Michael Wilkes

Direct-to-consumer prescription drug advertising and the public.

AbstractOBJECTIVE: Drug manufacturers are intensely promoting their products directly to consumers, but the impact has not been widely studied. Consumers’ awareness and understanding of, attitudes toward, and susceptibility to direct-to-consumer (DTC) drug advertising were examined. DESIGN: Random-digit dialing telephone survey with a random household member selection procedure (completion and response rates, 58% and 69%, respectively). SETTING: Respondents were interviewed while they were at their residences. PARTICIPANTS: Complete data were obtained from 329 adults in Sacramento County, California. MEASUREMENTS AND MAIN RESULTS: Outcome measures included awareness of advertisements for 10 selected drugs, misconceptions about DTC advertising, attitudes toward DTC ads, and behavioral responses to such promotions. The influence of demographic characteristics, health status, attitudes, beliefs, and media exposure on awareness and behaviors was examined. On average, respondents were aware of advertisements for 3.7 of the 10 drugs; awareness varied from 8% for Buspar (buspirone) to 72% for Claritin (loratadine). Awareness was associated with prescription drug use, media exposure, positive attitudes toward DTC advertising, poorer health, and insurance status. Substantial misconceptions were revealed; e.g., 43% thought that only “completely safe” drugs could be advertised. Direct-to-consumer advertisements had led one third of respondents to ask their physicians for drug information and one fifth to request a prescription. CONCLUSIONS: Direct-to-consumer advertisements are reaching the public, but selectively so, and affecting their behaviors. Implications for public policy are examined.

Policies, practices, and attitudes of north american medical journal editors

OBJECTIVE: To describe U.S. and Canadian medical journals, their editors, and policies that affect the dissemination of medical information.DESIGN: Mailed survey.PARTICIPANTS: Senior editors of all 269 leading medical journals published at least quarterly in the United States and Canada, of whom 221 (82%) responded.MAIN MEASURES: The questionnaire asked about characteristics of journal editors and their journals and about journals’ policies toward peer review, conflicts of interest, pre-publication discussions with the press, and pharmaceutical advertisements.RESULTS: The editors were overwhelmingly men (96%), middle-aged (mean age 61 years), and trained as physicians (82%). Although 98% claimed that their journals were “peer-reviewed,” the editors differed in how they defined a “peer” and in the number of peers they deemed optimal for review. Sixty-three percent thought journals should check on reviewers’ potential conflicts of interest, but only a minority supported masking authors’ names and affiliations (46%), checking reviewers’ financial conflicts of interest (40%), or revealing reviewers’ names to authors (8%). The respondents advocated discussion of scientific findings with the press (84%), but only in accord with the Ingelfinger rule, i.e.,after publication of the article (77%). Fifty-seven percent of the editors agreed that journals have a responsibility to ensure the truthfulness of pharmaceutical advertisements, and 40% favored subjecting advertisements to the same rigorous peer review as scientific articles.CONCLUSIONS: The responding editors were relatively homogeneous demographically and professionally, and they tended to support the editorial status quo. There was little sentiment in favor of tampering with the current peer-review system (however defined) or the Ingelfinger rule, but a surprisingly large percentage of the respondents favored more stringent review of drug advertisements.OBJECTIVE: To describe U.S. and Canadian medical journals, their editors, and policies that affect the dissemination of medical information. DESIGN: Mailed survey. PARTICIPANTS: Senior editors of all 269 leading medical journals published at least quarterly in the United States and Canada, of whom 221 (82%) responded. MAIN MEASURES: The questionnaire asked about characteristics of journal editors and their journals and about journals’ policies toward peer review, conflicts of interest, pre-publication discussions with the press, and pharmaceutical advertisements. RESULTS: The editors were overwhelmingly men (96%), middle-aged (mean age 61 years), and trained as physicians (82%). Although 98% claimed that their journals were “peer-reviewed,” the editors differed in how they defined a “peer” and in the number of peers they deemed optimal for review. Sixty-three percent thought journals should check on reviewers’ potential conflicts of interest, but only a minority supported masking authors’ names and affiliations (46%), checking reviewers’ financial conflicts of interest (40%), or revealing reviewers’ names to authors (8%). The respondents advocated discussion of scientific findings with the press (84%), but only in accord with the Ingelfinger rule, i.e.,after publication of the article (77%). Fifty-seven percent of the editors agreed that journals have a responsibility to ensure the truthfulness of pharmaceutical advertisements, and 40% favored subjecting advertisements to the same rigorous peer review as scientific articles. CONCLUSIONS: The responding editors were relatively homogeneous demographically and professionally, and they tended to support the editorial status quo. There was little sentiment in favor of tampering with the current peer-review system (however defined) or the Ingelfinger rule, but a surprisingly large percentage of the respondents favored more stringent review of drug advertisements.

Towards more empathic medical students: a medical student hospitalization experience

Objective  We designed a curricular exercise intended to expose healthy medical students, near the end of their basic science training, to the experience of hospitalization. We attempted to assess how a standardized hospitalization, for medical students just about to start their clinical rotations, was experienced by student participants.

Doctoring: University of California, Los Angeles

The Doctoring curriculum at the University of California, Los Angeles, UCLA School of Medicine covers all four years of medical school. Its goal is to train physicians to give care that is compassionate, humanistic, high-quality, and evidence-based through a longitudinal, interdisciplinary curriculum with integration of learning experiences within and between years and with more emphasis on certain topics that had been previously neglected (e.g., advanced physical diagnosis, nutrition, public health, ethics). The curriculum operates alongside the traditional one, but strong attempts are made to link the two curricula. The authors describe the gradual introduction of the Doctoring curriculum, the sometimes formidable barriers that were encountered and in some cases still exist (e.g., some faculty and student resistance, need to find funds, faculty recruitment and retention). Active, interested faculty are essential, and intensive faculty development is needed. A detailed description of each years courses and teaching approaches is given. Year one focuses on interpersonal communication, the medical interview, human development and behavior, and the role of the community in health care; year two, on clinical reasoning, physical diagnosis skills, population medicine, and ethics; year three, on clinical problem solving, health services, professionalization issues, and prevention; and year four (which is elective), on medical education and leadership. The methods of evaluating students, faculty, and the curriculum itself are described and assessed. The authors conclude with a review of plans, prospects, and ongoing problems.

Doctoring III: Innovations in Education in the Clinical Years.

Despite recent major changes in the practice of medicine, there has been relatively little change in medical education, particularly in the clinical years. Important areas such as ethics, domestic violence, nutrition, preventive medicine, and clinical decision making have been neglected in the curriculum. However, in 1994 the UCLA School of Medicine began to implement Doctoring III, a multidisciplinary, centralized, longitudinal course that spans the third year of medical school. This course addresses many underrepresented topics. Students spend one day every other week in Doctoring III. Half of the day is spent in community-based clinical sites and the other half is spent in small-group teaching sessions. In the small groups, students and faculty follow and manage a panel of simulated patients over the course of the year. The students thus have the opportunity to develop a sense of the progression of common illnesses over time and to explore related ethical, social, and other concerns. The approach taken in Doctoring III has enabled the UCLA School of Medicine to overcome many barriers to curricular change, and it may serve as a model for incorporating the teaching of underrepresented topics in the clinical years.

Doctoring: A Longitudinal Generalist Curriculum.

It is clear that no matter what type of national health care reform is adopted, there will be a shift in the care that physicians are asked to provide: from high-tech to patient-centered, from cost-indifferent to cost-conscious, from treatment-focused to prevention-focused. It is critical that physicians be adequately trained to meet these new challenges. The medical education community needs to search for innovative, creative approaches to help our students develop the knowledge, skills, and attitudes needed to practice medicine in the next century. Doctoring is UCLAs approach to such curriculum reform.

Attitudes of house officers toward the autopsy

Study Objective:To assess the attitudes of house officers in internal medicine and pathology about the value and use of the autopsy.Design:Self-administered multiple-choice questionnaire.Setting:Two New York City urban teaching hospitals.Subjects:112 internal medicine and 37 pathology house officers who were on site during the survey period.Main results:Most internal medicine house officers (86%) felt that the autopsy rate was too low and needed to be increased. The most common reason the residents cited for the low rate was the reluctance of families to grant permission. A majority of medicine housestaff (78%) felt they needed more instruction on how to ask for an autopsy, and 34% had never received feedback from the pathology department on autopsy results. Most pathology residents (94%) felt the autopsy rate was too low; the most common reasons they cited for the low rate were reluctance of clinicians to request permission and clinicians’ fears of being sued for malpractice.Conclusions:House officers in internal medicine and pathology agreed that autopsies should be performed more frequently, and identified problems in obtaining autopsies that should be addressed by educational, organizational, and regulatory strategies.

Health care reform as perceived by first year medical students

Our study objective was to evaluate the attitudes of first year medical students toward the health care system using a self administered questionnaire to all first year medical students at the medical schools in the University of California system. Of 631 students surveyed, 94% comleted the instrument. Students were asked about their attitudes toward and familiarity with concepts in health services, access to care, and managed care. Our findings indicated that most students were unfamiliar with concepts related to health services. Students were concerned about access to care; sixty-six percent of students favor a national health insurance plan. A majority of students supported allowing patients access to the current health care system regardless of the cost or utility of a medical test or procedure. Thirty-nine percent felt that rationing health care in any form (transplants, access to the intensive care unit, etc.) is contrary to the way medicine should be practiced. 72% felt that practicing physicians had a major responsibility to help reduce health care costs. When asked about specific changes intended to control health costs, students identified reform of medical malpractice system (63%) and increased spending on preventive health (60%) as the two proposals most likely to be effective. Students generally held negative attitudes toward managed care organizations; only 10% would chose to receive their care in HMOs. We conclude that first year medical students generally have little understanding of the health care system. Despite this, they hold strong opinions about access to care, managed care organizations and strategies intended to reduce health care spending. It is up to medical educators to find creative methods of introducing these content areas into an already bulging curriculum.

Medical, law, and business students' perceptions of the changing health care system

An unanswered question in previous research on attitudes to health care systems is whether the values held by medical students are unique to them or simply a cohort phenomenon. This study addresses this by measuring values and attitudes on entry to medical school, and comparing them with two other groups whose academic standing at entry and social status are likely to be comparable business and law students. In this paper four substantive areas are dealt with: managed care, cost controls such as rationing, access to care. and the role of the federal government in regulating health care. There was a high level of agreement between the three groups that society should provide health care to all citizens, and that individuals should have appropriate access. There was also a general preference for being treated in a fee-for-service setting. Some differences were that medical students held more negative views about managed care than some of the others. The students tended to disagree on cost controls, particularly on issues that might impact on their own professions. Medical students were more restrictive than others on concepts of rationing health care and with regard to high tech procedures. Thus the results reflect areas of extensive agreement, but also the fact that even at entry students may differ on issues that are likely to have an economic impact on their careers. The relationship of these attitudes to the changing health care system and to theories about professionalism and the state is discussed.

Addressing Telephone Medicine in Medical School Education

With the shift to ambulatory and managed care, physicians spend hours a week on the telephone with patients, pharmacies, and consultants, yet medical students rarely receive training in the use of the phone in medicine. To expose students to the challenges of practising medicine over the phone, we have incorporated phone medicine into UCLA’s longitudinal third year Doctoring Curriculum. In Doctoring, medical students meet every two weeks throughout the academic year in small groups of 8 students with two faculty tutors. Each classroom has a speakerphone. Throughout the year, simulated patients, pharmacies, and doctors’ offices call the students at designated times. The students discuss the limitations of not seeing the patient in person and must decide what can be done over the phone and how soon the patient should be seen in the office. In each of these cases, students deal not only with practice management issues but also with issues of ethics, doctor-patient communication, cost-effectiveness, billing, and documentation surrounding the use of the phone in the practice of medicine.