Japanese Practicing Physicians' Relationships with Pharmaceutical Representatives: A National Survey

BACKGROUND: Previous surveys on the relationship between physicians and pharmaceutical representatives (PRs) have been of limited quality. The purpose of our survey of practicing physicians in Japan was to assess the extent of their involvement in pharmaceutical promotional activities, physician characteristics that predict such involvement, attitudes toward relationships with PRs, correlations between the extent of involvement and attitudes, and differences in the extent of involvement according to self-reported prescribing behaviors. METHODS AND FINDINGS: From January to March 2008, we conducted a national survey of 2621 practicing physicians in seven specialties: internal medicine, general surgery, orthopedic surgery, pediatrics, obstetrics-gynecology, psychiatry, and ophthalmology. The response rate was 54%. Most physicians met with PRs (98%), received drug samples (85%) and stationery (96%), and participated in industry-sponsored continuing medical education (CME) events at the workplace (80%) and outside the workplace (93%). Half accepted meals outside the workplace (49%) and financial subsidies to attend CME events (49%). Rules at the workplace banning both meetings with PRs and gifts predicted less involvement of physicians in promotional activities. Physicians valued information from PRs. They believed that they were unlikely to be influenced by promotional activities, but that their colleagues were more susceptible to such influence than themselves. They were divided about the appropriateness of low-value gifts. The extent of physician involvement in promotional activities was positively correlated with the attitudes that PRs are a valuable source of information and that gifts are appropriate. The extent of such involvement was higher among physicians who prefer to ask PRs for information when a new medication becomes available, physicians who are not satisfied with patient encounters ending only with advice, and physicians who prefer to prescribe brand-name medications. CONCLUSIONS: Involvement in pharmaceutical promotional activities is widespread among practicing physicians in Japan. The extent of such involvement varies according to certain physician characteristics. As a group, they are at risk for influence by promotional activities

Evaluation of a communication skills seminar for students in a Japanese medical school: a non-randomized controlled study

BACKGROUND: Little data exist for the effectiveness of communication skills teaching for medical students in non-English speaking countries. We conducted a non-randomized controlled study to examine if a short intensive seminar for Japanese medical students had any impact on communication skills with patients. METHODS: Throughout the academic year 2001–2002, a total of 105 fifth-year students (18 groups of 5 to 7 students) participated, one group at a time, in a two-day, small group seminar on medical interviewing. Half way through the year, a five-station objective structured clinical examination (OSCE) was conducted for all fifth-year students. We videotaped all the students' interaction with a standardized patient in one OSCE station that was focused on communication skills. Two independent observers rated the videotapes of 50 students who had attended the seminar and 47 who had not. Sixteen core communication skills were measured. Disagreements between raters were resolved by a third observer's rating. RESULTS: There was a statistically significant difference in proportions of students who were judged as 'acceptable' in one particular skill related to understanding patient's perspectives: asking how the illness or problems affected the patient's life, (53% in the experimental group and 30% in the control group, p = .02). No differences were observed in the other 15 core communication skills, although there was a trend for improvement in the skill for asking the patient's ideas about the illness or problems (60% vs. 40%, p = .054) and one of the relationship building skills; being attentive and empathic nonverbally (87% vs. 72%, p = .064). CONCLUSION: The results of this study suggest that a short, intensive small group seminar for Japanese medical students may have had a short-term impact on specific communication skills, pertaining to understanding patient's perspectives

Chronological changes in Japanese physicians' attitude and behavior concerning relationships with pharmaceutical representatives: a qualitative study.

BACKGROUND: Recent qualitative studies indicated that physicians interact with pharmaceutical representatives depending on the relative weight of the benefits to the risks and are also influenced by a variety of experiences and circumstances. However, these studies do not provide enough information about if, when, how and why their attitudes and behaviors change over time. METHODS AND FINDINGS: A qualitative study using semi-structured face-to-face individual interviews was conducted on 9 Japanese physicians who attended a symposium on conflicts of interest held in Tokyo. Interviews were designed to explore chronological changes in individual physicians' attitude and behavior concerning relationships with pharmaceutical representatives and factors affecting such changes. Their early interaction with pharmaceutical representatives was passive as physicians were not explicitly aware of the meaning of such interaction. They began to think on their own about how to interact with pharmaceutical representatives as they progressed in their careers. Their attitude toward pharmaceutical representatives changed over time. Factors affecting attitudinal change included work environment (local regulations and job position), role models, views of patients and the public, acquisition of skills in information seeking and evidence-based medicine, and learning about the concepts of professionalism and conflict of interest. However, the change in attitude was not necessarily followed by behavioral change, apparently due to rationalization and conformity to social norms. CONCLUSIONS: Physicians' attitudes toward relationships with pharmaceutical representatives changed over time and factors affecting such changes were various. Paying attention to these factors and creating new social norms may be both necessary to produce change in behavior consistent with change in attitude

Mediastinal Germ Cell Tumor Exhibiting a Discrepancy between Tumor Markers and Imaging: A Case Study

We report a mediastinal germ cell tumor (GCT) that exhibited a discrepancy between the time course of serum human chorionic gonadotropin (hCG) levels and clinical consequences. An otherwise healthy man, aged 34 years, was diagnosed with a nonseminomatous GCT, most likely embryonal carcinoma (EC), based on a mediastinal tumor biopsy. Standard chemotherapy resulted in an optimal decrease in serum hCG levels. However, multiple lesions in the liver continued to enlarge, which led to his death. Autopsy revealed few viable tumor cells in the liver, with the great majority of the tumor cells appearing to have undergone necrosis, suggesting that they responded to the chemotherapy. The residual tumor cells in the mediastinum and the liver were similar to syncytiotrophoblast cells, suggesting a choriocarcinoma (CC). On immunohistochemical analysis, the mediastinal tumor cells in the diagnostic biopsy specimen expressed both CD30 and hCG, whereas residual mediastinal and hepatic tumor cells in the autopsy specimen after chemotherapy also expressed hCG, but not CD30. These findings suggested that the patient suffered from a primary mixed GCT consisting of an EC and a CC. Both pre- and postchemotherapy tumors strongly expressed matrix metalloproteinase-2, supporting the aggressive and invasive features of the tumor phenotype. We speculate that the extremely invasive tumor destroyed normal liver structure, whereas chemotherapy and central necrosis reduced the number of viable cells themselves, causing a discordant decrease in serum hCG levels