Only 23% of family medicine registrars surveyed by Sergeant et al.5 had read the Canadian Medical Association’s (CMA) guidelines on appropriate interactions between doctors and representatives. Although six of the seven training centres had policies or referred to guidelines, only 26% of residents thought that their institution did. Although accepting a private dinner provided by a company contravenes the CMA guidelines, residents who knew about the guidelines, or were aware that their training centre had a policy about this, were no less likely to say they would accept such a dinner. However at one centre where company-sponsored lunches were not allowed, and where there was a teaching session on interacting with industry representatives, residents were less likely to see the literature from sales representatives as useful, and were less likely to say they would accept the private dinner or see representatives when they were practicing.
Brotzman and Mark232 also looked at whether residency programmes’ policies on drug sales representatives affected the attitudes of residents in the programmes. They randomly selected 14 US family medicine residency programmes, of which seven had written policies and at least one restriction on the activities of sales representatives. Residents in programmes with no policy were four times as likely to see detailing as a helpful source of information, and twice as likely to see journal advertisements as helpful, as residents in programmes with policies (the latter difference was not statistically significant). Those in programmes without policies felt gifts were more acceptable, and had more interactions with sales representatives. Brotzman and Mark note several possible reasons for this association between policies and residents’ attitudes. Residents may interpret the absence of a policy as approval by the programme directors of promotional activities; programmes may differ in their culture regarding promotion; residents in programmes without policies may be exposed to more promotion, be more used to it and therefore more accepting. In addition programmes with policies may also include other interventions which shape residents’ attitudes. However, when Brotzman and Mark removed from the analysis the three programmes with an explicit curriculum in this area, the results remained the same.
Ferguson et al.233 asked practicing internists (internal medicine specialists) in the US whether they had trained in an institution with an enforced policy about sales representatives, and whether they now saw sales representatives and accepted samples. They found no differences in whether doctors now saw sales representatives and accepted samples between those who had trained in an institution with an enforced policy and others. This suggests that any impact of policies during training may not persist over time.
McCormick et al.234 reached different conclusions. They compared doctors who had trained at a Canadian medical school which did not have a policy restricting sales representatives’ access to residents, with those who trained at another medical school which did have such a policy. They also compared doctors who had trained at the second school before the policy had been introduced. Those who trained while the policy was in force were less likely to find information from sales representatives beneficial in guiding their practice than other doctors several years after they graduated. The authors speculate that this could be due to the educational environment, to strong faculty opinions, or the doctors never having learnt to interact in a constructive way with sales representatives.
CONCLUSION: There is conflicting evidence about whether guidelines affect the attitudes of trainee doctors and if so whether any effects persist over time. Guidelines alone seem to have no strong influence on the attitudes of trainee doctors, but can be effective together with active faculty support in an academic setting.