Several authors describe programmes to teach health professionals how to interact with sales representatives and interpret promotional information. Palmisano and Edelstein33 briefly describe a seminar programme used for a range of health professionals. This included a simulation of a sales representative’s sales pitch. Anastasio and Little235 describe a programme for family practice residents which aimed to improve their ability to obtain useful information from sales representatives. Over three hours, students were taught skills for controlling interactions with sales representatives, and for critically analysing promotion, and they discussed ethical issues. Students had two appointments with sales representatives to practice their skills, and these were watched and evaluated by others. Students rated themselves as more confident in their skills after the course.
Kelcher et al.236 describe a programme to provide family medicine residents with a structured approach to dealing with sales representatives. This consisted of a one-hour educational seminar, and five visits from sales representatives. The sales representatives were asked to give their presentations according to a structured plan, and during their presentations the residents completed evaluation forms and discussed the advertising techniques used. These were followed by discussions with preceptors where the residents discussed what they had learnt about the drugs. According to questionnaires most of the small number of residents (15) who had completed the programme thought it should continue. They authors argue that this approach is better than restricting residents’ access to sales representatives. The project was funded by two pharmaceutical companies.
Hopper et al.237 measured the effect of a 40 minute lecture and discussion session about pharmaceutical promotion, on primary care and internal medicine-paediatric residents. Surveys were completed three weeks before and four weeks after the teaching session. Very small numbers of people were involved. After the intervention residents were more likely to believe that sales representatives may use unethical marketing practices, that gifts with no patient benefit may be inappropriate, and that other doctors’ prescribing habits may be negatively influenced by accepting gifts. This study suffers from very small numbers of participants. It is also unclear whether these reported attitude changes are likely to persist over time.
Suryawati and Santoso238 described the effect of a teaching module for medical students in Indonesia. This consisted of a one-hour lecture on commercial and non-commercial sources of drug information, the WHO Ethical Criteria for Medicinal Drug Promotion, and examples of misleading promotion. This was followed by a two hour workshop in which participants critically assessed advertisements from local medical journals. Participants in the course, and two control groups, completed tests that involved assessing 10 different advertisements. The intervention group significantly improved after the course and this effect was still apparent after 12 months. One control group, who were part of the same class, improved somewhat after 12 months, probably due to cross-contamination, and the other control group performed poorly in the test 12 months after the course.
Shaughnessy et al.239 reported on an educational intervention for resident doctors in the USA. This centred around a Pharmaceutical Representative Evaluation Form which residents used to evaluate presentations by sales representatives. The form included the completeness of the presented information, the techniques of persuasion used, and the use of rational and irrational appeals. Using a modified version of the questionnaire developed by McKinney et al.16 the authors found that a year after the programme residents were more likely to disagree that sales representatives and gifts have no impact on prescribing. Similarly, Vinson et al.240 found a change in students’ attitudes after a lecture on concerns about pharmaceutical marketing practices to second year medical students. However this change was measured by questionnaire only seven weeks after the lecture.
Wilkes and Hoffman241 describe an educational programme in which university pharmacists portrayed pharmaceutical company representatives to model a promotional presentation, that they designed to generate critical thinking among third-year medical students about the influence of pharmaceutical representatives on physicians’ prescribing practices. The authors found that the programme increased the uncertainty many students felt about the accuracy and ethics of standard drug.detailing- Compared to questionnaire responses that students provided before the exercise, the attitudes they expressed in course assessments completed 12 weeks after the session revealed much more uncertainty about the ethics and value of interactions with representatives, and the number who stated that they wanted to interact with representatives during their residency fell from 86% to 61%. This is potentially a valuable approach for inoculating medical students against some of the worst potential consequences of biased drug detailing presentations.
In some of these studies it is difficult to determine whether any reported changes in attitudes after educational sessions are due to actual changes in attitudes, or to participants perceiving it to be less socially appropriate to express their original attitudes. However this is less of a problem in the Suryawati and Santoso study, because they tested participants’ skills at assessing advertisements, rather than their attitudes. This study provides a useful model and convincing evidence of its effects.
CONCLUSION: Education about promotion appears to change attitudes and can improve skills. The impact of education about promotion on prescribing has not yet been tested.