Study Shows Small "Reminder" Items Influence Med Students

A study in the current Archives of Internal Medicine provides some evidence that medical students are influenced by "reminder items" with drug company logos prominently displayed, and also by medical school policies approving or disapproving of contacts between students and drug industry marketers.

Penn's David Grande and colleagues studied 3rd and 4th year students at Penn and Miami using both explicit questions and the Implicit Association Test. The IAT has been thoroughly studied and validated as a psychological instrument to reveal subconscious prejudices such as racial bias, and has also been used to study marketing influence. Penn has a strict policy banning drug company reps, meals, and samples; Miami has a permissive policy. Half the students at each site where signed into the study using clipboards and notepads that prominently displayed a "Lipitor" logo. The explicit and implicit attitudes measured were the comparisons between Lipitor and Zocor as statin drugs (the latter being a drug considered generally equivalent and now available as a cheaper generic).

No differences of any sort were shown among the various groups of 3rd year students. The 4th year students displayed a more complex picture. At Miami, being exposed to the Lipitor logo yielded a significant change in the IAT favoring use of Lipitor. At Penn, the opposite result occurred. The authors interpreted the results as consistent with a boomerang effect of drug marketing in an environment where such marketing had explicitly been labeled as problematic--so that when students saw an obvious marketing ploy, it turned them off rather than making them favorably disposed toward the drug. This suggestion was reinforced by the explicit questionnaire data that showed that the Penn students had conscious views of drug marketing that were significantly more skeptical than those of the Miami students.

The fact that no differences were observed among the 3rd year students might be seen as calling into question the robustness of the findings with the 4th year students. The authors further suggest, however, that their results are consistent with the 4th year students being farther along in clinical training and hence more ready to display a preference for one drug over another.

The Archives accompanied the study by Grande et al. with a pointed editorial by Dr. Philip Greenland of Northwestern. Greenland notes that as of January 1 of this year, these "reminder items" like notepads and pens have supposedly been banned by the new PhRMA code of conduct. But the ban does not extend to meals, samples, and CME programs; hence Greenland suggests that the findings of the study are every bit as pertinent as they would have been prior to the new code. Greenland goes on:

We believe (1) that the evidence is solid that [drug company sponsored interactions with physicians] are designed for the purposes of influencing and biasing the physician-patient interaction and (2) that these adverse effects are achieved as a consequence of the interactions. ... Why are most of us still waiting? The evidence is clear, and the path is defined. It is time to act.

One of the most prevalent and long-lived rationalizations that we hear in response to attempts at reform at the medicine-Pharma interface is that physicians are highly trained scientists and that we can never be influenced by something as simple or as blatant as a pen or notepad. Grande et al. have just made that rationalization a bit harder to swallow.

One minor point is that in a typical interaction between a physician and a drug rep (at least before the Code of Conduct), the physician would be given the "reminder item" as a gift and then would be re-exposed to the drug logo each time the item was subsequently used. There would therefore be two routes of influence-- first, the sense of debt and reciprocity owed to a person who has given you a gift; and second, the effect of being reminded of the drug's name regularly. The Grande et al. study might therefore actually underestimate considerably the power of "reminder items" to influence physicians.

While subscriptions are required to link to the article and editorial, a press account of the study can be found at http://www.theglobeandmail.com/servlet/story/RTGAM.20090512.wlfreebies12art1832/EmailBNStory/specialScienceandHealth/

Grande D, Frosch DL, Perkins AW, Kahn BE. Effect of exposure to small pharmaceutical promotional items on treatment preferences. Arch Intern Med 169:887-893, May 11, 2009.

Greenland P. Time for the profession to act: new policies needed now on interactions between pharmaceutical companies and physicians [editorial]. Arch Intern Med 169:829-831, May 11, 2009.