ing courses. Fourteen articles contained information re-
garding outcomes of resident teaching courses and were
selected for intensive review. Five uncontrolled pre-post
studies used resident self-reported teaching skills and
behaviors as outcome measures; all reported some improve-
ment in self-reported skills. Three uncontrolled pre-post
studies examined live or videotaped resident teaching
encounters and all revealed improvement in some teaching
skills. One uncontrolled trial and three nonrandomized
controlled trials used learner evaluations of resident teach-
ing behaviors as outcomes and all revealed an improve-
ment in ratings of residents after course participation. Four
randomized controlled trials of resident teaching curricula
are included in this review. One study did not show any
quantitative benefit of a resident teaching course on
performance or an objective structured teaching evalua-
tion. Two studies assessing resident teaching evaluations
before and after course participation showed conflicting
results. One study noted improvements in resident teach-
ing skills assessed through videotape analysis. The authors
conclude that resident teaching courses improve resident
self-assessed teaching behaviors and teaching confi-
dence. Teaching courses are linked to improved stu-
dent evaluations. They also emphasize that further studies
must be completed to elucidate the best format, length,
timing, and content of resident teaching courses and to
determine whether they have an effect on learner
performance.—Valerie Biousse
*Department of Medicine, University of California, 400 Parnassus, Box
0320, San Francisco, CA; e-mail: wamsley@itsa.ucsf.edu
●
Doctors and drug companies. Blumenthal D.* N Engl
J Med 2004;351:1885–1890.
T
HE INTERACTION OF DOCTORS AND PHARMACEUTICAL
companies is extremely consequential for patients,
doctors, and society. Pervasive interactions between drug
companies and physicians begin in medical school, con-
tinue during residency training, and persist throughout
physicians’ careers. These interactions include ubiquitous
dispensing of gifts, payment of large honoraria and con-
sulting fees to prominent physicians who extol the virtues
of company products, and support of lavish trips and
entertainment for physicians who regularly prescribe com-
pany products. There is justifiable concern that such
proprietary conflicts influence physician behavior and that
the results, on balance, may be negative for the quality and
cost of health care and may reduce the credibility of the
medical profession in the eyes of patients and the public.
Despite the confidence of physicians in their ability to
resist efforts by drug companies to affect their behavior, a
substantial body of theoretical and empirical literature
suggests that this may not be the case. The idea that small
gifts may be as influential as large gifts seems counterin-
tuitive but is supported by substantial research in social
science. Numerous studies have confirmed that a wide
variety of interactions, from seemingly trivial and harmless
to criminal excess, are associated with changes in physi-
cians’ use of medications. The resulting changes in the use
of medications were often costly and “nonrational” in that
the newly prescribed or requested drugs had no therapeutic
advantages over the alternatives. Efforts by government,
drug companies, and physicians’ organizations to formally
clarify and codify standards that differentiate appropriate
from inappropriate relationships have been applauded by
some as a reasonable solution to this problem, but rejected
by others as totally inadequate in addressing the basic
problem of inevitable bias generated by these relationships,
including the American Medical Student Association
which has advocated the extreme position that physicians
should not accept anything of financial value, no matter
how trivial, from drug companies under any circumstances.
It is far too early to assess the ways in which recent efforts
to manage physician-industry interactions will influence
the nature, extent, and effects of these relationships. As
long as these relationships remain legal, the parties in-
volved will face constant temptations to test the limits of
professional and industry codes and government regula-
tions. The final arbiter of the nature, extent, and conse-
quences of interactions between drug companies and
physicians will have to be the medical profession
itself.—Michael D. Wagoner
*D. Blumenthal, Institute for Health Policy, Massachusetts General
Hospital, Boston, MA 02114.
●
Financial conflicts of interest in physicians’ relation-
ships with the pharmaceutical industry-self regulation in
the shadow of federal prosecution. Studdert DM, Mello
MM, Brennan TA.* N Eng J Med 2004;351:1891–1900.
P
ROFESSIONAL REGULATORY BODIES, THE PHARMACEU-
tical industry, and the government have all decided
that physicians and drug manufacturers need stronger
advice about appropriate relationships. The failure of
ethical norms to deter unacceptable behavior in the
financial entanglements that bred close ties between the
pharmaceutical industry and physicians has triggered the
progressive imposition of legal norms. The federal govern-
ment is clearly intent on addressing, with criminal and
civil penalties, practices that heretofore were simply dis-
missed as matters of “ethical oversight.” Federal prosecu-
tors have begun applying anti-kickback statutes and false-
claim laws, with success, in prosecuting cases dealing with
improper interactions between physicians and pharmaceu-
tical companies, and it has been made clear, through
documents released from the Office of the Inspector
General, that physicians are exposed to the same threat of
liability as the drug companies for inappropriate behavior.
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