Microsoft Word - 4 Journal of Medical Ethics and History of Medicine       Attitude  and  practice  of  dental  surgeons  towards  pharmaceutical  companies’ marketing gifts   Shaila Tahir1, Adeela Rafique1, Farkhanda Ghafoor2, Akif Saleem1 and Amanullah Khan1   1Fatima Memorial College of Medicine & Dentistry, Lahore, Pakistan; 2PMRC centre NHRC, Shaikh Zayed Medical Complex Lahore, Pakistan.   Corresponding Author: Farkhanda Ghafoor Senior Research Officer, PMRC centre NHRC, Shaikh Zayed Medical Complex, Lahore, Pakistan. Email : fghafoor99@hotmail.com Received: 06 Sep 2012 Accepted: 23 Jan 2013 Published: 05 Apr 2013 J Med Ethics Hist Med, 2013, 6:4 http://journals.tums.ac.ir/abs/23423 © 2013 Shaila Tahir et al.; licensee Tehran Univ. Med. Sci. Abstract Interaction of pharmaceutical companies (PC) with healthcare services has been a reason for concern. In medicine,  awareness of the ethical implications of these interactions have been emphasized upon, while this issue has not  been highlighted in dentistry. This study undertook a cross‐sectional rapid assessment procedure to gather views  of  dentists  in  various  institutions  towards  unethical  practices  in  health  care  and  pharmaceutical  industry.  The  purpose  of  this  study  was  to  assess  the  need  for  the  formulation  and  implementation  of  guidelines  for  the  interaction of dentists with the pharmaceutical and device industry in the best interest of patients.  A  group  of  209  dentists  of  Lahore  including  faculty  members,  demonstrators,  private  practitioners  and  fresh  graduates responded to a questionnaire to assess their attitudes and practices towards pharmaceutical companies’  marketing gifts.  The study was conducted during 2011 and provided interesting data that showed the pharmaceutical industry is  approaching  private  practitioners  more  frequently  than  academicians  and  fresh  graduates.  Private  practioners  accepted the gifts but mostly recognized them as unethical (over 65%). Both groups considered sponsoring of on‐ campus lectures as acceptable (over 70%).  Respondents are not fully aware of the ethical demands which are imperative for all health care industries, and  there is a dire need of strict guidelines and code of ethics for the dentist’s interaction with the pharmaceutical and  device industry so that patient interest is protected.    Keywords: Attitude, practice, Pharmaceutical companies, Dentists, Marketing gifts Introduction The global pharmaceutical industry has grown at a tremendous pace reaching up to $956 billion and is expected to rise to nearly $1.2 trillion in 2016, representing a compound annual growth rate of 3-6 percent the world over (1). With this aggressive growth and ever increasing competition the marketing strategies of pharmaceutical and some dental/medical equipment companies are becoming ethically questionable (2-4). Although the pharma- ceutical industry is sponsoring a lot of research J Med Ethics Hist Med 6:4 April, 2013 jmehm.tums.ac.ir Shaila Tahir et al. Page 2 of 5 (page number not for citation purposes)     worldwide, the major portion of their budget is allocated to promotional activities (4, 5). The usual promotional activities are obliging doctors by minor gifts, like stationery items, donating equip- ments, kits and even invitations for dinners, or sponsoring participation in seminars and training programs. This brings about a conflict between the physician’s financial interest and the welfare of the patient (4-13). In medicine, awareness of the ethical implica- tions of such gifts has been raised for the past few decades and a code of ethics has been formulated for interaction between medical practitioners and pharmaceutical companies. In dentistry, the need to realize the ethical implications of such interactions is greater than medicine because of the more active involvement of device industry and material manufacturers. The interactions of dentists include those with pharmaceutical, biotech, medical device and research equipment industry. Interactions with these industries can be positive if kept above reproach (14). However, with the growing competi- tion amongst the pharmaceutical industry, device industry and material manufacturers, the unethical marketing practices are also growing. The present study was undertaken to assess the attitudes and practices of fresh dental graduates, faculty members and private practitioners in dentistry towards pharmaceutical gifts, and consequently the need for implementation of guidelines and a code of ethics in the dental fraternity in Pakistan. Another purpose of this study was to assess the difference in perception of fresh graduates, residents, faculty members and private practitioners. Method The study sample included dentists of various categories: fresh graduates, resi- dents/demonstrators, faculty members and private practitioners. The assessment tool was a question- naire that was designed based on previously published studies in India (15) and Norway (16). It was handed out at various teaching and training dental institutions, clinics and dental conferences, and was filled in anonymously. The data was collected from October 2011 to December 2011. The teaching & training institutions included in this study were de’ Montmorency College of Dentistry, Sharif Medical and Dental College, Lahore Medical and Dental College and Fatima Memorial Dental College and Hospital. The sample size for each category selected was based on the expected representative size. All the data was compiled and analyzed using Microsoft Excel (Windows 7) and SPSS (version 17). For testing significance, since the data was predominantly qualitative in nature, Chi square test was applied at a P value of 0.05 or less. Results A total of 220 participants were requested to fill a study instrument, 209 (95 %) completed it and were included for data analysis. The participants included fresh graduates (FG), demonstrators (D), faculty members (FM) and private practitioners (PP) working in dentistry. The demographic data of the study participants are summarized in table 1 and Figure 1. Table 1: Demographic data of study participants Category (Dentist) Respondents Data completed Fresh graduates 70 67 Demonstrators 90 87 Faculty members 30 26 Private practitioners 30 29 Total 220 209 (95%) Gender (n=209) Male 98 46.9% Female 111 53.1% Age (years) < 30 74 35.4% >30 135 64.6% The response of the four different groups to the pharmaceutical representative (PR) is shown in tables 2 and 3. It appeared that private practitioners (PP) were more frequently contacted by the PRs. During the previous 3 months, 89.6% of PPs had been visited as compared to 62.8% of faculty. A similar trend was observed in the offering of gifts, with the highest percentage of gifts being offered to private practitioners (over 75%) as against 61.1% to fresh graduates, demonstrators and faculty members. When gifts were offered, the PPs accepted in higher proportion (69.0%) than faculty (43.1%). From the ethical point of view of accepting gifts, a very high percentage (92%) of faculty members declared that accepting gifts from J Med pharmace of fresh Fig. 1 Table 1 2 3 4 5 6 7 8 *Thes Table 1 2 3 4 5 6 7 8 *Thes F re q u e n cy d Ethics Hist M eutical industr graduates, 7 : Work experi e 2: Response Views/R Interaction cal represen 3 months Gifts offere Gifts accep Considerin unethical Gifts affect Allowing P campus lec Receiving h lecture acc Considerin interaction se values were e 3: Response Views/R Interaction representati Gifts offere Gifts accept Considering Gifts affect Allowing P lectures Receiving acceptable Considering tion as usefu se values were F re q u e n cy   6 Med 6:4 April, 2 ry was unethic 70.1% of dem ience of study outcome of p Responses n with pharmac ntatives in the ed pted ng accepting g t prescription PRs to arrange ctures honorarium fo eptable ng pharmaceut as useful e statistically s outcome of p Responses with p ives in the last ed ted g accepting gi prescription PRs to arrang honorarium g pharmaceut ful e statistically s 8 67 2013 cal while 58.2 monstrators a y participants articipants of Fr n= ceuti- e last 43 43 31 gifts 39 31 e on 57 or a 44 tical 58 significant articipants of pharmaceutica t 3 months ifts unethical ge on campu for a lecture tical interac significant Work Experi 25 7 jmehm.tums 2% and 65 ac the academic resh graduates =67 3 (64.1%) 3 (64.1%) 1 (46.2%) 9 (58.2%) 1 (46.2%) 7 (85.0%) 4 (65.6%) 8 (86.5%) the academic Academ group (n=180)* al 113 (62 110 (61 78 (43. 124 (69 72 (40. s 135 (75 e 106 (59 - 144 (80 ence  1 s.ac.ir 5% of priv cceptance of g group s Dem n=87 54 (6 54 (6 41 (4 61 (7 39 (4 61 (7 51 ( 67 (7 and private g mic P tion (n=2 2.8%) 2 1.1%) 2 .3%) 2 9.0%) 1 .0%) 1 5.0%) 2 9.0%) 1 0.0%) 2 13 (page num vate practitio gifts as unethic monstrators 7 62.0%) 62.0%) 47.0%) 70.1%) 44.8%) 70.1%) 58.6%) 78.1%) groups Private practi ners 29) 25 (89.6%) 22 (75.8%) 20 (69.0%) 19 (65.5%) 12 (41.3%) 21 (72.4%) 15 (55.1%) 22 (75.8%) Shaila T mber not for citati oners consid cal. Faculty n=26 16 (61. 13(50.0 6 (23.0 24 (92. 2 (7.6% 17(65.3 11 (42. 19 (73. i- P valu <0.05 <0.05 <0.05 >0.05 >0.05 >0.05 >0.05 >0.05 Tahir et al. Page 3 of 5 on purposes)     dered the y .5%) 0%) 0%)* .3%) %)* 3%) .3%)* .0%) e J Med Ethics Hist Med 6:4 April, 2013 jmehm.tums.ac.ir Shaila Tahir et al. Page 4 of 5 (page number not for citation purposes)     The academic group included fresh graduates, demonstrators and teaching faculty. An interesting observation was that almost 69% of private practitioners accepted gifts from the PRs but 65% of them considered it unethical at the same time. This shows a clear contrast in their actions and opinions. An average of 44% of the fresh gradu- ates, demonstrators and private practitioners revealed that their prescriptions were affected by their interaction with the PRs while only 7.6% of the faculty members considered their interaction with PRs to affect their prescribing habit. It was interesting to note that both fresh gradu- ates and demonstrators were offered gifts and accepted them in the ratio of 1.4: 1, while the academic staff accepted gifts to a lesser degree, the ratio between gifts offered and accepted being 2.2: 1.0. In the additional question on commenting about the gift as ethical or unethical, the academic group by far declared them as unethical and the ratio of labeling it as unethical was faculty: demonstrators: fresh graduates: 1.6: 1.2: 1. In terms of accepting and declaring it as unethical, the academic staff provided a ratio of 4 declaring unethical: 1 accepting. This ratio was much narrower in the other groups. In the entire study group 75% of the subjects who were offered gifts accepted them, and ac- ceptance of gifts affected 40% of the prescribing practice. Discussion This study gave an insight on the impact of pharmaceutical industry’s interaction with dental surgeons at various levels from fresh graduates to faculty members and private practitioners. Histori- cally, pharmaceutical industry has been trying to influence doctors’ prescribing habits and has often not adhered to ethical principles (17). In dentistry, interaction with device industry and material manufacturers is also a necessary evil along with the pharmaceutical industry. This renders a dentist more susceptible to their marketing strategies than a physician (13). Pharmaceutical industry exploits the fact that long term habits are developed early in a doctor’s career, so they make special efforts to stay in constant touch with the fresh graduates and students along with the senior members of the dental fraternity (18). These efforts of the pharma- ceutical industry create a conflict of interest in ethical practices (8-12). The pharmaceutical industry seems to focus significantly more on private practitioners than on fresh graduates, demonstrators or the faculty members of different teaching institutions. Private practitioners showed the highest percentage of accepting gifts offered to them and they also appeared to disregard the ethical considerations, and their approach was mainly more focused on the business and commercial aspects of their relation- ship with the pharmaceutical industry. In compari- son, faculty members were offered 10% less gifts than private practitioners, while their gift ac- ceptance rate was almost 63% less than private practitioners. This contrast in percentage of accepting gifts can be attributed to the difference in the level of education of private practitioners and faculty members, since most of the private practi- tioners are general dentists while faculty members invariably have some postgraduate qualifica- tion. According to a study, physician response to the pharmaceutical industry may vary by practice settings. A more ethically aware environment in a university setting leads to better ethical practices, while professional isolation of private practice may lead to being influenced by the information provided by the pharmaceutical representatives (19). This trend was also reported in a very recent study conducted in Libya (20). The results showed some confusing responses especially in fresh graduates and demonstrators who accepted gifts regardless of considering them as unethical. This finding is similar to one of the recent studies in which it was concluded that although physicians understood the concept of conflict of interest, their interaction with the pharmaceutical industry led to psychological dynamics that influenced their reasoning (2). In some of the earlier studies, however, no sta- tistically significant differences were found in the responses of the faculty members and residents (5). Such trends probably indicate inadequacies in the training and curricula in terms of professional ethics. One limitation of the present study was an ab- sence of control over the validity of the responses since it could not be ascertained whether the respondents were trying to project certain concepts or simply report their actual practices. True evaluation for built-in validity assessment could be a blend of knowledge, attitudes and practices. The majority of fresh graduates, demonstrators and private practitioners seemed to have their prescribing habits affected by gifts; however, only a very small percentage of faculty members appeared to be influenced by gifts. This difference can again be attributed to the latter’s academic qualifications and their awareness of ethical implications. On the other hand, all the four groups consid- ered their interaction with the pharmaceutical industry as useful. This finding is also similar to results from previous studies (21). The present study highlights the need for regula- tions to be imposed by the government, but laws alone cannot reinforce ethical practice, and physicians themselves need to abstain from the negative commercial influences of marketing (22). J Med Ethics Hist Med 6:4 April, 2013 jmehm.tums.ac.ir Shaila Tahir et al. Page 5 of 5 (page number not for citation purposes)     Conclusion The present study indicates lack of awareness on ethical implications of interaction with the pharma- ceutical industry in the undergraduate and post- graduate training. Pakistan Medical and Dental Council has laid clear guidelines on interaction with the pharmaceutical industry, but unfortunately most of the medical and dental graduates are unaware of even the existence of such a docu- ment. 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