Building better relations with tomorrow’s doctors

pharmafile | May 6, 2009 | Feature | Sales and Marketing |  doctors, industry relations 

A huge amount of time and money is spent by the pharma industry on interacting with the medical community and to improve how the industry is perceived.

Concerns continue to centre on the use of key opinion leaders, and fears they are being manipulated by the industry, but controversy also persists around how companies approach medical students or newly qualified doctors.

Sensational headlines such as "Only six medical schools free of industry influence" have recently been published in the US, and have been accompanied by calls for Continuing Medical Education (CME) funding by pharma/device companies in medical schools and teaching hospitals to be cut or even banned. Thus the basic premise that the industry and the future medical community need to interact is being questioned. But if these interactions are curtailed, there could be a severe lack of understanding among tomorrow's medical experts about the newest drugs and drug development itself.

Medical students polarised on industry

To understand how the industry is perceived by doctors in training, our company myPHID (my PHysican/PHarmaceutical IDentity) conducted a telephone survey of the opinions of 25 medical undergraduates. The interviewees were drawn from two prestigious medical schools in the UK, and five from each year of study were selected for interview.

Although the numbers involved were too small to draw scientific significance, the results give an insight into 'grass roots' thoughts on the role of drugs companies and their potential future relationships with medical undergraduates.

When asked to convey their immediate reaction to the role of the pharma industry and its contribution to advancing medical science, opinions were polarised. Reactions included the description of the industry as a "necessary evil"; others frequently mentioned the prices pharma companies charge in comparison with those of generic producers, and several articulated uneasiness about "unethical practices in the third world". (Notably, when pressed, these interviewees struggled to cite actual examples of poor practices.) Industry's production of 'me-too' drugs was heavily criticised, as was the focus on "producing drugs for diseases of the wealthy". In general, there appeared to be some hostility towards making profit out of healthcare, but also an understanding that drugs wouldn't get made without the innovation of companies. Yet despite voicing anti-industry views, most of the interviewees also expressed sympathy for the poor regard and suspicion under which pharmaceutical professionals have to operate. One student felt that "it's difficult to be ethical if you have to make money". In contrast, some of the interviewees remained more realistic and positive in their observation: "They're just like any other business; their shareholders are their priority, and within the current system and financial climate, looking after that isn't immoral. We wouldn't have as many drugs without them – universities just wouldn't be able to compete."

Asked to talk through precisely what a pharma company does, their knowledge of the basic processes and phases of drug development was fairly accurate, but vague regarding clinical trial design details – notably use of surrogate markers, different disease populations and translation into clinical significance. There was some awareness of the differences between the companies, and the clinical areas they focus on, especially among those more exposed to promotions and clinical practice.

'Freebies' and hospitality were a frequently mentioned topic. By the time students had reached their fifth year of study, all conveyed that they had had their "fair share of free pens and sandwiches", but a reduction in more promotional interactions has been noticed. One student said: "if you want good stuff now, you need to go to the medical equipment companies". Many were appreciative of free equipment (stethoscopes and tourniquets were the most popular 'gifts'), but the commonly expressed view was: "you never get anything for free – it's implicit they're wanting something in return".

There was considerable distrust surrounding promotional "drug lunches", and a general suspicion as to where drug companies' medical education ends and promotional activities begin. One student voiced a common feeling: that "drug reps don't give a fair appraisal of the drug. They'll not focus on side-effects, fail to differentiate absolute and relative risk, and show statistics that compare efficacy to a placebo rather than its competitors. They treat us like we're stupid. Be transparent with what is good and bad about a drug and we can make up our own minds. If we felt their talks were evidence based and honest, it would make us keener to work with them, and their focus on sales damages that."

When asked whether any companies particularly stand out (negatively or positively) in the way they interact, the response was: "They're all equally smarmy."

Use of key opinion leaders

Opinions were also divided on the use of key experts by industry and how the medical scientists choose to interact with industry. Some were very opposed: "It's a betrayal of trust – they're not giving their honest professional opinion, and it shouldn't be allowed"; while others took a lighter view: "It's potential employment!" Some students appreciated industry funding of outside speakers for medical education, albeit with a desire for neutrality: "If they get someone impartial, it shows they've made an effort."

Sponsored information leaflets and educational materials funded by industry were considered useful, but drug company websites were regarded with scepticism: "I'm sure that the information is right, it probably has to be, but I wouldn't trust its balance. Independent sites like e-medicine and webMD I would trust more."

Do students believe that certain types of activities will influence the way they will prescribe in future? Opinions once again were divided. One fifth year said: "You like to think that you're impartial, but I suppose it must have an effect – they wouldn't spend money on it if it didn't," while another disputed the idea that he would be influenced to prescribe something against the evidence. Another interviewee said that promotion would "make you more aware of a drug, so more likely to use it in comparison with one you've never heard of, but if it was the wrong drug for the clinical situation, you wouldn't prescribe it". One first-year student said that "anyone bright enough to be a doctor should be bright enough not to be bought with some freebies".

Notably absent was a desire to work directly for the pharma industry. Students have firm opinions about drug development, about the quality of information about drugs, and how industry interacts with key experts. When asked if they knew of actual roles for medical professionals within industry, however, or if they had considered the benefits (personal, scientific and social) of working in the industry, their responses reflected alarming ignorance.

Levels of promotional literacy about the industry are low

The formal education of medical students about the industry, the drug development process and how to conduct interactions is recognised as being woefully inadequate. It is difficult to ascertain the time given over to training about the pharma industry in medical schools. Few studies have assessed this; a 2001 paper suggested that US medical school students receive only 32 hours of formal education on drug development in eight years of training.

This concern was replicated in the myPHID interviews. There was a universal response from those coming to the end of their course that medical curricula do not include formal education about industry interactions. The majority of information about industry is gained during clinical placements, from peers who have had bad experiences with industry or from media outlets. Not surprisingly, therefore, the final-year students in the forum felt this basic on-the-job education in statistics, research methods and judging sources of funding leaves them unprepared to assess drugs and establish good practices in their relations with industry.

Promotional literacy

The lack of experience among medical students in interacting with industry could be perpetuating the distrust many feel towards it. The students were generally in favour of a more formal 'promotional literacy' agenda (ie being able to comprehend how and why industry will market products, as well as receiving better basic education about clinical pharmacology and the clinical trial culture and data it produces), but questioned where any of this could be fitted into the already demanding medical curriculum. Some students hinted that their wariness may be due to ignorance of industry and drug development practices: "cynicism is our only weapon".

Most of the students interviewed felt that, despite the crowded curriculum, more and better training to increase development, commercial and promotional literacy was essential. They agreed that their ability to care for patients is compromised if they cannot engage knowledgeably with industry.

The mismatch between trainees' preparation for interacting with the industry and their level of exposure has led to the introduction of new courses and codes of practice in a number of US medical schools. This is starting to be considered in the UK. In February 2009, for example, the Royal College of Physicians (RCP) published recommendations from an 18-month working party to evaluate interactions between the industry, physicians, academia and the National Health Service.

As part of multiple recommendations from this working party, there was a clear concern that good prescribing practice should be learned at medical school but that "traditional courses in clinical pharmacology and therapeutics have been squeezed in an ever-more pressurised curriculum". Coupling this with an error rate in prescribing that manifests itself alarmingly in the first few years after graduation, and the call for educational funding from industry to be cut, we are evidently at an impasse. Training about the development, delivery and prescription of pharmaceuticals needs to be prioritised, but we don't trust that funding from the pharma industry will be distributed appropriately.

This major obstacle led the RCP working party to state that "Industry has a distinctive voice that students deserve to hear" and recommended a more collaborative culture between industry and physicians be created.

Accordingly, good relationship practice hubs like www.myPHID.com are being integrated into consultation groups from this working party to ensure the recommendations are turned into action and to mark the start of a new and informed era of engagement.

A more collaborative culture

All in all, this cross-section of medical student opinion should be disquieting reading for those trying to improve perceptions of industry. It is clear that 'big pharma' is hardly the most loved branch of the economy, but the depth of suspicion held by those who'll make up its target market in future years should be a cause for concern.

While most students interviewed were not openly hostile to the industry, they were certainly sceptical, which will make it difficult to create the 'flourishing, collaborative culture' now being sought. Part of pharma's problem may lie with the 'public service' culture of national healthcare providers such as the NHS, meaning there is opposition to the idea of making a profit from health; this is likely a bigger factor in the UK than the US, with its more business-orientated healthcare market.

More corporate social responsibility initiatives from industry, particularly in the third world, might answer some of the ethical concerns that people hold, as would greater transparency in marketing and promotions. Making a more positive case for the role of the drugs industry in promoting human health might also help. The students interviewed by myPHID all recognised that the achievements in creating new drugs cannot easily be matched by academia or government; pitching this in the right way could turn interacting with drugs companies from a 'necessary evil' into a positive good. However, to what extent any of these measures can remove the scepticism of the interviewees remains to be seen.

Online discussion

The rise of social networking is slowly convincing pharma executives that web 2.0 tools, which rely on 'user-generated content', should be part of the infrastructure to develop a more collaborative community.

These new media provide an excellent arbiter to enhance transparency and improve the authenticity of interactions between medical and pharmaceutical professionals, and could trigger a renaissance of productive relationships that will enhance patient care. Yet despite industry's desire to use social media to have a dialogue with 'customers', the customers themselves seem reluctant to reciprocate. Forums like Sermo.com, for example, do not allow industry to 'speak' in their community. Furthermore, representative bodies of industry are vague about what is and is not permissible in online conversations in such e-societies – little wonder industry feels restricted in using these new media if their own support networks are crouching ready to criticise. At present, lack of clear guidelines means most industry personnel are forced to ignore social media's potential to improve relationships with the medical community. But love them or loathe them, the immediacy of blogs, podcasts and discussion boards will challenge the importance of the medical journal. These developments mean future interactions between industry and the medical community will have to centre on openly aligning aspirations and ambitions.

It's not surprising that the myPHID interviews found the students interested to learn more about promotional literacy. Naturally, the students further advanced in their studies showed greater competency in judging promotional materials. At all training levels, however, students felt they needed a greater understanding of how industry operates, and specific interpersonal training in "how to deal with reps appropriately".

This isn't just a problem at the student level. A study published in Psychological Science in the Public Interest in 2008 (www.psychologicalscience.org) raised concerns that many doctors could be "statistical illiterates", unable to understand the statistics and efficacy/safety reporting, which can result in misinterpretation about pharmaceutical products. This can be either embellished understanding of benefits or overconcern about adverse effects that, in some cases, can have devastating impact for the patient. According to the study, "many doctors, patients, journalists, and politicians alike do not understand what health statistics mean".

It seems that improving the perceptions of industry's intentions and increasing the ability to interpret drug development data is not a need that is solely limited to students. Medical schools and drug companies have their work cut out to ensure a basis for harmonious physician-pharma interactions in the future.

Emma D'Arcy is founder and leader of scientific insights at MyPHID: emmad@myphid.com . A one-day conference on pharma-clinician relationships, ACTIVATE 09, will be held on 8 September. Visit: www.myphid.com for more information.