Attitudes of physicians and public to pharmaceutical industry ‘gifts’

Background: Few studies have reported the attitudes of both individual doctors and members of the public toward the appropriateness of ‘gifts’ from pharmaceutical companies. Aims: To investigate the attitudes of both doctors and members of the public toward the appropriateness of receiving particular ‘gifts’ from pharmaceutical companies, and to consider whether public acceptability is a suitable criterion for determining the ethical appropriateness of ‘gifts’. Methods: A survey questionnaire of medical specialists in Australia and a survey questionnaire of members of the public itemised 23 ‘gifts’ (valued between AU$10 and AU$2500) and asked whether or not each was appropriate. Results: Both medical specialists and members of the public believe certain ‘gifts’ from pharmaceutical companies are appropriate but not others. There was a tendency for members of the public to be more permissive than medical specialists. Conclusion: Although some professional guidelines place importance on the attitudes of the general public to ‘gift’ giving, and other guidelines give importance to a need for transparency and public accountability, we question whether public acceptability is a suitable criterion for determining the ethical appropriateness of ‘gifts’. We suggest that more weight be given to the need for independence of clinical decision making, with empirical evidence indicating that even small ‘gifts’ can bias clinicians’ judgments, and to important values such as the primacy of patient welfare, autonomy and social justice. We conclude that it is time to eliminate giving and receiving of promotional items between the pharmaceutical industry and members of health professions.     

A comparison of physicians’ and patients’ attitudes toward pharmaceutical industry gifts

OBJECTIVE: To compare physicians’ and their patients’ attitudes toward pharmaceutical gifts. DESIGN: Survey of physicians and their patients. SETTING: Two tertiary-care medical centers, one military and one civilian. PARTICIPANTS: Two hundred sixty-eight of 392 consecutively surveyed physicians, 100 of 103 randomly selected patients at the military center, and 96 patients in a convenience sample at the civilian center completed the survey. MEASUREMENTS: Participants rated 10 pharmaceutical gifts on whether they were appropriate for physicians to accept and whether they were likely to influence prescribing. Patients found gifts less appropriate and more influential than did their physicians. About half of the patients were aware of such gifts; of those unaware, 24% responded that this knowledge altered their perception of the medical profession. Asked whether they thought their own physician accepted gifts, 27% said yes, 20% no, and 53% were unsure. For patients, feeling that gifts were inappropriate was best predicted by a belief that gifts might influence prescribing, while for physicians, the best predictor was knowledge of guidelines. CONCLUSIONS: Patients feel pharmaceutical gifts are more influential and less appropriate than do their physicians. Physicians may want to consider this in deciding whether to accept particular gifts. Broader dissemination of guidelines may be one means of changing physician behavior. At the same time, future guidelines should further consider the potentially different viewpoints of patients and physicians. The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense. Part of this work was presented at the Society of General Internal Medicine annual meeting, May 1–3, 1997.     

The alcohol industry and public interest science

Aims This report argues that the growing involvement of the alcohol industry in scientific research needs to be acknowledged and addressed. It suggests a set of principles to guide ethical decision‐making in the future. Methods We review relevant issues with regard to relationships between the alcohol industry and the international academic community, especially alcohol research scientists. The guiding principles proposed are modelled after expert committee statements, and describe the responsibilities of governmental agencies, the alcohol industry, journal editors and the academic community. These are followed by recommendations designed to inform individuals and institutions about current ‘best practices’ that are consistent with the principles. Findings and conclusions Growing evidence from the tobacco, pharmaceutical and medical fields suggests that financial interests of researchers may compromise their professional judgement and lead to research results that are biased in favour of commercial interests. It is recommended that the integrity of alcohol science is best served if all financial relationships with the alcoholic beverage industry are avoided. In cases where research funding, consulting, writing assignments and other activities are initiated, institutions, individuals and the alcoholic beverage industry itself are urged to follow appropriate guidelines that will increase the transparency and ethicality of such relationships.     

Digital health competencies for the next generation of physicians

As health care continues to change and evolve in a digital society, there is an escalating need for physicians who are skilled and enabled to deliver care using digital health technologies, while remaining able to successfully broker the triadic relationship among patients, computers and themselves. The focus needs to remain firmly on how technology can be leveraged and used to support good medical practice and quality health care, particularly around resolution of longstanding challenges in health care delivery, including equitable access in rural and remote areas, closing the gap on health outcomes and experiences for First Nations peoples and better support in aged care and those living with chronic disease and disability. We propose a set of requisite digital health competencies and recommend that the acquisition and evaluation of these competencies become embedded in physician training curricula and continuing professional development programmes.     

Evaluating the performance of inpatient attending physicians

OBJECTIVE: Instruments available to evaluate attending physicians fail to address their diverse roles and responsibilities in current inpatient practice. We developed a new instrument to evaluate attending physicians on medical inpatient services and tested its reliability and validity. DESIGN: Analysis of 731 evaluations of 99 attending physicians over a 1-year period. SETTING: Internal medicine residency program at a university-affiliated public teaching hospital. PARTICIPANTS: All medical residents (N= 145) and internal medicine attending physicians (N= 99) on inpatient ward rotations for the study period. MEASUREMENTS: A 32-item questionnaire assessed attending physician performance in 9 domains: evidence-based medicine, bedside teaching, clinical reasoning, patient-based teaching, teaching sessions, patient care, rounding, professionalism, and feedback. A summary score was calculated by averaging scores on all items. RESULTS: Eighty-five percent of eligible evaluations were completed and analyzed. Internal consistency among items in the summary score was 0.95 (Cronbach's alpha). Interrater reliability, using an average of 8 evaluations, was 0.87. The instrument discriminated among attending physicians with statistically significant differences on mean summary score and all 9 domain-specific mean scores (all comparisons, P <.001). The summary score predicted winners of faculty teaching awards (odds ratio [OR], 17; 95% confidence interval [CI], 8 to 36) and was strongly correlated with residents' desire to work with the attending again (r =.79; 95% CI, 0.74 to 0.83). The single item that best predicted the summary score was how frequently the physician made explicit his or her clinical reasoning in making medical decisions (r(2)=.90). CONCLUSION: The new instrument provides a reliable and valid method to evaluate the performance of inpatient teaching attending physicians.     

Professional satisfaction experienced when caring for substance-abusing patients

This survey aimed to describe and compare resident and faculty physician satisfaction, attitudes, and practices regarding patients with addictions. Of 144 primary care physicians, 40% used formal screening tools; 24% asked patients’ family history. Physicians were less likely (P<.05) to experience at least a moderate amount of professional satisfaction caring for patients with alcohol (32% of residents, 49% of faculty) or drug (residents 30%, faculty 31%) problems than when managing hypertension (residents 76%, faculty 79%). Interpersonal experience with addictions was common (85% of faculty, 72% of residents) but not associated with attitudes, practices, or satisfaction. Positive attitudes toward addiction treatment (adjusted odds ratio [AOR], 4.60; 95% confidence interval [95% CI], 1.59 to 13.29), confidence in assessment and intervention (AOR, 2.49; 95% CI, 1.09 to 5.69), and perceived responsibility for addressing substance problems (AOR, 5.59; CI, 2.07 to 15.12) were associated with greater satisfaction. Professional satisfaction caring for patients with substance problems is lower than that for other illnesses. Addressing physician satisfaction may improve care for patients with addictions. This work was presented in part at the annual meeting of the Robert Wood Johnson Foundation Generalist Physician Faculty Scholars Program, Tucson, Ariz, December 4, 1998, the annual meeting of the Society of General Internal Medicine, San Francisco, Calif, April 29, 1999, and at the annual meeting of the Association of Medical Education and Research on Substance Abuse, Alexandria, Va, November 5, 1999. Deceased. Dr. Saitz received support from the Robert Wood Johnson Foundation as a Generalist Physician Faculty Scholar (Grant No. 031489) for this work. He and Dr. Samet were also supported in this work by the Center for Substance Abuse Prevention (Faculty Development Grant T26-SP08355). Drs. Samet, Saitz, and Sullivan, and Mr. Winter and Ms. Lloyd-travaglini receive support from the National Institute on Alcohol Abuse and Alcoholism (R01-AA10870). Dr. Friedmann was supported by a Mentored Clinical Scientist Career Development Award (K08-DA 00320).     

Marital and parental satisfaction of married physicians with children

OBJECTIVE: To evaluate personal and professional factors associated with marital and parental satisfaction of physicians. STUDY DESIGN: Cross-sectional study. PARTICIPANTS: A survey was sent to equal numbers of licensed male and female physicians in a Southern California county. Of 964 delivered questionnaires, 656 (68%) were returned completed. Our sample includes 415 currently married physicians with children, 64% male and 36% female. MEASUREMENTS AND MAIN RESULTS: Ratings of marital and parental satisfaction were measured on a 5-point Likert scale, 5 being extremely satisfied. Prevalence of work and home life factors was also evaluated. The mean score for marital satisfaction was 3.92 (range 1.75-5.0). Approximately half of the physicians reported high levels of marital satisfaction (63% of male physicians and 45% of female physicians). The gender difference disappeared after adjusting for age differences. Two factors were associated with high marital satisfaction: a supportive spouse (odds ratio [OR] 10.37; 95% confidence interval [CI] 2.66, 40.08) and role conflict (OR 0.61; 95% CI 0.42, 0.88). The mean score for parental satisfaction was 3. 43 (range 1.0-5.0), and approximately two thirds of both male and female physicians reported at least moderate levels of parental satisfaction. The major factors associated with parental satisfaction were a supportive spouse (OR 2.24; 95% CI 1.32, 3.80), role conflict (OR 0.35; 95% CI 0.23, 0.53), salaried practice setting (OR 2.14; 95% CI 1.21, 3.81), marriage to a spouse working in a profession (OR 2.14; 95% CI 1.21, 3.81), and marriage to a spouse working as a homemaker (OR 2.33; 95% CI 1.20, 4.56). Number of hours worked was not found to be related to either satisfaction score, but rather to an intervening variable, role conflict. CONCLUSIONS: For physicians with children, our study indicates that minimizing the level of role conflict and having a supportive spouse are associated with higher levels of marital and parental satisfaction. Working in salaried positions and marriage to a spouse who is either working in a profession or who is a stay-at-home parent are also related to high parental satisfaction.     

Ozbug: an email mailing list for physicians that works

Abstract
Very few studies of the quality of electronic mailing lists have been published. Ozbug was established in 1997 as a moderated and closed mailing list for infectious diseases physicians in Australia and New Zealand. A broad range of clinical and professional issues is discussed by ­subscribers. An email survey of subscribers in 2002 indicated a high degree of satisfaction with the service. (Intern Med J 2003; 33: 532−534)     

Evaluation of housestaff physicians’ preparation and interpretation of sputum gram stains for communityacquired pneumonia

Objective:To evaluate the preparation and interpretation of sputum Gram stains by housestaff physicians in the assessment of patients with community-acquired pneumonia. Design:A prospective, multicenter study. Setting:Two university-affiliated hospitals in Pittsburgh. Patients:Ninety-nine cases of clinically and radiographically established pneumonia occurring in 97 patients. Diagnostic test assessment:Housestaff and microbiology personnel prepared a Gram stain for each case of pneumonia. Housestaff assessed the presence and identity of a predominant microbial organism on the slides they prepared. Two senior staff microbiologists, blinded to patient and preparer, evaluated all slides for preparation, sputum purulence, and identification of the predominant organism. Two reference standards were used to assess the sensitivity, specificity, and predictive values of housestaff’s Gram-stain interpretations: 1) senior staff microbiologists’ determinations of the microbes present using the slides without benefit of culture results, and 2) the etiologic agent derived from results of sputum culture, blood culture, or serology. Measurements and main results:Housestaff physicians completed a Gram stain in 58% of the pneumonia episodes. Gram stains were not made in 42% of cases, primarily because patients were unable to produce sputum. Fifteen percent of housestaff’s smears were judged inadequately prepared, compared with 3% for the laboratory personnel (p<0.01). Housestaff obtained purulent sputum samples significantly more often than did nursing personnel (58% versus 38%; p<0.01). Housestaff’s Gram stains were 90% sensitive for detecting pneumococcus, with a 50% falsepositive rate. The sensitivity of the Gram stain was less for identification of Haemophilus influenzaethan for identification of Streptococcus pneumoniae.A single antimicrobial agent was chosen as initial therapy for 50% of the patients in whom housestaff identified a predominant organism, compared with 30% in whom a predominant organism was not identified (p≤0.05). Conclusions:Although housestaff obtained purulent sputum samples more frequently than did nursing personnel, they made systematic errors in the preparation and interpretation of Gram-stained slides. Housestaff physicians should receive formal training in the preparation and interpretation of Gram stains; the specific defects elucidated in this study warrant special attention. Received from the Divisions of General Medicine and Infectious Diseases, Department of Medicine, University of Pittsburgh and VA Medical Center, Pittsburgh, Pennsylvania.     

Dangerous liaisons: doctors‐in‐training and the pharmaceutical industry

Interaction between doctors and the pharmaceutical industry is long‐standing and ingrained in modern practice. Doctors‐in‐training are at a vulnerable stage of their careers, both in requiring knowledge and forming lasting relationships. There is evidence that limiting contact between industry and junior doctors has a positive effect on subsequent clinical behaviour. Currently in Australia, there is no limitation on pharmaceutical representatives approaching doctors‐in‐training, and the majority of education sessions are sponsored by pharmaceutical companies. This purposefully creates a sense of reciprocity, which may have adverse long‐term consequences on attitudes, behaviours and patient care. Several guidelines exist that may assist junior doctors in navigating these potential interactions, most notably the Royal Australasian College of Physicians' own Guidelines for Ethical Relationships between Physicians and Industry. Despite this, there is no reflection of its importance or necessity within subspecialty curricula. This should be rectified, to the benefit of both the profession and public.     

Frequency and impact of housestaff contact with primary care physicians

To determine how often housestaff notified primary care providers (PCPs) of admissions, whether notification prompted a visit, and whether PCP input impacted care, 210 medical inpatients were asked about their PCPs, and at discharge, housestaff completed a questionnaire on the patient’s PCP, and whether he or she was contacted, came to the hospital, and influenced care. Of 105 patients with a PCP, 74 were contacted and 26 visited their patients. The PCPs spoken with personally more often made hospital visits than those contacted only by message (p<0.0001). PCP input frequently contributed to patient care by providing continuity, clarifying history/diagnosis, managing chronic problems, and elucidating psychosocial/cultural factors. Having a PCP did not influence length of stay or readmission rates. Received from the Department of Medicine, University of Washington, Seattle, Washington.     

Racial and ethnic disparities in access to physicians with HIV-related expertise

OBJECTIVE: Professional medical associations recommend that physicians who treat patients with human immunodeficiency virus (HIV) have a measurable form of disease-specific expertise, such as high HIV patient volume or infectious diseases certification. Although it is known that racial/ethnic minorities generally have worse access to care than do whites, previous work has not examined disparities in the use of physicians with HIV-related expertise. DESIGN, SETTING, AND PARTICIPANTS: We linked data from a prospective cohort study of 2,207 persons with HIV receiving care in the United States with a cross-sectional survey of 404 physicians caring for them. Using multivariate analysis, we estimated the association of patient race/ethnicity with the experience and training of their physicians, controlling for health status, socioeconomic status, demographic characteristics, and geographic variation in provider supply. RESULTS: Compared with white patients, African Americans were less likely to have an infectious diseases specialist as a regular source of care (odds ratio [OR], 0.60; 95% confidence interval [CI], 0.37 to 0.95). Persons of Alaskan Native, American Indian, Asian, Pacific Islander, or mixed racial background were also less likely than whites to have an infectious diseases specialist (OR, 0.44; 95% CI, 0.23 to 0.83). Conversely, Latino patients had physicians whose HIV patient volume was, on average, 24% higher than the physicians of white patients (incident rate ratio, 1.24; 95% CI, 1.03 to 1.50). CONCLUSIONS: Some groups of racial/ethnic minorities are less likely than are whites to have infectious diseases specialists as a regular source of care. The finding that the physicians of Latino patients had relatively higher HIV caseloads suggests that this particular patient subpopulation has access to HIV expertise. Further work to explain racial/ethnic differences in access to physicians will help in the design of programs and policies to eliminate them.     

Adherence counseling practices of generalist and specialist physicians caring for people living with HIV/AIDS in North Carolina

CONTEXT: National guidelines recommend that practitioners assess and reinforce patient adherence when prescribing antiretroviral (ART) medications, but the extent to which physicians do this routinely is unknown. OBJECTIVE: To assess the adherence counseling practices of physicians caring for patients with HIV/AIDS in North Carolina and to determine characteristics associated with providing routine adherence counseling. DESIGN: A statewide self-administered survey. SETTING AND PARTICIPANTS: All physicians in North Carolina who prescribed a protease inhibitor (PI) during 1999. Among the 589 surveys sent, 369 were returned for a response rate of 63%. The 190 respondents who reported prescribing a PI in the last year comprised the study sample. MAIN OUTCOME MEASURES: Physicians reported how often they carried out each of 16 adherence counseling behaviors as well as demographics, practice characteristics, and attitudes. RESULTS: On average, physicians reported spending 13 minutes counseling patients when starting a new 3-drug ART regimen. The vast majority performed basic but not more extensive adherence counseling; half reported carrying out 7 or fewer of 16 adherence counseling behaviors "most" or "all of the time." Physicians who reported conducting more adherence counseling were more likely to be infectious disease specialists, care for more HIV-positive patients, have more time allocated for an HIV visit, and to perceive that they had enough time, reimbursement, skill, and office space to counsel. After also controlling for the amount of reimbursement and availability of space for counseling, physicians who were significantly more likely to perform a greater number of adherence counseling practices were those who 1). cared for a greater number of HIV/AIDS patients; 2). had more time allocated for an HIV physical; 3). felt more adequately skilled; and 4). had more positive attitudes toward ART. CONCLUSIONS: This first investigation of adherence counseling practices in HIV/AIDS suggests that physicians caring for patients with HIV/AIDS need more training and time allocated to provide antiretroviral adherence counseling services.     

Views of united states physicians and members of the American medical association house of delegates on physician-assisted suicide

OBJECTIVE: To ascertain the views of physicians and physician leaders toward the legalization of physician-assisted suicide. DESIGN: Confidential mail questionnaire. PARTICIPANTS: A nationwide random sample of physicians of all ages and specialties, and all members of the American Medical Association (AMA) House of Delegates as of April 1996. MEASUREMENTS: Demographic and practice characteristics and attitude toward legalization of physician-assisted suicide. MAIN RESULTS: Usable questionnaires were returned by 658 of 930 eligible physicians in the nationwide random sample (71%) and 315 of 390 eligible physicians in the House of Delegates (81%). In the nationwide random sample, 44.5% favored legalization (16.4% definitely and 28.1% probably), 33.9% opposed legalization (20.4% definitely and 13.5% probably), and 22% were unsure. Opposition to legalization was strongly associated with self-defined politically conservative beliefs, religious affiliation, and the importance of religion to the respondent (P <.001). Among members of the AMA House of Delegates, 23.5% favored legalization (7.3% definitely and 16.2% probably), 61.6% opposed legalization (43.5% definitely and 18.1% probably), and 15% were unsure; their views differed significantly from those of the nationwide random sample (P <.001). Given the choice, a majority of both groups would prefer no law at all, with physician-assisted suicide being neither legal nor illegal. CONCLUSIONS: Members of the AMA House of Delegates strongly oppose physician-assisted suicide, but rank-and-file physicians show no consensus either for or against its legalization. Although the debate is sometimes adversarial, most physicians in the United States are uncertain or endorse moderate views on assisted suicide.     

Coming to terms with the era of AIDS:

Purpose: To examine factors associated with residents’ willingness to provide care to persons with AIDS. Patients and methods: Survey of all senior residents in internal medicine and family medicine in ten geographically representative states in early 1989. Results: Preferring not to care for persons with AIDS was less common in the western United States and more common among those with more conservative politics, men physicians, Asian physicians, and foreign medical graduates. Multivariate analysis revealed scores on six attitudinal scales (homophobia, dislike of intravenous drug users, professional responsibility, fear of AIDS, futility of providing AIDS care, and clinical difficulty of AIDS care) to be strong independent predictors of willingness to care for persons with AIDS (adjusted R²=0.42). The authors postulated a model in which these six fundamental attitudes functioned as intervening variables between demographic characteristics and expressed willingness to provide AIDS care. Regression results supported the hypothesis that the associations between demographic characteristics and willingness to provide AIDS care were mediated via these attitudes. However, having had ambulatory experience in AIDS care during residency was associated with future intentions to provide such care, independent of negative attitudes. Conclusions: Physician willingness to care for persons with AIDS is inversely related to fear of acquiring AIDS, viewing treatment as futile or difficult, dislike of certain risk groups, and a lower sense of professional responsibility. These results identify concerns and stresses that should be addressed by residency programs, and emphasize the need for attention to the ethics and ideals of the profession in medical education. Presented in part at the National American Federation of Clinical Research Meeting, Washington, DC, May 1990. Supported by a grant from The Robert Wood Johnson Foundation.     

Why older community-dwelling adults do not discuss urinary incontinence with their primary care physicians

OBJECTIVES: This study explored reasons why older adults with urinary incontinence (UI) do not initiate discussions with or seek treatment for UI from their primary care provider. DESIGN: A randomized, prospective controlled trial involving 41 primary care sites. SETTING: Primary care practice sites. PARTICIPANTS: 49 older adults age 60 and older not previously screened for UI by their primary care doctor. MEASUREMENTS: Demographic data, self-reported bladder-control information using questionnaires, and health status. RESULTS: Adults who did not discuss UI were older, had less-frequent leaking accidents and fewer nighttime voids and were less bothered by UI than those who did. The two main reasons why patients did not seek help were the perceptions that UI was not a big problem (45%) and was a normal part of aging (19%). CONCLUSIONS: Embarrassment or lack of awareness of treatment options were not significant barriers to discussing UI. Adults with a fairly high frequency of UI (average of 1.7 episodes per day) did not view UI as abnormal or a serious medical condition.     

The use of evidence-based medicine in the practice of consultant physicians. Results of a questionnaire survey

Abstract Background: Information is lacking about the extent to which Australasian physicians apply methods of evidence‐based medicine (EBM) in routine practice. Aims: To assess the frequency and predictors of use of EBM methods in a sample of consultant physicians in adult medicine. Methods: Self‐administered questionnaires were distributed to a convenience sample of 545 physicians from October 1998 to January 1999. Results: One hundred and eleven questionnaires were returned (20% response rate). Ninety‐eight (88%) respondents formulated five or less clinical questions per week; 69 (62%) undertook five or more evidence searches per week, the majority as MEDLINE searches involving therapeutic topics. Respondents identified insufficient time (74%), limited search skills (41%), and limited access to evidence (43%) as search impediments. In determining evidence quality, 37% frequently relied on global impressions, while 22% frequently applied explicit critical appraisal (p=0.008). Efficiency of literature searches was rated on average as good/very good by 18%, fair by 52% and poor by 30%. As a result of EBM, 47% frequently had confidence in pre‐existing decisions increased, 39% gained improved knowledge, and 5% altered clinical decisions. Frequently encountered inhibitors to changing practice were personal conservatism (40%), organisational constraints (40%), and interdisciplinary tensions (39%). Perceived weaknesses of EBM included: limited applicability to individual patients (26%); evidence deficiencies (25%); and too time consuming (13%). In making EBM more attractive, one third requested reliable evidence sources at the point of care. Conclusions: The application of EBM to routine practice by physicians is constrained by deficient EBM skills, limited access to evidence, lack of time, and cognitive and environmental factors. Targeted education in EBM and systems that quickly deliver high‐quality evidence at the point of care are needed in realising the full potential of EBM to improve care.