Pharmaceutical Promotion in Medical and Pharmacy Education in The Netherlands: Readiness for Curriculum Change

Report | 5 July, 2017 | Download PDF

Introduction: Despite the importance of the pharmaceutical industry, a substantial amount of pharmaceutical companies’ expenditure is targeted at the promotion of pharmaceuticals in order to increase sales. This so-called pharmaceutical promotion affects, among other things, the quality, frequency and costs of prescribing, as well as the sustainability of healthcare systems, and may also result in patients receiving suboptimal care. It is therefore essential that healthcare professionals—primarily doctors and pharmacists—understand these pharmaceutical promotion strategies and have the skills to respond appropriately. However, physicians and medical students, alike, underestimate the effects of promotion on their prescribing behaviour, and receive little to no training on how to critically assess these sophisticated pharmaceutical promotion activities.

Aim: The current study aimed to identify aspects of the effects of pharmaceutical promotion that were addressed during medical and pharmacy training, either explicitly or implicitly. On top of that, faculty’s readiness, divided into motivational and capability factors, to integrate education on pharmaceutical promotion in the formal curriculum was explored. This helped identify aspects that facilitate or impede change, thereby providing the opportunity for targeted recommendations to the training programmes.

Methods: A qualitative approach was chosen using semi-structured interviews with deans, education coordinators, and faculty in pharmacology/pharmacotherapy from all Dutch medical faculties (N=8) and pharmacist trainings (N=2). Potential respondents were identified from universities’ websites and Health Action International’s and the researcher’s networks. Snowball sampling was applied to gather additional respondents. A total of 18 interviews were conducted with medical (N=14) and pharmacy (N=4) deans (N=2), education coordinators/directors (N=7) and pharmacologists/pharmacotherapists (N=13). Interviews took 50 minutes on average (SD +- 15 min). Interviews were recorded and transcribed verbatim. Open and closed coding was performed on the data.

Results: Aspects of the effects of pharmaceutical promotion are well covered in the curricula of pharmacy training in the Netherlands. In medical education, the issue is, generally, barely if at all, explicitly addressed in the formal curriculum. A lot is achieved via implicit education, including evidence-based medical training and the instilling of a critical attitude. Faculty did consider it important and appropriate to address pharmaceutical promotion and associated techniques explicitly. The main barrier for integration in the curriculum was a lack of prioritization in an overly full curriculum. Motivational factors that impeded readiness to change were a lack of time, naivety of faculty, difficulty in addressing transcending subjects, and simply forgetting the issue. Expertise to educate about pharmaceutical promotion was generally present, although it was considered difficult to provide in-depth training. If expertise was considered an impeding factor, external professionals, such as Health Action International, may be needed to complement education. Resources were available, although not knowing whether suitable education material was available, or considering the available material too extensive, could impede integration in the curriculum. The opportunity to deploy the expertise and resources is complicated by the lack of priority allocated to education about pharmaceutical promotion.

Policies limiting commercial influence on education were absent at many of the medical faculties. Furthermore, conflict of interest policies seemed limited or absent, and faculty members were often unaware of its existence and/or content. Respondents did indicate that commercial influence on education is rare and believed there are no structural shortcomings. Faculty attitudes towards industry salesmen were dismissive. Role models were considered highly important and aware of the effects of pharmaceutical promotion, but did not communicate this explicitly to students. The norm seems to be shifting and pharmaceutical promotion has become less problematic than it used to be, although influence is still widespread.

Discussion: Pharmaceutical promotion is a neglected subject in undergraduate medical and pharmacy training and not offered structurally, which has also been found in other studies. Although the biasing effects of pharmaceutical promotion were acknowledged by medical faculty leaders, teaching about it was not considered a priority. Instead, principles of evidence-based medicine and scientific rigour were thought to provide medical students with a sufficiently critical attitude towards pharmaceutical promotion. This may be caused by an underestimation of the severity of the biasing effects of pharmaceutical promotion. Pharmaceutical promotion should, however, be embedded more structurally and over the breadth of the curriculum. Large variation was observed between medical schools, which is at least partially due to the dedication of individual professors. Large variations were also observed between medical faculties and pharmacy training.

It seems that no strong messages or values are conveyed to students and faculty members by Dutch UMCs surrounding interaction with the pharmaceutical industry and pharmaceutical promotion. This becomes clear from an apparent absence of strong policies that limit or eliminate contact with the industry, a lack of inclusion of the topic in examinations and evaluations, and the limited resources allocated to education. As such, the ‘hidden’ curriculum does not reinforce education activities on pharmaceutical promotion.

Role models and medical opinion leaders should communicate to students to not engage with the industry, but do not carry out this stance explicitly despite being aware of it. There may be a relation between the attitudes and stances of role models and the extent to which the issue is educated, as becomes clear from pharmacy training. This corresponds to faculty’s role as change agents as change blockers.

Conclusion: Large differences were observed between pharmacy and medical education. Pharmaceutical promotion is rarely and not structurally addressed in the formal curriculum of medical schools, and large differences were observed between medical faculties as to which aspects were addressed. Although most universities try to develop students critically and teach evidence-based medicine, it is important that the issue becomes structurally integrated in curricula and that pharmaceutical promotion is addressed ‘just in time’, when students also become increasingly exposed to promotion. Additionally, pharmaceutical promotion should be addressed in graduate training and included in continuing medical education.

This study focused on faculty members’ attitudes. To complement the present study, future research should focus on students’ attitudes and exposure to pharmaceutical promotion. Furthermore, document analysis of universities’ conflict of interest policies should be conducted to reveal shortcomings and act on these.

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