The importance of the relationship of a practicing physician with pharmaceutical industry and its representatives is irrefutable. According to previous estimates, 85-90% of medical doctors in US, Canada, Britain and New Zealand meet with pharmaceutical representatives (PR)
. PRs are drug marketing personals who approach physicians, present research and provide incentives, all of which is aimed towards convincing the physician to prescribe their brand. Incentives include drug promotional offers and also free samples, gifts and sponsorship of conferences among others. At this point, three key factors need to be considered: the appropriateness of accepting these incentives, favoring a particular company based on such incentives, and being able to objectively scrutinize the worth of the drug as well as that of the research being presented to support it.
The concern for drug company-physician relationship and its negative influence on prescription writing, has led numerous professional organizations, such as the American Medical Association (AMA) and the American Medical Student Association (AMSA), to develop guidelines and recommendations. AMSA recommendations discourage physicians and students from accepting gifts from drug companies, urge hospitals and residency programs to discontinue drug company-funded lectures and lunches, and oppose continuing medical education (CME) granted credit for drug company-sponsored events
In this regard, AMSA initiated its PharmFree campaign in 2002 and released a policy statement regarding best practice aimed for the benefit of both practicing and training physicians. This policy aims to guide medical doctors and students towards ethically sound attitudes that should be fostered towards pharmaceutical industry sponsored gifts and meals, free pharmaceutical samples, pharmaceutical representatives, conferences and “indulgence” of pharma industry in medical student education and training. An excerpt from the current AMSA pharma-free policy is as below:
Gifts and Meals:
Best Practice: All gifts and on-site meals funded by industry are prohibited, regardless of nature or value.
Best Practice: Industry samples are prohibited, except under certain narrow circumstances approved by the institution that protect the interests of indigent patients and prevent the use of samples as a marketing tool.
Best Practice: Pharmaceutical and device representatives are not allowed to market their products anywhere inside the medical center and associated clinics and offices.
On-site Educational Activities:
Best Practice: Industry is not permitted to provide direct financial support for educational activities, including CME, directly or through a subsidiary agency.
Compensation for Travel or Attendance at Off-site Lectures & Meetings:
Best Practice: Personnel may not accept payment, gifts or financial support from industry to attend lectures and meetings.
Industry Support for Scholarships & Funds for Trainees:
Best Practice: The policy must either prevent industry from earmarking or awarding funds to support the training of particular individuals.
Medical school curriculum (or other documentation of educational objectives/course content):
Best Practice: Students are to be trained to understand institutional conflict-of-interest policies and recognize how industry promotion can influence clinical judgment.
One must realize that the very first interaction that a physician-in-training has with a pharmaceutical representative is during the early years of medical school
[3–5]. In many instances, medical students are provided with small gifts as pens, calendars and books, as well as free lunches as part of drug promotion offers
. Studies at various US and Canadian medical schools have found that students receive many such gifts and their interaction with PRs is quite common; some studies have shown this interaction to be as frequent as ten times per month
[3, 7–11]. Additional studies have suggested that medical students tend to favor these interactions (3–7). Comparable results were demonstrated in a recent study from India
. This has led many critics to believe that these subliminal marketing strategies affect prescription-writing behavior when these students enter the professional world (8, 11). However, literature assessing medical students’ attitudes and exposures to the pharmaceutical industry and the marketing tactics deployed by them is quite sparse. Available studies report that most students believe that they are not much affected by the marketing schemes used by the pharmaceutical companies
[12, 13]. Many regard receiving trivial gifts from the pharmaceutical companies as ethically correct. For instance, one study found that although 85% of medical students believed it to be highly improper for a politician to receive a $50 gift, however receiving a similar gift from a pharmaceutical representative themselves was regarded as unsuitable by only 46% of students (10). Nevertheless, many have sensed the serious lack of training at undergraduate level pertaining to student interactions with PRs
. Substantial deficits have been found in students’ knowledge about pharmaceutical marketing expenditures, professional ethics and accuracy of drug information from pharmaceutical representatives
Strong evidence suggests that medical students are at-risk of being influenced by pharmaceutical company marketing strategies in the form of free gifts
[5, 14, 15]. Students who receive gifts may believe that they are receiving something for nothing, contributing to a sense of entitlement which is not in the best interests of their moral development as future doctors. Alternatively, students may be subject to recognized or unrecognized reciprocal obligations that potentially influence their decision making
. A randomized controlled experiment by Grand D et al. validated that subtle exposure to even small pharmaceutical promotional items influences implicit attitudes towards marketed products among medical students
According to the Pakistan Medical and Dental Council (PMDC), the number of medical schools in Pakistan has considerably increased in the past 15 years from a mere 30 in the year 2000 to almost 90 in 2013. Out of these, 38 are public and 52 are private institutions. The structure of medical education in Pakistan varies considerably in terms of teaching methods. However, all programs consist of a 5-year rigorous training curriculum during medical school. This is usually followed by relevant specialty training/residency. Medical college falls under a specific university in its undergraduate medical education (UGME) program. Each university also usually has its own residency programs for multiple specialties under its postgraduate medical education (PGME) program.
A literature search was conducted on Pubmed/Medline using the keywords “attitudes”, “medical students”, “pharmaceutical industry”, “Education, Medical, Undergraduate” and “Pakistan” in different combinations to identify studies from Pakistan. To the best of our knowledge, we found no similar studies on the presented topic. This in itself enhances the need for conducting such a study in Pakistan. We, as medical students, have observed that PRs approach students in pharmaceutical exhibitions held within college premises, at medical conferences and also during outpatient clinics. Often at times, there is an exchange of small gift items and free meals. Ethical impact of these transactions as perceived by young medical students has not been investigated in Pakistan before.
Through this study, we aim to assess the attitude of medical students towards: a) gifts and sponsorship offered by pharmaceutical companies, b) effects of pharmaceutical marketing on prescribing behavior of physicians, c) interaction between pharmaceutical companies and healthcare professionals. We also aim to investigate the differences of opinions between medical students from public-sectored and private institutes. Finally, we aim to assess the association between socio-demographic variables and the subsequent attitude of medical students towards pharmaceutical companies and their incentives. To the best of our knowledge, this study is the first attempt by any authority to gauge not only the attitudes and perceptions of medical students regarding the pharmaceutical industry, but also to identify the socio-demographic patterns related to such thinking.