Drug company gifts to medical students: the hidden curriculum

As relationships between healthcare professionals and the drug industry have come under increasing scrutiny in the United States, the industry’s role in the education of medical trainees has emerged as a particularly contentious topic. A linked study (doi:10.1136/bmj.f264) by King and colleagues provides some empirical data to inform the debate.1

Students in the United States have traditionally had a high level of exposure to drug industry sales representatives during their undergraduate medical education.2 3 For example, one survey at eight US medical schools published in 2005 found that, by their third year, 96.8% students reported attending a lunch sponsored by a drug company and 94.1% reported receiving a non-educational gift.4 Students justified accepting meals and gifts by citing their lack of income and large debts, and educators pointed to the valuable support that industry could provide to didactic programs.4 Data on the influence of promotional gifts on physicians’ prescribing patterns were of questionable relevance, however, because students cannot write prescriptions or make decisions about patient care.

Medical schools have recently started to re-examine their policies. Many have stopped representatives gaining access to patient care areas and the distribution of gifts, often at the suggestion of their own students.5 6 These moves have been justified mainly on ethical reasons, appealing to professional and personal integrity.7 They have been opposed by faculty members who worry about damaging collaborations between industry and academia, and by other students and educators who are sceptical that science based medical education could be corrupted by company sponsored textbooks, lunches, or educational conferences.5

Remarkably, little data exist on the effect of student-industry interactions, apart from a few small surveys showing that such interactions are associated with positive attitudes about industry marketing in general and scepticism about its negative consequences.2 As a result, policies on industry interaction on medical school campuses around the US vary greatly.8

The current study adds an important new dimension to this debate.1 King and colleagues examined the effect of restricting industry gifts to students on the prescription of three recently approved brand name drugs; prescription trends were measured at least four years after the policy was implemented, when all students had completed their residencies. Notably, the study drugs were members of pharmaceutical classes in which many other well validated alternatives, including generic drugs, were available, and the study drugs had no clear advantages. It was a clever choice because use of these drugs would be strongly related to physicians’ susceptibility to the manufacturers’ promotional tactics.

Using a difference-in-differences statistical model, the study found that attending a school with a gift restriction policy significantly decreased the odds of prescribing two of the three study drugs. Because none of the drugs was available when the study cohorts were in medical school, the gift restrictions could not have affected gifts directly related to the drugs. These restriction policies may have been accompanied by programs to educate students about the role promotional gifts can have on physicians’ behavior, although such formal curriculums are rare. More likely, the results provide some insight into the “hidden curriculum” of medical education—the influence of the social environment, the daily routine of student life, and informal cues from mentors and peers on whom students model their professional development.9

According to this explanation, students in a school where industry promotion is regulated may be more likely to assimilate a healthy scepticism about pharmaceutical marketing into their professional development, with measurable downstream effects. Other research has shown that medical school experiences can predict future professional behavior,10 so school level policy changes might also have this effect. The results are consistent with another recent study showing that limiting industry promotion to psychiatry residents was associated with more evidence based prescribing of antidepressants.11

An association between gift restriction policies and subsequent patterns of professional clinical practice provides empirical support to supplement the ethical arguments made by students and medical schools seeking to curtail industry promotion. If physicians who attended a medical school with a culture of receptiveness to industry gifts are more likely to prescribe heavily promoted brand name drugs that provide questionable therapeutic advantage, instituting restrictive industry interaction policies may be justified as a way of favoring evidence based medicine. This could also help reduce unnecessary expenditure at a time when healthcare spending continues to grow.

Another implication of the effect of the hidden curriculum on medical students’ subsequent behavior is that the way industry interaction policies are implemented is as important as the policies themselves. King and colleagues evaluated graduates of schools that were the earliest to adopt these policies and probably had relatively solid support for them. As policies emerge on more divided campuses they may contain loopholes—such as restricting on-campus interactions but supporting them off campus—or be undermined by dismissive comments from educators. Such a counterproductive environment may, paradoxically, contribute to worse outcomes. Thus, advocates for gift restrictions and other industry interaction policies should seek campus consensus about the measures, soliciting input from all affected parties and focusing on practical interventions that make compliance straightforward and not overly onerous. Although such consultations require an investment of institutional resources, they should reinforce the impact of these policies on medical trainees’ professional development and future prescribing habits.