During a lecture, randomly some second year medical students received small gifts, while others received nothing. Students who received a pen were four times more likely to believe non-authentic slides to be true than those who received nothing. We conclude that small promotional incentives are not harmless.
Medical doctors tend to think that other doctors are influenced by promotional activities of pharmaceutical companies, but that they themselves are not.1,2 From a company’s perspective, however, there is evidence that promotional activities are quite successful.3 In addition, pharmaceutical companies would not spend 15,000 million dollars per year on promotional activities if they did not believe it to be effective.4
For medical students the influence of promotional activities of pharmaceutical companies seems to be only of remote concern. Having all been students ourselves, we remember the temptation of obtaining free pencils and presents whenever possible. In a student mind this might be morally justified because of their low income, the fact that they do not yet write drug prescriptions, and the relative innocence of these incentives.5
To explore the influence of small promotional incentives, we simulated a promotional activity during a university lecture to second year medical students and assessed the consequence of it on students’ judgments of information credibility.
The experiment was done during a lecture in a regular course on scientific reasoning for all second year medical students. At the start of the lecture the group was divided into two groups, one at either side of the central corridor. Then, a clinical researcher told the students they were part of an experiment, of which the purpose would be revealed later. The researcher addressed the students on the – randomly chosen – left side in a positive way, by saying they were intelligent students who participated very well during the previous lectures. As a reward for their behavior, he gave them a pen with the logo of the Leiden University Medical Center, and he promised them a small toy, a yo-yo, after the experiment. The yo-yos were presented on the bench before the students and were not distributed to prevent the students from using them during the experiment. The other half of the students was neglected and addressed negatively once, by saying they seemed less interested during the previous lectures and, as a result of that, they were not given the free gifts. Then, the researcher presented a series of nine slides. The presentation was a fabricated review on the evolutionary development of the nose. In the first five slides truly existing species like an elephant, a spiny anteater, and a platypus were described. The last four slides showed pictures of animals belonging to the non-existent species of rhinogradentia.6 All students received a form together with the instruction to check a box whether they believed the authenticity of each slide. After the presentation, paper forms were collected and analyzed. We counted the number of students in each group believing at least one of the last four slides.
During the lecture, 172 students were present, all participated. Of the 97 students who received a pen, 20 believed the authenticity of at least one of the slides with non-existent species. Of the 75 students who did not receive a pen, only four believed the authenticity of at least one of these slides (relative risk 3.9, 95% CI 1.4 – 10.8).
By giving medical students some small incentives in a comforting style, we were able to accomplish extended belief in information that was ultimately not true. We found a statistically significant difference between the groups although the type of incentives we used were cheap (a pen and a yo-yo) and the lecturer was not trained in selling activities or commercial presentations.
Several studies have shown that students and physicians tend to underestimate the effect of promotional activities on their own opinions.1,5.We believe we are the first to show the effect of promotional activities in a direct controlled experiment with medical students. Our results support the analysis of Dana and Loewenstein who argue that small gifts may be surprisingly influential, as judgments on for instance the credibility of information are subject to an unconscious and unintentional self-serving bias.7 In the United States pharmaceutical companies seem to realize this, as over 90% of third-year medical students receive promotional incentives, like pens and coffee mugs, with a mean exposure frequency of one gift or sponsored activity per week.5
Moves towards disentanglement have been recognized.8 The American Medical Student Association issued a ‘Pharmfree’ campaign, calling for an end to gift giving, free lunches, and so on.9 Recently they produced the PharmFree scorecard 2009 evaluating conflicts-of-interest policies of medical schools in the United States.10 Moreover, recently Brennan and colleagues proposed a policy under which academic medical centers in the United States should take the lead in eliminating the conflicts of interest that still characterize the relationship between physicians and the health care industry.11 Yale University School of Medicine developed their own guidelines that do not allow any form of gifts to Yale physicians, regardless of monetary value.12 To our knowledge, in Europe no information, university guidelines, or teaching programs are available.
As a means of stimulating students to reflect on the effects of accepting small gifts, an experiment like this could be part of any regular curriculum. In our university, the experiment has been done before and, although not formally tested, the results were similar and always elicited meaningful discussion with students. An experiment like this could well be an instructive element in educational interventions that recently have been developed.13,14
In conclusion, we have demonstrated that offering small promotional incentives in a comforting style can influence judgments of information credibility of second year medical students. The experiment was relatively simple to carry out and can easily be introduced into any medical curriculum to directly show to medical students that small promotional incentives are not harmless.
CONFLICT OF INTEREST
The last five years, FWD received unrestricted grants for research from Amgen and Johnson & Johnson, and was involved in projects which received unrestricted grants from Abbott, Baxter Healthcare, and Genzyme. AJMdC was involved in a project sponsored by Bristol Myers-Squib. In addition, at congresses both authors received pens and small presents from various companies.
The idea behind this experiment has been developed and tested by Prof. Enrico Marani, Leiden University Medical Center, The Netherlands.
- Steinman, M.A., Shlipak, M.G., and McPhee, S.J. Of principles and pens: attitudes and practices of medicine housestaff toward pharmaceutical industry promotions. American Journal of Medicine. 2001; 110: 551-557.
- McNeill, P.M., Kerridge, I.H., Henry, D.A., Stokes B., Hill, S.R., Newby, D., Macdonald, G.J., Day, R.O., Maguire, J., and Henderson, K.M. Giving and receiving of gifts between pharmaceutical companies and medical specialists in Australia. Internal Medicine Journal. 2006; 36: 571-578.
- Wazana, A. Physicians and the pharmaceutical industry. Is a gift ever just a gift? Journal of the American Medical Association. 2000; 283: 373-380.
- Blumenthal, D. Doctors and drug companies. New England Journal of Medicine. 2004; 351: 1885-1890.
- Sierles, F.S., Brodkey, A.C., Cleary, L.M., McCurdy, F.A., Mintz, M., Frank, J., Lynn, D.J., Chao, J., Morgenstern, B.Z., Shore, W., Woodard J.L. Medical students’ exposure to and attitudes about drug company interactions. A national survey. Journal of the American Medical Association. 2005; 294: 1034-1042.
- Stümpke, H. Bau und leben der rhinogradentia. 2001, Spektrum Akademischer Verlag, Heidelberg – Berlin.
- Dana, J., and Loewenstein, G. A social science perspective on gift to physicians from industry. Journal of the American Medical Association. 2003; 290: 252-255.
- Moynihan, R. Who pays for the pizza? Redefining the relationships between doctors and drug companies. 2: Disentanglement. British Medical Journal. 2003; 326: 1193-1196.
- American Medical Students Association. Pharmfree campaign. http://www.pharmfree.org/ [accessed July 26, 2009].
- American Medical Students Association. AMSA PharmFree Scorecard 2009. http://www.amsascorecard.org/ [accessed July 26, 2009].
- Brennan, T.A., Rothman, D.J., Blank, L., Blumenthal, D., Chimonas S.C., Cohen, J.J., Goldman, J., Kassirer, J.P., Kimball, H., Naughton, J., and Smelser, N. Health industry practices that create conflicts of interest. A policy proposal for academic medical centers. Journal of the American Medical Association. 2006; 295: 429-433.
- Coleman, D.L., Kazdin, A.E., Miller, L.A., Morrow, J.S., and Udelsman, R. Guidelines for interactions between clinical faculty and the pharmaceutical industry: one medical school’s approach. Academic Medicine. 2006; 81: 154-160.
- Agrawal, S., Saluja, I., and Kaczorowski, J. A prospective before-and-after trial of an educational intervention about pharmaceutical marketing. Academic Medicine. 2004; 79: 1046-1050.
- Schneider, J.A., Arora, V., Kasza, K., Van Harrison, R., and Humphrey, H. Residents’ perceptions over time of pharmaceutical industry interactions and gifts and the effect of an educational intervention. Academic Medicine. 2006; 81: 595-602.