Free Full Text]
- Tondo L, Hennen J, Baldessarini R: Lower suicide risk with long-term lithium treatment in major affective illness: A meta-analysis. Acta Psychiatr Scand 2001; 104:163–172[CrossRef][Medline]
- Lithium decline reflects economic, not clinical trends. Clinical Psychiatry News, Vol 29 #12, 12/01, pp1,9
- Medawar C: The antidepressant web: marketing depression and making medicines work. Int J Risk & Safety in Med 1997; 10:75–126
- Rosencheck R, Perlick D, Bingham S, et al: Effectiveness and cost of olanzapine and haloperidol in the treatment of schizophrenia. A randomised controlled trial. JAMA 2003; 290:2693–2702[Abstract/Free Full Text]
- Healy D: Manufacturing Consensus, in Greenslit N (Ed.), Pharmaceutical Cultures: Marketing Drugs and Changing Lives in the U.S., Rutgers University Press (in press)
- Wilkes M, Doblin B, Shapiro M: Pharmaceutical advertisements in leading medical journals: expert’s assessments. Ann Intern Med 1992; 116:912–919
- Loke T, Koh F, Ward J: Pharmaceutical advertisement claims in australian medical publications. Is evidence accessible, compelling and communicated comprehensively? Med J Aust 2002; 177:291–293[Medline]
- Stryer D, Bero L: Characteristics of materials distributed by drug companies. J Gen Int Med 1996; 11:575–583[Medline]
- Ziegler M, Lew P, Singer B: The accuracy of drug information from pharmaceutical sales representatives. JAMA 1995:273;1296–128
- Lexchin J: What information do physicians receive from pharmaceutical representatives? Can Fam Physician 1997; 43:941–945[Medline]
- Bowman M: The impact of drug company funding on the content of continuing medical education. Mobius 1986; 1:133–136
- Jackson T: Are you being duped? How drug companies use opinion leaders. BMJ 2001; 322:1312[Free Full Text]
- Kjaergard LL, Als-Nielson B: Association between competing interests and authors’ conclusions: epidemiological study of randomised clinical trials published in the. BMJ BMJcom 2002; 325:249–253
- Davidson RA: Source of funding and outcome of clinical trials. J Gen Intern Med 1986; 1:155–158[Medline]
- Lexchin J, Bero L, Djulbegovic B, et al: Pharmaceutical industry sponsorship and research outcome and quality: systematic review. BMJ 2003; 326:1167–1173[Abstract/Free Full Text]
- Bekelman J, Li Y, Gross C: Scope and impact of financial conflicts of interest in biomedical research: a systematic review. JAMA 2003; 289:454–465[Abstract/Free Full Text]
- Cho MK, Bero LA: The quality of drug studies published in symposium proceedings. Ann Intern Med 1996; 124:485–489[Abstract/Free Full Text]
- Bero L, Rennie D: Influences on the quality of published drug studies. Int J Technology Assessment in Health Care 1996; 12:209–237
- Massie B, Rothenberg D: Publication of sponsored symposiums in medical journals. N Engl J Med 1993; 328:1196–117[Free Full Text]
- Morgan S, Barer M, Evans R: Health economists meet the fourth tempter: drug dependency and scientific discourse. Health Econ 2000; 9:659–667[CrossRef][Medline]
- Freemantle N, Mason L, Young P: Predictive value of pharmacological activity for the relative efficacy of antidepressant drugs: meta-regression analysis. Br J Psychiatr 2000; 177:292–302[Abstract/Free Full Text]
- Melander H, Ahlqvist-Rastad J, Meijer G, et al: Evidence b(i)ased medicine-selective reporting from studies sponsored by pharmaceutical industry: review of studies in new drug applications. BMJ 2003; 326 1171–9
- Safer D: Design and reporting modifications in industry-sponsored comparative psychopharmacology trials. J Nerv Ment Dis 2002; 190:583–592[CrossRef][Medline]
- Schulman K, Seils M, Timbie J, et al: A national survey of provisions in clinical trial agreements between medical schools and industry sponsors. N Engl J Med 2002; 347:1335–1341[Abstract/Free Full Text]
- Flanagan A, Carey L, Fontanarosa P, et al: Prevalence of articles with honorary authors and ghost authors in peer-reviewed medical journals. JAMA 1998; 280:222–224[Abstract/Free Full Text]
- Rennie D, Flanagan A: Authorship! authorship! guests, ghosts, grafters, and the two-sided coin. JAMA 1994; 271:469–471[Abstract/Free Full Text]
- Healy D, Cattell D: Interface between authorship, industry and science in the domain of therapeutics. Br J Psychiatr 2003; 183:22–27[Abstract/Free Full Text]
- Choudhry N, Stelfox H, Detsky A: Relationships between authors of clinical practice guidelines and the pharmaceutical industry. JAMA 2002; 287:612–617[Abstract/Free Full Text]
- Lo B, Wolf L, Berkeley J: Conflict-of-interest policies for investigators in clinical trials. N Engl J Med 2000; 343:1616–1620
- Van McCrary S, Anderson C, Jakovljevic J, et al: A national survey of policies on disclosure of conflicts of interest in biomedical research. N Engl J Med 2000; 343:1621–165
- Whittington C, Kendall T, Fonagy P, et al: Selective serotonin reuptake inhibitors in childhood depression: systematic review of published versus unpublished data. The Lancet 2004; 363:1341–1345[CrossRef][Medline]
- Sandberg WS: The effect of educational gifts from pharmaceutical firms on medical students’ recall of company names or produces. Acad Med 1997; 72:916–918[Medline]
- Wazana A: Physicians and the pharmaceutical industry. Is a gift ever just a gift? JAMA 2000; 283:373–380[Abstract/Free Full Text]
- Monaghan M, Galt K, Turner P, et al: Student understanding of the relationship between the health professions and the pharmaceutical industry. Teaching and Learning in Med 2003; 15:14–20
- Steinman M, Shlipak M, McPhee S: Of principles and pens: attitudes and practices of medicine housestaff toward pharmaceutical sales representatives. Am J Med 2001; 110:551–557[CrossRef][Medline]
- Hodges B: Interactions with the pharmaceutical industry: experiences and attitudes of psychiatry residents, interns and clerks. Can Med Assoc J 1995; 153:553–559[Abstract]
- Bellin M, McCarthy S, Drevlow L, et al: Medical students’ exposure to pharmaceutical industry marketing: A survey at one U.S. medical school. Acad Med 2004; 79:1041–1045[CrossRef][Medline]
- Keim S, Sanders A, Witzke D, et al: Beliefs and practices of emergency medicine faculty and residents regarding professional interactions with the biomedical industry. Ann Emerg Med 1993; 22:1576–1581[CrossRef][Medline]
- McKinney W, Schiedermayer D, Lurie N, et al: Attitudes of internal medicine faculty and residents toward professional interaction with pharmaceutical sales representatives. JAMA 1990; 264:1693–167[Abstract/Free Full Text]
- Palmisano P, Edelstein J: Teaching drug promotion abuses to health profession students. J Med Educ 1980; 55:453–455[Medline]
- American Medical Student Association’s PharmFree Medical Student Pledge www.amsa.org/prof/pledge.cfm Jan 22, 2001
- Lichstein P, Turner R, O’Brien K: Impact of pharmaceutical company representatives on internal medicine residency programs. Arch Intern Med 1992; 152:1009–1013[Abstract/Free Full Text]
- Ludmerer K: Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care. New York: Oxford University Press 1999
- Brodkey A, Sierles F, Spertus I, et al: Clerkship directors’ perceptions of the effects of managed care on medical students’ education. Acad Med 2002; 77:1112–1120[Medline]
- Relman A: Why Johnny Can’t Operate: The Collapse of Medical Education in America. The New Republic, 10/2/00:42
- Chren M, Landefeld C: Doctors, drug companies, and gifts. JAMA 1989; 262:3448–3451[Abstract/Free Full Text]
- Rogers W, Mansfield P, Braunack-Mayer A, et al: The ethics of pharmaceutical industry relationships with medical students. Med J Australia 2004; 180:411–414
- Caudill T, Johnson M, Rich E, et al: Physicians, pharmaceutical sales representatives and the cost of prescribing. Arch Fam Med 1996; 5:201–206[Abstract/Free Full Text]
- Haayer F: Rational prescribing and sources of information. Soc Sci Med 1982; 16:2017–2023
- Watkins C, Harvey I, Carthy P, et al: Attitudes and behaviour of general practitioners and their prescribing costs: a national cross sectional survey. Qual Saf Health Care 2003; 12:29–34[Abstract/Free Full Text]
- Caamanol F, Figueirasl A, Gestal-Oterol J: Influence of commercial information on prescription quantity in primary care. The Eur J Public Health 2002; 12:187–191
- Galt K, Rich E, Kralewski J: Group practice strategies to manage pharmaceutical cost in an HMO network. Am J Managed Care 2001; 7:1081–1090[Medline]
- Lasser K, Allen P, Woolhandler S, et al: Timing of new black box warnings and withdrawals for prescription medications. JAMA 2002; 287:2215–2220[Abstract/Free Full Text]
- Murray T, Campbell I: Finance, not learning needs, makes general practitioners attend courses: A database survey. Br Med J 1997; 315:353[Free Full Text]
- Baird P: Funding medical and health related research in the public interest. Can Med Assoc J 1996; 155:299–301[Abstract]
- Tallon D, Chard J, Dieppe P: Relation between agendas of the research community and the research consumer. Lancet 2000; 355:2037–2040[CrossRef][Medline]
- Rothman D: Medical professionalism-focusing on the real issues. N Engl J Med 2000; 342:1284–126[Free Full Text]
- Nathan D, Weatherall D: Academia and industry: lessons from the unfortunate events in toronto. The Lancet 1999; 353:771–772[CrossRef][Medline]
- Bitter Pill. The Guardian, 5/7/01
- The Center for Science in the Public Interest maintains a searchable database on the financial ties of nonprofit groups and scientists to corporate sources at: http://cspinet.org/integrity/nonprofits/.
- Blake RL, Early EK: Patients’ attitudes about gifts to physicians from pharmaceutical companies. J Am Board Fam Pract 1995; 8:457–464
- Gibbons R, Landry F, Blouch D, et al: A comparison of physicians’ and patients’ attitudes toward pharmaceutical industry gifts. J Gen Intern Med 1998; 13:151–154[CrossRef][Medline]
- Mainous A, Hueston W, Rich E: Patient perceptions of physician acceptance of gifts from the pharmaceutical industry. Arch Fam Med 1995; 4:335–339[Abstract/Free Full Text]
- Arthur Andersens of Medicine. Washington Post, 4/29/02, p. A21
- Moynihan R, Health I, Henry D: Selling sickness: the pharmaceutical industry and disease mongering. BMJ 2002; 324:886–891[Free Full Text]
- No Free Golf. Time Online Edition http://www.time.com/time/insidebiz/article/. accessed 11/5/02
- Hospital, Drug Firm Relations Probed. Boston Globe, Business Section, p. A1, 6/29/03
- Accreditation Council of Graduate Medical Education. Principles to Guide the Relationship between Graduate Medical Education and Industry. Washington, D.C: 9/10/02
- Wazana A, Primeau F: Ethical considerations in the relationship between physicians and the pharmaceutical industry. Psychiatr Clin N Am 2002; 25:647–663[CrossRef][Medline]
- Self D, Baldwin D. Moral reasoning in medicine. In: Rest JR, Narvaez D, Eds. Moral Development in the Professions: Psychology and Applied Ethics. Hillsdale, N.J: Lawrence Erlbaum Associates 1994; 147–162
- Wilkes M, Hoffman J: An innovative approach to educating medical students about pharmaceutical promotion. Acad Med 2001; 76:1271–1277[Medline]
- Hopper J, Speece M, Musial J: Effects of an educational intervention on residents’ knowledge and attitudes toward interactions with pharmaceutical representatives. J Gen Intern Med 1997; 12:639–642[CrossRef][Medline]
- Shear N, Black F, Lexchin J: Examining the physician-detailer interaction. Can J Pharmacol 1996; 3:175–179
- Vinson DC, et al: Medical students’ attitudes toward pharmaceutical marketing: possibilities for change. Fam Med 1993; 25:31–33[Medline]
- Shaugnessy A, Slawson D, Bennett J: Teaching information mastery: evaluating information provided by pharmaceutical representatives. Fam Med 1995; 27:581–585[Medline]
- Agrawal S, Saluja I, Kaczorowski J: A prospective before-and-after trial of an educational intervention about pharmaceutical marketing. Acad Med 2004; 79:1046–1050[CrossRef][Medline]
- Education Council, Residency Training Programme in Internal Medicine, Dept. of Medicine, McMaster University, Hamilton, Ont. Development of residency program guidelines for interaction with the pharmaceutical industry. Can Med Assoc J: 1993; 149:405–408[Abstract]
- Brotzman G, Mark D: Policy recommendations for pharmaceutical representative-resident interactions. Fam Med 1992; 24:431–432[Medline]
- Wazana A, Granich A, Primeau F, et al: Using the literature in developing mcgill’s guidelines for interactions between residents and the pharmaceutical industry. Acad Med 2004; 79:1033–1040[CrossRef][Medline]
- Brotzman G, Mark D: The effect on resident attitudes of regulatory policies regarding pharmaceutical representative activities. J Gen Intern Med 1993; 8:130–134[Medline]
- McCormick B, Tomlinson G, Brill-Edwards P, et al: Effect of restricting contact between pharmaceutical company representatives and internal medicine residents on posttraining attitudes and behavior. JAMA 2001; 286:1994–199[Abstract/Free Full Text]
- Wolfsthal S, Beasley B, Kopelman R, et al: Benchmarks of support in internal medicine residency training programs. Acad Med 2002; 77:50–56[Medline]
This article has been cited by other articles:
|
|
|
|
 
M. Sernyak and R. Rosenheck
Experience of VA Psychiatrists With Pharmaceutical Detailing of Antipsychotic Medications
Psychiatr Serv,
October 1, 2007;
58(10):
1292 - 1296.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
F. S. Sierles
The Association of Directors of Medical Student Education in Psychiatry
Acad Psychiatry,
April 1, 2007;
31(2):
107 - 109.
[Full Text]
[PDF]
|
|
|
|
|
|
|
C. M.A. Geppert
Medical Education and the Pharmaceutical Industry: A Review of Ethical Guidelines and Their Implications for Psychiatric Training
Acad Psychiatry,
February 1, 2007;
31(1):
32 - 39.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. J. Burke and A. C. Brodkey
Trends in Undergraduate Medical Education: Clinical Clerkship Learning Objectives
Acad Psychiatry,
April 1, 2006;
30(2):
158 - 165.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
L. J. Kirmayer
Beyond the 'New Cross-cultural Psychiatry': Cultural Biology, Discursive Psychology and the Ironies of Globalization
Transcultural Psychiatry,
March 1, 2006;
43(1):
126 - 144.
[Abstract]
[PDF]
|
|
|
|
|
|
|
M. D. Jibson
Medical Education and the Pharmaceutical Industry: Managing an Uneasy Alliance
Acad Psychiatry,
February 1, 2006;
30(1):
36 - 39.
[Full Text]
[PDF]
|
|
|
|
|
|
|
F. S. Sierles, A. C. Brodkey, L. M. Cleary, F. A. McCurdy, M. Mintz, J. Frank, D. J. Lynn, J. Chao, B. Z. Morgenstern, W. Shore, et al.
Medical Students' Exposure to and Attitudes About Drug Company Interactions: A National Survey
JAMA,
September 7, 2005;
294(9):
1034 - 1042.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. D. Jibson
Psychopharmacology Training in Psychiatric Education: The Debate
Acad Psychiatry,
June 1, 2005;
29(2):
120 - 123.
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. F. Klein
Comments on Psychiatric Education
Acad Psychiatry,
June 1, 2005;
29(2):
128 - 133.
[Full Text]
[PDF]
|
|
|
|
|
|
|
I. D. Glick and S. Zisook
The Challenge of Teaching Psychopharmacology in the New Millennium: The Role of Curricula
Acad Psychiatry,
June 1, 2005;
29(2):
134 - 140.
[Abstract]
[Full Text]
[PDF]
|
|
|
Get information about faster international access.
Privacy Policy
Copyright © 2005
Academic Psychiatry.
All rights reserved.
Home
| Search
| Current Issue
| Past Issues
| Subscribe
| All APPI Journals
| Help
| Contact Us
|
TOP
ABSTRACT
INTRODUCTION
