A Study of Attitude and Knowledge of the Psychiatry Resident Doctors toward Clinician-Pharmaceutical Industry Interaction.

BACKGROUND: Pharmaceutical industry and clinicians are the two important stakeholders in the modern-day health care. However, concerns have been expressed about the lack of congruence between the goals of these two. AIMS: The current study aimed at exploring the knowledge and attitude of the psychiatry resident doctors toward the clinician-pharmaceutical industry interaction and also at exploring the knowledge of the residents about the new Medical Council of India guidelines on this issue.
MATERIALS AND METHODS: The survey was conducted among psychiatry residents. Descriptive statistics with frequency distribution was carried out by using SPSS version 17.0.
RESULTS: It had a good response rate of around 90%. The survey reveals the knowledge and attitude of the psychiatry residents toward the psychiatrist-pharmaceutical industry interaction.
CONCLUSIONS: The survey provides understanding in knowledge and attitude of the psychiatry residents towards the psychiatrist-pharmaceutical industry interaction.

INTRODUCTION

Pharmaceutical industry and clinicians are the two most important stakeholders in the modern-day health care. However, concerns have been expressed about the lack of congruence between the goals of these two.[1] The practice of the drug industry to persuade doctors to prescribe certain brands by giving gifts or providing ‘hospitality’ has also been documented.[1]

Worldwide there has been a sea change in the field of medical ethics with regard to the clinician–pharmaceutical industry interaction.[2] The Medical Council of India (MCI) has issued a new code of ethics for the clinicians while dealing with the pharmaceutical industry.[3] Concerns have been expressed about the possible impact of these new amendments.[4]

The current study aimed at exploring the knowledge and attitude of the psychiatry resident doctors toward the clinician–pharmaceutical industry interaction and also at exploring the knowledge of the residents about the new MCI guidelines on this issue.

MATERIALS AND METHODS

Setting, sample frame, and methodology

The study used a cross-sectional survey design. Resident doctors from the department of psychaitry of a total of six colleges were included in the study.

One of the authors approached the resident doctors after their duty hours and briefed them about the study. They were requested to participate in the survey. The study questionnaire was provided to them, which they filled and returned to the interviewer there and then.

Questionnaire

The survey questionnaire consisted of a total of 34 items. The survey questions were aimed at exploring four domains: (1) benefits of the psychiatrist–pharmaceutical industry interaction; (2) impact of the psychiatrist–pharmaceutical industry interaction on prescribing practices; (3) regulation of the psychiatrist–pharmaceutical industry interaction; (4) knowledge and awareness of the MCI guidelines. Conditions of anonymity and confidentiality were ensured. A total of 43 psychiatry resident doctors were approached. Thirty-nine of them returned the questionnaire. The data were analyzed by using SPSS version 17.0.

RESULTS

Psychiatry resident doctors from six colleges were approached for the participation in the study. A total of 39 psychiatry residents participated in the survey. The response rate was high at 90%. All the resident doctors were involved in the clinical care of the patients and were managing patients in the outpatient as well as inpatient settings.

Benefits of the psychiatrist–pharmaceutical industry interaction

Forty-five percent of the residents felt that the psychiatrist–pharmaceutical industry interaction was of benefit to the psychiatrists. While 71% believed that such an interaction was of benefit to the pharmaceutical industry, 51% were of the view that such an interaction was of benefit to the patients and their family members [Figure 1].

Figure 1

Who derives benefits out of the psychiatry–pharmaceutical industry interaction?

Sixty-three percent of the respondents reported that the pharmaceutical industry derived the maximum benefit out of such an interaction. Psychiatrists were the biggest beneficiary of such an interaction as per 21% of the respondents, while 16% reported patients/family members to be the biggest beneficiary [Figure 2].

Figure 2

Who derives maximum benefits out of the psychiatry–pharmaceutical industry interaction?

Impact of the psychiatrist–pharmaceutical industry interaction on prescribing practices

Forty-seven percent of the residents found prescribing a particular brand of medication in lieu of some free samples for poor patients is an acceptable practice. Prescribing a particular brand of medication in lieu of some academic material was endorsed by only 20% of the subjects. Forty-seven percent of the subjects reported that the acceptance of a gift from the pharmaceutical company would affect a clinician's decision while prescribing medications. However, a majority of them (55%) refuted the possibility that the acceptance of a gift from a pharmaceutical company would make a clinician overlook the cost impact of his or her prescription on the patient [Figures 3 and 4].

Figure 3

Impact of the psychiatry–pharmaceutical industry interaction on knowledge

Figure 4

Impact of the psychiatry–pharmaceutical industry interaction on prescribing practices of the clinicians

Regulation of the psychiatrist–pharmaceutical industry interaction

Seventy-one percent of the residents believed that psychiatrists in general are competent enough in deciding what they should accept from a pharmaceutical company. Seventy-six percent of the residents believed that they are competent enough in deciding what they should accept from a pharmaceutical company. They were further asked about different potential criteria while deciding whether to accept or decline a gift offered by a pharmaceutical company. The factors to be taken into consideration while making such decisions included cost (45%), type of product (45%), academic value (37%), likelihood that it would lead to professional improvement in terms of skill or knowledge (50%), and likely intentions of the pharmaceutical company (24%).

Only 35% of the residents believed that there should be some external regulation on the interaction between a psychiatrist and a pharmaceutical company.

Knowledge and awareness of the MCI guidelines

Fifty-eight percent of the respondents reported awareness of MCI guidelines for the regulation of clinician–pharmaceutical industry interaction. The positive response rate for different provisions of the guidelines included gifts (63%), travel facilities (55%), hospitality (32%), and cash or monitory grant (58%). A majority of the respondents (50%) were not aware of the value of the ‘gift’ acceptable under the new guidelines. Only 13% responded that any amount for such a purpose is prohibited.

A restriction on industry-sponsored travel was reported for self to attend a national conference (26%), for self to attend an international conference (34%), for self to go on a vacation (29%), for family members to attend a national conference (18%), and for family members to go on a vacation (26%). Thirty-four percent of the residents were not aware of the provision of any penalties for violation of these guidelines.

DISCUSSION

The survey was conducted among psychiatry residents and has a good response rate of around 90%. The survey reveals the knowledge and attitude of the psychiatry residents toward the psychiatrist–pharmaceutical industry interaction. We tried to carry out a comprehensive evaluation and involved different dimensions in our survey.

While the issue has been researched in greater depth in western settings, it largely remains unexplored in Indian settings. One prior study (that too with fresh medical graduates) has been published till date on this issue.[5] The current study focused on this ill-researched but essential issue. We have selected the resident doctors as our subjects since they are actively involved in clinical practice and are in direct contact with the pharmaceutical industry. Consequently, their views reflect the findings from real-life experiences. In this regard this is the first study on this work among clinically active resident doctors. Also, the experiences in these formative years could be detrimental to their attitudes on the issue for the rest of their clinical lives.

A majority of the respondents find the psychiatrist–pharmaceutical industry interaction to be of benefit to both psychiatrist and pharmaceutical industry, with pharmaceutical industry deriving the maximum benefit. While most of the residents look up to these interactions with an aim to enhance their knowledge on the therapeutic agents, a significant proportion is in favor of the pharmaceutical industry support for continuing medical education (CME)/conference participation. Concerns have been expressed about the subtle biases that pharmaceutical industry funding of the CME activities brings in. Conflicts of interest threaten the integrity of scientific investigations, the objectivity of professional education, the quality of patient care, and the public's trust in medicine.[6] A complete avoidance of the influence of pharmaceutical funding on the professional development has been deemed essential to ensuring its integrity.[7]

Forty-seven percent of the subjects reported that the acceptance of a gift from a pharmaceutical company would affect a clinician's decision while prescribing medications. However, a majority of them (55%) refuted the possibility that the acceptance of a gift from a pharmaceutical company would make a clinician overlook the cost impact of his or her prescription on the patient.

Need for institutions such as the MCI, the Indian Medical Association, the Indian Drug Manufacturers’ Association, the Drug Controller of India, and the judiciary to have suitable guidelines and to ensure their implementation has been expressed for long.

A majority of the residents believe themselves to be competent enough to regulate their interaction with the pharmaceutical industry. Only a minor proportion is in favor of some sort of external control. Support for MCI as a regulating agency is also minimal.

To the best of our knowledge, this is the first study of its kind that has explored the view of the resident doctors on the recent MCI guidelines. The awareness of the residents was limited on these recent amendments. Not only were a majority of them unaware of the different prohibitions, but they were also lacking information on the possible penal actions for violations of these guidelines. The MCI guidelines prohibit clinicians from accepting any gifts, travel facility, or hospitality from any pharmaceutical company or the health-care industry.

A majority of the residents do not think that MCI is the correct authority to regulate the clinician–pharmaceutical industry interaction. While there was some support for some kind of external regulation for such an interaction, a majority of the residents thought that they themselves were in the best position to do so. This finding is in contrast to the support for MCI amendments reflected in the work by Sharma et al.[5] Difference in the sample characteristics of the two studies might explain this difference. The subjects in the work by Sharma et al. were fresh graduates, but we have surveyed the resident doctors. A direct involvement with the pharmaceutical industry might influence the attitude and practice of the clinicians. This issue brings in a concern of loss of objectivity while making such decisions. This is because research has shown that even exposure to small promotional items influenced the attitude of clinicians toward a company's products.[8] Lack of compliance to such ethical guidelines has been considered an important limiting factor in their effective implementation.[9] The role of self-regulation in such interactions has been criticized for lack of effectiveness.[10] A paradoxical stance of the doctors on the issue reflected their opposition to incentives but conviction in the fact that accepting gifts would not influence their professional behavior and belief that promotion is ineffective has been highlighted.[11]

Concerns over the clinician–pharmaceutical industry interaction in Indian settings have been expressed in works of different authors.[12-18] A prior study focusing on fresh medical graduates came out with similar findings. However, we reckon that the current work gives a more realistic picture on the issue as the residents are involved in clinical work and are likely to share their personnel experiences. Also we have covered wider domains in this study. In a study by Campbell et al., two-thirds of the respondents (63.8%) received drug samples, 70.6% food and beverages, 18.3% reimbursements, and 14.1% payments for professional services.[19] Studies from Western settings have also revealed that gifts of lower monetary value are more acceptable to the doctors.[20-23] The findings of the current study suggest that the psychiatry resident find the gifts with some kind of ‘academic interest’ to be equally acceptable.

There is no consensus on the regulation of the clinician–pharmaceutical industry interaction. While some guidelines have not specified the monetary value of the gift as acceptable, others have varied in the ceiling amount. The American Medical Association has set a cutoff value of $100,[24] while the Department of Veterans Affairs has set the value at $20 per occurrence and less than $50 in aggregate value over a year from a single source.[25] The relevance of the gift to the patient care has also been proposed as one of the deciding criteria. However, other guidelines have given more significance to the context and intentions of the interaction as compared to the value of the gift.[26] The MCI guidelines have kept a cutoff value of INR 1000. A large proportion of the resident doctors in the current study have mentioned the monetary value to be an important factor while deciding the acceptability of a gift.

The new guidelines by the MCI have found both support and criticism from different stakeholders. However, concerns have been raised about their implementation. Also, lack of awareness of these changes is an area of concern. A majority of the resident doctors even in a big city were unaware of such changes. This partly reflects the lack of importance given to these issues in the clinical training of the residents. Introduction of stricter guidelines has shown positive impact.[19] Due importance needs to be given to the ethical issues in medical education and training. This would help the resident doctors and future clinicians to be in a better position to make these tough decisions. Approaches such as ‘academic detailing’ ‘(also known as ‘counterdetailing’) could be used as alternatives to the residents’ need of pharmaceutical industry as a source of information on therapeutic agents. These programs are designed to supply doctors with independent, evidence-based information about drugs to counter the presentations of sales representatives and other corporate information sources.[27]