Keywords: Fiduciary relationship, pharmaceutical promotion, physicians

I read with great interest the editorial on the pharmaceutical company–healthcare relationship published in the April-June issue of this journal [1]. Clinical practice guidelines are increasingly used by physicians to guide treatment decisions, and the pharmaceutical industry focuses on influencing the authors of these guidelines. Almost one in four guideline writers with no disclosed ties may have potentially relevant undisclosed ties to pharmaceutical companies [2]. Doctors are in a fiduciary relationship with patients and expected to act in their best interests. The relationship with the industry influences doctors in several ways; they may obtain information about medicines, but this information has been provided with an intention of influencing prescribing and increasing sales of the medicine [3].

Educating students

My colleagues and I have been involved in teaching the rational use of medicines along with understanding and responding to pharmaceutical promotions to medical students for over two decades [4]. Health Action International, in association with the World Health Organization, published a book on Understanding and responding to pharmaceutical promotion, which is one of the free resources available to educate students about such promotions [5]. Disparate methods are used to teach medical students to interact “properly” with the industry, making comparison of the effectiveness of different teaching methods difficult [6]. Identification and analysis of context-dependent educational interventions is needed. Published studies from developing nations may be few. Incorporating understanding and responding to pharmaceutical promotion in the medical curriculum is required. It is also important to study the impact of this initiative.

Clinicians’ interactions with the industry

Medical representatives are a key part of the pharmaceutical sales force. They build personal relationships with doctors and may provide incomplete medical information to influence prescribing and offer a variety of incentives to prescribers [7]. Clinicians may have a positive attitude toward promotion, regarding it as a means to obtain information about drugs and other benefits [8]. They also expect their continuing medical education (CME) needs to be sponsored by pharmaceutical companies. Developing countries do not yet require CMEs to be provided independent of the industry. A recent article argues that the fiduciary nature of the physician’s relationship with patients requires CMEs to be provided by medical professional societies [9].

Academic detailing

Medical students should learn to understand and respond to pharmaceutical promotion during pharmacology sessions and their clinical training. Several exercises can be conducted using free resources. Clinicians should be role-models of appropriate behaviour with the industry. This education should be reinforced during postgraduation, and unbiased information must be provided through academic detailing, a structured educational programme in which a trained healthcare professionals visits healthcare professionals in their practice to provide tailored evidence-based information [10]. In developing nations like India, major challenges to implementing academic detailing include inadequate funding, lack of human resources, lack of health information, and the influence of pharmaceutical promotion. Educating doctors and other professionals about pharmaceutical promotion is vital for them to fulfil their primary fiduciary duty to their patients.

Pathiyil Ravi Shankar ([email protected]), IMU Centre for Education, IMU University, Kuala Lumpur, MALAYSIA.