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Background To assess mentorship experiences among the faculty of a large academic department of medicine and to examine how those experiences relate to academic advancement and job satisfaction. Methods Among faculty members in the Massachusetts General Hospital Department of Medicine, we assessed personal and professional characteristics as well as job satisfaction and examined their relationship with two mentorship dimensions: (1) currently have a mentor and (2) role as a mentor. We also developed a mentorship quality score and examined the relationship of each mentorship variable to academic advancement and job satisfaction. Results 553/988 (56.0%) of eligible participants responded. 64.9% reported currently having a mentor, of whom 21.3% provided their mentor a low quality score; 66.6% reported serving as a mentor to others. Faculty with a current mentor had a 3.50-fold increased odds of serving as a mentor to others (OR 3.50, 95% CI 1.84–6.67, p

Background Three-quarters of homeless people smoke cigarettes. Competing priorities for shelter, food, and other subsistence needs may be one explanation for low smoking cessation rates in this population. We analyzed data from two samples of homeless smokers to examine the associations between subsistence difficulties and 1) smoking cessation readiness, confidence, and barriers in a cross-sectional study, and 2) smoking abstinence during follow-up in a longitudinal study. Methods We conducted a survey of homeless smokers (N = 306) in 4/2014–7/2014 and a pilot randomized controlled trial (RCT) for homeless smokers (N = 75) in 10/2015–6/2016 at Boston Health Care for the Homeless Program. In both studies, subsistence difficulties were characterized as none, low, or high based on responses to a 5-item scale assessing the frequency of past-month difficulty finding shelter, food, clothing, a place to wash, and a place to go to the bathroom. Among survey participants, we used linear regression to assess the associations between subsistence difficulty level and readiness to quit, confidence to quit, and a composite measure of perceived barriers to quitting. Among RCT participants, we used repeated-measures logistic regression to examine the association between baseline subsistence difficulty level and carbon monoxide-defined brief smoking abstinence assessed 14 times over 8 weeks of follow-up. Analyses adjusted for demographic characteristics, substance use, mental illness, and nicotine dependence. Results Subsistence difficulties were common in both study samples. Among survey participants, greater subsistence difficulties were associated with more perceived barriers to quitting (p

The 1996 Bermuda Principles launched a new era in data sharing, reflecting a growing belief that the rapid public dissemination of research data was crucial to scientific progress in genetics. A historical review of data sharing policies in the field of genetics and genomics reflects changing scientific norms and evolving views of genomic data, particularly related to human subjects' protections and privacy concerns. The 2013 NIH Draft Genomic Data Sharing (GDS) Policy incorporates the most significant protections and guidelines to date. The GDS Policy, however, will face difficult challenges ahead as geneticists seek to balance the very real concerns of research participants and the scientific norms that propel research forward. This article provides a novel evaluation of genetic and GDS policies' treatment of human subjects' protections. The article examines not only the policies, but also some of the most pertinent scientific, legal, and regulatory developments that occurred alongside data sharing policies. This historical perspective highlights the challenges that future data sharing policies, including the recently disseminated NIH GDS Draft Policy, will encounter.

BACKGROUND: Michigan’s approach to Medicaid expansion, the Healthy Michigan Plan (HMP), emphasizes primary care, prevention, and incentives for patients and primary care practitioners (PCPs). OBJECTIVE: Assess PCPs’ perspectives about the impact of HMP on their patients and practices. DESIGN: In 2014–2015, we conducted semi-structured interviews then a statewide survey of PCPs. SETTING: Interviewees came from varied types of practices in five Michigan regions selected for racial/ethnic diversity and a mix of rural and urban settings. Surveys were sent via mail. PARTICIPANTS: Interviewees were physician (n = 16) and non-physician practitioners (n = 3). All Michigan PCPs caring for ≥ 12 HMP enrollees were surveyed (response rate 55.5%, N = 2104). MEASUREMENTS: PCPs’ experiences with HMP patients and recent changes in their practices. RESULTS: Interviews include examples of the impact of Medicaid expansion on patients and practices. A majority of surveyed PCPs reported recent increases in new patients (52.3%) and patients who had not seen a PCP in many years (56.2%). For previously uninsured patients, PCPs reported positive impact on control of chronic conditions (74.4%), early detection of serious illness (71.1%), medication adherence (69.1%), health behaviors (56.5%), emotional well-being (57.0%), and the ability to work, attend school, or live independently (41.5%). HMP patients reportedly still had more difficulty than privately insured patients accessing some services. Most PCPs reported that their practices had, in the past year, hired clinicians (53.2%) and/or staff (57.5%); 15.4% had colocated mental health care. Few (15.8%) reported established patients’ access to urgent appointments worsened. LIMITATIONS: PCP reports of patient experiences may not be accurate. Results reflect the experiences of PCPs with ≥ 12 Medicaid patients. Differences between respondents and non-respondents present the possibility for response bias. CONCLUSIONS: PCPs reported improved patient access to care, medication adherence, chronic condition management, and detection of serious illness. Established patients’ access did not diminish, perhaps due to reported practice changes. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-018-4487-6) contains supplementary material, which is available to authorized users.

Small changes in bioavailability of narrow therapeutic index (NTI) drugs can alter clinical outcomes, raising concern over generic NTI substitution. We surveyed pharmacists to identify their perceptions of generic NTI drugs, their frequency of performing generic NTI substitution, and predictors of this behavior. Of 710 respondents (33% response rate), 87% perceived generic NTI drugs as effective as their brand-name versions and 94% as safe. Whereas 82% almost always performed generic NTI substitution for initial prescriptions, only 60% did for refills. Pharmacists in non-chain settings (odds ratio (OR) = 2.37; 95% confidence interval (CI) = 1.40-4.02), in practice longer (per year OR = 1.04; 95% CI = 1.02-1.06), in states with affirmative patient consent laws (OR = 1.88; 95% CI = 1.06-3.32), and in states with NTI-specific substitution requirements (OR = 1.95; 95% CI = 1.16-3.26) were more likely not to substitute initial prescriptions. Education of non-chain and veteran pharmacists and elimination of affirmative patient consent and NTI-specific substitution requirements could increase generic NTI substitution.

The US Food and Drug Administration uses drug safety communications (DSCs) to release emerging information regarding post-market safety issues, but it is unclear the extent of awareness by patients and providers of these communications and their specific recommendations. We conducted semi-structured interviews with patients and physicians to evaluate their awareness and understanding of emerging drug safety information related to two sleep aids: zolpidem or eszopiclone. We conducted interviews with 40 patients and ten physicians recruited from a combination of insurer claims databases and online sources. We evaluated (1) sources of drug safety information; (2) discussions between patients and physicians about the two medications; (3) their knowledge of the DSC; and (4) preferences for learning about future drug safety information. Interviews were transcribed and analyzed thematically. Patients cited their physicians, pharmacy inserts, and the Internet as sources of drug safety information. Physicians often referred to medical journals and online medical sources. Most patients reported being aware of information contained in the DSC summaries they were read. Almost all patients and physicians reported discussing side effects during patient-provider conversations, but almost no patients mentioned that physicians had communicated with them key messaging from the DSCs at issue: the risk of next-morning impairment with zolpidem and the lower recommended initial dose for women. Some risks of medications are effectively communicated to patients and physicians; however, there is still a noticeable gap between information issued by the Food and Drug Administration and patient and physician awareness of this knowledge, as well as patients’ decisions to act on this information. Disseminators of emerging drug safety information should explore ways of providing user-friendly resources to patients and healthcare professionals that can update them on new risks in a timely manner.

Physicians have dual responsibilities to make medical decisions that serve their patients' best interests but also utilize health care resources wisely. Their ability to practice cost-consciously is particularly challenged when faced with patient expectations or requests for medical services that may be unnecessary.To understand how physicians consider health care resources and the strategies they use to exercise cost-consciousness in response to patient expectations and requests for medical care.Exploratory, qualitative focus groups of practicing physicians were conducted. Participants were encouraged to discuss their perceptions of resource constraints, and experiences with redundant, unnecessary and marginally beneficial services, and were asked about patient requests or expectations for particular services.Sixty-two physicians representing a variety of specialties and practice types participated in nine focus groups in Michigan, Ohio, and Minnesota in 2012 MEASUREMENTS: Iterative thematic content analysis of focus group transcriptsPhysicians reported making trade-offs between a variety of financial and nonfinancial resources, considering not only the relative cost of medical decisions and alternative services, but the time and convenience of patients, their own time constraints, as well as the logistics of maintaining a successful practice. They described strategies and techniques to educate patients, build trust, or substitute less costly alternatives when appropriate, often adapting their management to the individual patient and clinical environment.Physicians often make nuanced trade-offs in clinical practice aimed at efficient resource use within a complex flow of clinical work and patient expectations. Understanding the challenges faced by physicians and the strategies they use to exercise cost-consciousness provides insight into policy measures that will address physician's roles in health care resource use.

Purpose: We evaluated whether primary care physicians (PCPs) from urban and rural practices differ on attitudes and behaviors related to quality improvement (QI) activities, patient relationships, and professionalism/self-regulation. Methods: Data from a national survey that assessed physician attitudes and behaviors based on the Physician Charter on Medical Professionalism were used. Of the 1,891 survey respondents, N = 840 were PCPs (n = 274 family medicine (response rate = 67.5%); n = 257 general internal medicine (60.8%); and n = 309 pediatricians (72.7%)). Using Rural-Urban Commuting Area (RUCA) codes, PCPs were classified as urban and rural according to their practice ZIP code. Findings: A total of n = 691 physicians were urban and n = 127 rural. Attitudes regarding participating in QI did not differ by practice location; however, rural PCPs were more likely to have reviewed an other physician’s records for QI than urban PCPs (65.6% vs 48.0%, P < .001). Rural physicians were more likely to agree that physicians should talk with their patients about the cost of care than urban PCPs (40.5% vs 29.2%, P = .02). While all PCPs endorsed attitudes regarding the importance of professional behaviors (eg, reporting impaired/incompetent colleagues, disclosing medical errors) at generally similar levels, their behaviors differed. More rural physicians had a personal knowledge of an impaired/incompetent physician than urban physicians (20.7% vs 12.7%, P = .02). Conclusions: PCPs from rural and urban areas share similar attitudes regarding the importance of participating in QI and fulfilling professional responsibilities. However, certain behaviors (eg, knowledge of impaired colleagues) do differ. These results should be confirmed in larger studies of rural PCPs.

Background Resident physicians are the direct care providers for many patients with addiction. This study assesses residents’ self-perceived preparedness to diagnose and treat addiction, measures residents’ perceptions of the quality of addictions instruction, and evaluates basic knowledge of addictions. Methods A survey was e-mailed to 184 internal medicine residents at Massachusetts General Hospital in May 2012. Results Responses were obtained from 55% of residents. Residents estimated that 26% of inpatients they cared for met criteria for a substance use disorder (SUD). Twenty-five percent of residents felt unprepared to diagnose and 62% felt unprepared to treat addiction. Only 13% felt very prepared to diagnose addiction. No residents felt very prepared to treat addiction. Preparedness to diagnose or treat addiction did not differ significantly across postgraduate year (PGY) level. Fifty-five percent rated the overall instruction in addictions as poor or fair. Seventy-two percent of residents rated the quality of addictions training as poor or fair in the outpatient clinical setting, and 56% in the inpatient setting. No resident answered all 6 knowledge questions correctly. Slightly more than half correctly identified the mechanism of buprenorphine and 19% correctly answered a question about naltrexone. Nine percent of residents responded that someone had expressed concern about the respondent's substance use. Conclusions Despite providing care for a substantial population with addiction, the majority of internal medicine residents in this study feel unprepared to treat SUDs. More than half rate the quality of addictions instruction as fair or poor. Structured and comprehensive addictions curriculum and faculty development are needed to address the deficiencies of the current training system.

BACKGROUND Increasingly, medical school policies limit pharmaceutical representatives’ access to students and gifts from drugmakers, but little is known about how these policies affect student attitudes toward industry.

Skepticism about the safety and effectiveness of certain generic drugs remains, particularly related to generic drugs that are approved by the Food and Drug Administration (FDA) using product-specific bioequivalence studies that differ from the standard testing pathway. The current study was designed to assess patient knowledge and perceptions of the generic drug approval process.We conducted a survey of patients with 10 different chronic diseases. We recruited survey participants from the CVS Advisor Panel, a proprietary database of 124 621 CVS customers pre-consented to participate in online research activities. We created a survey to collect data on patients' perceptions of the FDA's generic drug approval process, as well as their experiences with generic drugs approved using modified bioequivalence approaches used to treat their chronic medical conditions.Our survey of 753 patients with chronic diseases (65% response rate) showed that most (74%) expressed little familiarity with FDA's approval process for generic drugs, but nearly all (89%) believed that FDA approval ensures the safety and effectiveness of generic drugs. About one-fifth of respondents reported hearing concerns about their generic drugs, most commonly from physicians (35-36%) and the Internet (32-38%), but there were no differences in patients' reports of concerns about generic versions of the six study drugs approved using product-specific pathways versus comparator drugs.Patients have little knowledge about the generic drug approval system, but positive belief in the safety and effectiveness of generic drugs. Patients do not appear to have greater concern about generic drugs approved via product-specific pathways. Copyright © 2017 John WileySons, Ltd.

Background Generic drugs are cost-effective versions of brand-name drugs approved by the Food and Drug Administration (FDA) following proof of pharmaceutical equivalence and bioequivalence. Generic drugs are widely prescribed by physicians, although there is disagreement over the clinical comparability of generic drugs to brand-name drugs within the physician community. The objective of this survey was to assess physicians' perceptions of generic drugs and the generic drug approval process. Methods and Findings A survey was administered to a national sample of primary care internists and specialists between August 2014 and January 2015. In total, 1,152 physicians comprising of internists with no reported specialty certification and those with specialty certification in hematology, infectious diseases, and endocrinology were surveyed. The survey assessed physicians’ perceptions of the FDA’s generic drug approval process, as well as their experiences prescribing six generic drugs approved between 2008 and 2012 using product-specific approval pathways and selected comparator drugs. Among 718 respondents (62% response rate), a majority were comfortable with the FDA’s process in ensuring the safety and effectiveness of generic drugs overall (91%) and with letting the FDA determine which tests were necessary to determine bioequivalence in a particular drug (92%). A minority (13–26%) still reported being uncomfortable prescribing generic drugs approved using product-specific pathways. Overall, few physicians heard reports of concerns about generic versions of the study drugs or their comparators, with no differences between the two groups. Physicians tended to hear about concerns about the safety or effectiveness of generic drugs from patients, pharmacists, and physician colleagues. Conclusions Physicians hold largely positive views of the FDA's generic drug approval process even when some questioned the performance of certain generic drugs in comparison to brand-name drugs. Better education about the generic drug approval process and standards may alleviate concerns among the physician community and support the delivery of cost-effective health care.

Objectives Although nursing homes provide complex care requiring attention to safety, research on safety climate in nursing homes is limited. Our study assessed differences in attitudes about safety among nursing home personnel and piloted a new survey, specifically designed for the nursing home context. Methods Drawing on previous safety climate surveys for hospitals and nursing homes, researchers developed the Survey on Resident Safety in Nursing Homes and administered it March to June 2008 to frontline caregivers and managers in 8 randomly selected Massachusetts nursing homes. Our sample consisted of 751 employees, including all full-time, direct-care staff and managers from participating facilities. First, we performed factor analysis and determined Cronbach alphas for the Survey on Resident Safety in Nursing Homes. Then, we described facilities' safety climate and variation by personnel category and among facilities by calculating the proportion of responses that were strongly positive by item, personnel category, and nursing home. Results Of 432 respondents (57% response), 29% gave their nursing home an excellent rating overall. Scores varied by personnel category and home: 51% of senior managers gave an excellent safety grade versus 26% of nursing assistants; the range in top safety grades among nursing homes was 30 percentage points. Conclusions Safety climate varied substantially among this small sample of nursing homes and by personnel category; managers had more positive perceptions about safety than frontline workers. Efforts to measure safety climate in nursing homes should include the full range of staff at a facility and comparisons among staff categories to provide a full understanding for decision making and to promote targeted response to improve resident safety.

Rationale This article proposes a systems level conceptualization of physician professionalism that is embedded in and results from the characteristics of the organizations in which doctors work such as hospitals, group practices and physician organizations. Aims and objectives The goal of this study was to develop and test the systems model of professionalism. Methods In total, 25 interviews were conducted in Minneapolis and Miami. Job titles of the subjects included hospital presidents, medical directors, chairs of hospital departments, quality and safety directors, chief of quality improvement and practising physicians. The data from the interviews were coded and then sorted by members of the study team into major and minor themes. Results Virtually, all of the subjects were readily able to confirm aspects of the model by providing real-life examples of factors at the practice, hospital and market levels that they believed strongly influenced the extent to which physicians adhere, or fail to adhere, to the professional norms. Conclusions The systems model of professionalism was consistent with the views and experiences of physicians and administrators in two different geographic regions of the USA. If born out by further research, this model has implications for interventions aimed at improving professionalism as well as for professionalism as a field of study.

Background Medical students attending schools with policies limiting industry/student interactions report fewer relationships with pharmaceutical representatives. Objective To investigate whether associations between students' medical school policies and their more limited industry interaction behaviors persist into residency. Methods We randomly sampled 1800 third-year residents who graduated from 120 allopathic US-based medical schools, using the American Medical Association Physician Masterfile. We surveyed them in 2011 to determine self-reported behavior and preferences for brand-name prescriptions, and we calculated the strength of their medical schools' industry interaction policies using the 2008 American Medical Student Association and Institute on Medicine as a Profession databases. We used logistic regression to estimate the association between strength of school policies and residents' behaviors with adjustments for class size, postresidency career plan, and concern about medical school debt. Results We achieved a 44% survey response rate (n = 739). Residents who graduated from schools with restrictive policies were no more or less likely to accept industry gifts or industry-sponsored meals, speak with marketing representative about drug products, attend industry-sponsored lectures, or prefer brand-name medications than residents who graduated from schools with less restrictive policies. Residents who correctly answered evidence-based prescription questions were about 30% less likely to have attended industry-sponsored lectures (OR = 0.72, 95% CI 0.56–0.98). Conclusions Any effect that medical school industry interaction policies had on insulating students from pharmaceutical marketing did not persist in the behavior of residents in our sample. This suggests that residency training environments are important in influencing behavior.

Evaluating unnecessary US medical practices, and the strategies that reduce them, are increasingly recognized as crucial to healthcare financing sustainability. Provider factors are known to affect unnecessary medical practices, yet little is known about how physician responses to patient requests for unnecessary care affect these practices. Among primary care physicians (PCPs), we investigated 2 types of unnecessary medical practices triggered by patient requests: a) unnecessary specialty referrals and b) prescriptions for brand-name drugs when generic alternatives are available.We used data from a survey of a nationally representative sample of 840 US PCPs in 2009. Response rates for family practice (n = 274), internal medicine (n = 257), and pediatrics (n = 309) were 67.5%, 60.8%, and 72.7%, respectively.In response to patient requests, 51.9% of PCPs reported making unnecessary specialty referrals and 38.7% prescribed brand-name drugs. Family physicians (odds ratio [OR], 2.77; 95% CI, 1.77-4.34) and internal medicine physicians (OR, 4.51; 95% CI, 2.87-7.06) were more likely than pediatricians to prescribe brand-name drugs. PCP specialty was similarly associated with unnecessary referrals. Other predictors of acquiescence to patient requests included interactions with drug/device representatives, more years of clinical experience, seeing fewer safety net patients, and solo/2-person practice organizations. Area-level Medicare spending was not associated with the 2 unnecessary practices.Many PCPs reported acquiescing to patient requests for unnecessary care. Provider and organizational factors predicted this behavior. Policies aimed at reducing such practice could improve care quality and lower cost. Patient and physician incentives that can potentially reduce unnecessary medical practices warrant exploration.

Article-at-a-Glance Background An appreciation of how human factors affect patient safety has led to development of safety climate surveys and recommendations that hospitals regularly assess safety attitudes among caregivers. A better understanding of variation in patient safety climate across units within hospitals would facilitate internal efforts to improve safety climate. A study was conducted to assess the extent and nature of variation in safety climate across units within an academic medical center. Methods The Agency for Healthcare Research and Quality (AHRQ) Hospital Survey of Patient Safety was administered in 2008 to all nurses and attending physicians (N = 4,283) in a 900-bed acute care hospital (overall response rate, 69% [n = 2,961]). Responses were analyzed from the 2,163 physicians and nurses (73% of respondents) who could be assigned to one specific clinical unit. Results were examined for 57 units, categorized into six types. Results Ratings of various safety climate domains differed markedly across the 57 units, with the percentage reporting a safety grade of excellent ranging from 0% to 50%. The overall percentage of positive ratings was lower for the operating and emergency unit types than for inpatient medical and other clinical units. Even within the six unit types, substantial variation across individual units was evident. Unlike previous findings, physicians reported more negative ratings than nurses for some safety climate dimensions. Conclusions Safety climate may vary markedly within hospitals. Assessments of safety climate and educational and other interventions should anticipate considerable variation across units within individual hospitals. Furthermore, clinicians at individual hospitals may offer different relative perceptions of the safety climate than their professional peers at other hospitals.

Background Maintenance of appropriate boundaries in the doctor-patient relationship is central to medical professionalism. Little is known about physician attitudes toward personal relationships with patients. Objective To explore physician attitudes toward a range of personal relationships with patients and the connection between them and other facets of professional behavior. Research design National survey by mail using a stratified random sample. Subjects Active physicians specializing in internal medicine, family medicine, pediatrics, cardiology, surgery, and anesthesiology. Measures Respondents rated the appropriateness of social, business, and sexual contacts with patients and expressed level of agreement with statements regarding other aspects of medical professionalism relating to patient welfare and professional self-regulation. Endorsement of relationships was dichotomized as never versus rarely, sometimes, often, or always appropriate. Results A total of 1662 eligible physicians responded of 3504 sampled (adjusted response rate: 58%). Support was high for social relations (91%), somewhat less for business relations (65%), and low for sexual contact (9%). Women, nonwhites, and foreign medical school graduates were less likely to support all 3 relationships. Support for sensitive relationships was associated with rejection of the primacy of patient welfare over physician financial interests (P = 0.015), providing care to indigent patients (P = 0.010), reporting medical errors (P = 0.002), and participating in peer evaluations (P = 0.002). Conclusion Physicians may perceive different types of relations with patients to fall on a continuum of potential for conflict with their professional role. Support for personal relationships was associated with physician demographic characteristics. More permissive interpersonal boundaries may be associated with weaker support for other professional standards.

e18612Background: Novel cancer research frequently involves storage of biospecimens for future use. However, ethical questions related to collection, control, and use of stored tissue persist. We s...

Understanding whether electronic health records, as currently adopted, improve quality and efficiency has important implications for how best to employ the estimated $20 billion in health information technology incentives authorized by the American Recovery and Reinvestment Act of 2009. We examined electronic health record adoption in U.S. hospitals and the relationship to quality and efficiency. Across a large number of metrics examined, the relationships were modest at best and generally lacked statistical or clinical significance. However, the presence of clinical decision support was associated with small quality gains. Our findings suggest that to drive substantial gains in quality and efficiency, simply adopting electronic health records is likely to be insufficient. Instead, policies are needed that encourage the use of electronic health records in ways that will lead to improvements in care.

Sexual dysfunction is an important issue that affects many cancer survivors who are increasingly being cared for by internists.To examine the attitudes and reported practices of internists regarding survivorship care as it pertains to sexual dysfunction.Surveys were sent to 406 physicians affiliated with the Department of Internal Medicine at the University of Colorado Denver School of Medicine. Of the 319 eligibles, 227 were returned (71% RR).Of the 227 responders, 46% were "somewhat/very" likely to initiate a conversation about sexual dysfunction; 62% "never/rarely" addressed sexual dysfunction. Each additional weekly hour spent in patient care was associated with a 2% increase in the likelihood of sexual dysfunction being addressed or discussions about sexual dysfunction being initiated. Reported inadequate preparation/formal training around survivorship issues was associated with sexual dysfunction being addressed less often (odds ratio [OR] = 0.45). Perception of patient anxiety or fears about health was associated with sexual dysfunction being addressed more often (OR = 2.38). Perceived preparedness to evaluate long-term effects was associated with a greater likelihood of physicians initiating discussions about sexual functioning (OR = 2.49).Cancer survivors receive their long-term care from internists. Our results suggest that sexual dysfunction is often not addressed during their follow-up care. Additional training is needed to prepare physicians to negotiate this difficult issue.

In 1907, Frederick Cottrell, professor of chemistry at the University of California-Berkeley and father of the modern academic patent, worried that if universities became too directly involved in p...

Despite a consensus that the use of health information technology should lead to more efficient, safer, and higher-quality care, there are no reliable estimates of the prevalence of adoption of electronic health records in U.S. hospitals.We surveyed all acute care hospitals that are members of the American Hospital Association for the presence of specific electronic-record functionalities. Using a definition of electronic health records based on expert consensus, we determined the proportion of hospitals that had such systems in their clinical areas. We also examined the relationship of adoption of electronic health records to specific hospital characteristics and factors that were reported to be barriers to or facilitators of adoption.On the basis of responses from 63.1% of hospitals surveyed, only 1.5% of U.S. hospitals have a comprehensive electronic-records system (i.e., present in all clinical units), and an additional 7.6% have a basic system (i.e., present in at least one clinical unit). Computerized provider-order entry for medications has been implemented in only 17% of hospitals. Larger hospitals, those located in urban areas, and teaching hospitals were more likely to have electronic-records systems. Respondents cited capital requirements and high maintenance costs as the primary barriers to implementation, although hospitals with electronic-records systems were less likely to cite these barriers than hospitals without such systems.The very low levels of adoption of electronic health records in U.S. hospitals suggest that policymakers face substantial obstacles to the achievement of health care performance goals that depend on health information technology. A policy strategy focused on financial support, interoperability, and training of technical support staff may be necessary to spur adoption of electronic-records systems in U.S. hospitals.

The often close relationship between academia—specifically academic medicine—and industry has been highlighted in a number of sensational stories in the popular and academic press.1–3 Often the focus of such articles is on individuals with close ties to industry, but conflicts of interest (COIs) also exist at the institutional level, and these may pose far greater threats to the integrity of science and medicine. Institutional conflicts can arise through close institutional ties to industry, via patent agreements or financial investments, for example, but can also arise through the individual conflicts of officers or others who act on behalf of the institution. One such group is members of institutional review boards (IRBs) who review and approve research protocols on behalf of the institution. These persons serve the institution, and yet are often seasoned investigators who frequently have relationships with industry. Prior research has found that some IRB members in academic medical centers receive research funding from industry or financial compensation for participation in meetings and conferences; serve as paid consultants or members of speakers’ bureaus or scientific advisory boards; serve as an officer, executive, or paid employee in industry; receive royalties or equity; or serve on a board of directors. Altogether, more than one third of IRB members may have one or more such relationship with industry in any given year.4 The ramifications of IRB members’ industry relationships and COIs are not well understood, but the perception is that the risks to IRB functions are real. For example, in 1999, at least 2000 studies involving human subjects at Duke University were suspended after the federal government determined that Duke did not adequately protect patients involved in such studies.5 Among the 20 deficiencies cited by the Office for Protection from Research Risks (now the Office of Human Research Protections, or OHRP) was that the COIs of senior level administrators at Duke had compromised the ability of the IRB to make independent and unbiased decisions regarding research protocols. The concern over the potential impact of industry relationships on institutional and IRB decisions with regard to medical research has led to a number of discussions and recommendations from both federal and non-federal organizations6–8, with the most recent report issued by a joint Association of American Medical Colleges (AAMC) and Association of American Universities (AAU) advisory committee in February 2008. 9 However, despite the promulgation of federal guidance by the U.S. Department of Health and Human Services,10 there are currently no regulatory requirements placed on IRBs. Current Federal regulations state only that IRB members may not participate in discussions or decisions on any protocol in which they may have a conflicting interest, except to provide information.10(45 CFR 46.107e) This policy provides no standards on what constitutes a meaningful COIs, nor does it suggest policies and procedures to protect IRB-related activities from conflicts. The most recent recommendation by the joint AAMC-AAU advisory committee asks institutions to require the routine reporting of data on all financial interests from all IRB members and to establish clear policies for defining COIs, but lacks a concrete recommendation about who should be responsible for these activities within the institution.9 Establishing a Conflict of Interest Committee, separate from the IRB, is one possible approach suggested by the National Human Research Protections Advisory Committee in their comments to the Deputy Assistant Secretary for Health on draft interim guidance in 2001.11 This recommendation was based in part on an internal investigation by the National Institutes of Health (NIH), which found that only 25% of all IRBs routinely deal with investigators’ and IRB members’ industry relationships and financial COIs during IRB deliberations.12 There is no recent data on the management of conflicts during deliberations, or other tactics IRBs use to manage relationships and COIs prior to final deliberations. This study seeks to provide information on IRB-specific policies and practices with regard to industry relationships and conflicts, and to determine if current policies and procedures are consistent with existing federal guidance. This study examines how IRBs at the most research-intensive medical institutions in the United States manage industry relationships and COIs among their members, and whether IRB chairs feel that current policies are sufficient to ensure the integrity of the IRB’s activities.

Some hospitals that disproportionately care for poor patients are falling behind in adopting electronic health records (EHRs). Data from a national survey indicate early evidence of an emerging digital divide: U.S. hospitals that provide care to large numbers of poor patients also had minimal use of EHRs. These same hospitals lagged others in quality performance as well, but those with EHR systems seemed to have eliminated the quality gap. These findings suggest that adopting EHRs should be a major policy goal of health reform measures targeting hospitals that serve large populations of poor patients.

BACKGROUND Electronic health records have the potential to improve the delivery of health care services. However, in the United States, physicians have been slow to adopt such systems. This study assessed physicians' adoption of outpatient electronic health records, their satisfaction with such systems, the perceived effect of the systems on the quality of care, and the perceived barriers to adoption. METHODS In late 2007 and early 2008, we conducted a national survey of 2758 physicians, which represented a response rate of 62%. Using a definition for electronic health records that was based on expert consensus, we determined the proportion of physicians who were using such records in an office setting and the relationship between adoption and the characteristics of individual physicians and their practices. RESULTS Four percent of physicians reported having an extensive, fully functional electronic-records system, and 13% reported having a basic system. In multivariate analyses, primary care physicians and those practicing in large groups, in hospitals or medical centers, and in the western region of the United States were more likely to use electronic health records. Physicians reported positive effects of these systems on several dimensions of quality of care and high levels of satisfaction. Financial barriers were viewed as having the greatest effect on decisions about the adoption of electronic health records. CONCLUSIONS Physicians who use electronic health records believe such systems improve the quality of care and are generally satisfied with the systems. However, as of early 2008, electronic systems had been adopted by only a small minority of U.S. physicians, who may differ from later adopters of these systems.

[I]n the beginning [of my career], it was just two or three authors. I think that part has changed dramatically.... I think, in part, the change is due to the complexity.... In order to carry out your projects, no one person, sometimes not even one group, will have all of the techniques, the skills, that are necessary to really answer a particular question. Fifteen years back scientists could have one or two papers in a year. That [was] considered to be productive.... Science is getting more complicated. You cannot possibly finish a big project by yourself and without cooperation with others. The senior faculty members quoted above acknowledge that scientific authorship has changed enormously in the past few decades. Recent competing forces create situations in which the usual "rules" of authorship in science are tested. Graduate students, postdoctoral fellows, and junior faculty move in and out of labs over the course of a research project. International collaboration, contextual factors specific to a lab, a particular line of research, the critical importance of first-author and last-author status in hiring and promotion processes, and variations in institutional and disciplinary statements about authorship all bear on the decisions made by individual scientists. While there is substantial consensus on the most general authorship-related guidelines, how credit should actually be assigned is less clear. Fraud, fabrication, and plagiarism are the focus of attention by the media, professional associations, and the government, but little consideration has been given to the ethical tensions faced by faculty as they try to do the right thing in allocating credit for work that is being done. Authorship decisions increasingly require juggling the pressures of uncertain funding environments; regulations developed by journals, universities, and funding agencies; and the expectations of those who have worked on the research underlying any particular paper. Our article is drawn from a larger study of everyday ethical dilemmas faced by university scientists. We examine how the increasing complexity of science is affecting conventions of authorship assignment on published papers and how scientists resolve ambiguity among competing values in their research settings. Specifically, we focus on how scientists employ a combination of professional guidelines and situation-specific interpretations to address dilemmas that they face in assigning credit on publications. Background and Literature Review The major change that has occurred in the basic sciences in recent years is a dramatic increase in the number of authors on each paper (Barker & Powell, 1997; Kyvik, 2003). This shift has created tensions in authorship assignment that have resulted in a recent outpouring of concern (Council of Science Editors, 2000), as well as attempts to tighten authorship standards. In this section, we look first at investigations of the practical dimensions of the problem--emerging tensions and current institutional responses. We then examine the deeper issue of scientific and scholarly values in investigations of the professional and social expectations that govern the behavior of scientists. Authorship Tensions Issues related to authorship extend beyond disciplinary boundaries and relate to intellectual ownership and the competitive nature of the academic enterprise. Authorship has consequences for individuals, in that academic researchers are awarded funding, prestige, prizes, promotion, and tenure based almost exclusively on their publication history (Wilcox, 1998). There are, of course, also system-level effects of authorship, because authorship helps to regulate scientific activity by establishing "accountability, responsibility, and credit for scientific information reported in [scientific] publications" (Flanagin et al., 1998, p. 222; Smith, 1997a, 1997b). …

This article focuses on the experiences of graduate students and postdoctoral fellows in science. Our interest in this population is based on the assumption that today’s graduate students and postdoctoral fellows represent the future of the university. The socialization of potential scientists begins when they are undergraduates, but it is during their period of formal training and apprenticeship that they learn both the values and skills that are needed to make an effective transition to leadership in their fields. Their experiences as students confront them with increasing pressures that arise out of many factors, ranging from stable or declining government funding to the rapidly changing expectations related to collaboration and entrepreneurship (Etzkowitz & Leydesdorff, 2000). As a consequence, we view graduate and postdoctoral students as “canaries in the mine.” One indicator that the scientific enterprise is healthy is that these students are productive and are acquiring the values and norms that will allow them to participate fully and interactively as scientists. If their socialization is not effective, they may not be learning how to be “good scientists.”

Relationships between physicians and pharmaceutical, medical device, and other medically related industries have received considerable attention in recent years. We surveyed physicians to collect information about their financial associations with industry and the factors that predict those associations.We conducted a national survey of 3167 physicians in six specialties (anesthesiology, cardiology, family practice, general surgery, internal medicine, and pediatrics) in late 2003 and early 2004. The raw response rate for this probability sample was 52%, and the weighted response rate was 58%.Most physicians (94%) reported some type of relationship with the pharmaceutical industry, and most of these relationships involved receiving food in the workplace (83%) or receiving drug samples (78%). More than one third of the respondents (35%) received reimbursement for costs associated with professional meetings or continuing medical education, and more than one quarter (28%) received payments for consulting, giving lectures, or enrolling patients in trials. Cardiologists were more than twice as likely as family practitioners to receive payments. Family practitioners met more frequently with industry representatives than did physicians in other specialties, and physicians in solo, two-person, or group practices met more frequently with industry representatives than did physicians practicing in hospitals and clinics.The results of this national survey indicate that relationships between physicians and industry are common and underscore the variation among such relationships according to specialty, practice type, and professional activities.

Objective The Accreditation Council for Graduate Medical Education measures surgical residents’ experience in the United States by mandating that residents log each procedure in which they have participated. This system is the primary mechanism by which breadth and depth of surgical training are documented, and data are used for program accreditation and by individual program directors to assess resident preparedness. The study objective was to learn from residents across surgical specialties how this system is being used, and whether they believe these data are reliable. Design Investigators developed and administered a voluntary, 45-item survey. Resident demographic data, program details, logging behaviors, and attitudes were examined using descriptive statistics. Authors used multivariate logistic regression to assess respondent and program characteristics associated with logging habits. Setting The survey was administered at a large academic medical center. Participants All general surgery, obstetrics and gynecology, orthopedics, urology, neurosurgery, otolaryngology, and plastic surgery residents were eligible. Of 126 surgical residents, 82 participated, yielding a response rate of 65%. Results Overall, 7.5% considered the case log system highly inaccurate, 28.8% somewhat inaccurate, 52.5% somewhat accurate, and 11.3% highly accurate. Nearly half (48.1%) use an incorrect metric to log their role as surgeon or assistant. Half logged monthly or less frequently. The longest time residents reported falling behind ranged from less than a week to more than a year, with about half (51.4%) reporting backlogs of 3 months or longer. Approximately two-thirds considered the system difficult to navigate (64.2%) and burdensome (68.8%). Departmental training and reminders to log were associated with high fidelity logging habits. Conclusions Inconsistency of logging habits and perceived lack of accuracy raise concerns about use of the system for assessing surgical preparedness or accrediting training programs. Academic departments playing an active role may benefit from more reliable data to guide improvements in surgical training.

The conflicts of interest that may arise in relationships between academic researchers and industry continue to prompt controversy. The bulk of attention has focused on financial aspects of these relationships, but conflicts may also arise in the legal obligations that faculty acquire through consulting contracts. However, oversight of faculty members' consulting agreements is far less vigorous than for financial conflicts, creating the potential for faculty to knowingly or unwittingly contract away important rights and freedoms. Increased regulation could prevent this, but it is unclear what forms of oversight universities view as feasible and effective. In this article, we report on a Delphi study to evaluate several approaches for oversight of consulting agreements by medical schools. The panel was comprised of 11 senior administrators with responsibility for oversight of faculty consulting relationships. We found broad agreement among panelists regarding the importance of institutional oversight to protect universities' interests. There was strong support for two specific approaches: providing educational resources to faculty and submitting consulting agreements for institutional review. Notwithstanding the complexities of asserting authority to regulate private consulting agreements between faculty members and companies, medical school administrators reached consensus that several approaches to improving institutional oversight are feasible and useful.

For the past decade, more attention and concern has been directed toward financial relationships between the life science industry and physicians. Relationships between industry and institutional review board (IRB) members represent an important subclass that has the potential to broadly influence decisions regarding medical research.To study the nature, extent, and perceived consequences of industry relationships among IRB members in academic health centers and to compare our results with findings from 2005.A survey mailed to IRB members from the 115 most research-intensive medical schools and teaching hospitals in the United States from January 16 through May 16, 2014. The survey included questions identical to those used in 2005. Data analysis was conducted from June through October 2014.The frequency of industry relationships among IRB members and the perceived effect of those relationships on IRB-related activities.We found no significant change in the percentage of IRB members with an industry relationship from 2005 through 2014 (2005: 37.2%; 95% CI, 32.7%-42.0%; 2014: 32.1%; 95% CI, 28.0%-36.4%; P = .09). However, since 2005, the percentage of members who felt another member did not properly disclose a financial relationship decreased from 10.8% (95% CI, 8.0%-14.4%) to 6.7% (95% CI, 4.7%-9.4%) (P = .04), as did the percentage who felt pressure from their institution or department to approve a protocol (2005: 18.6%; 95% CI, 15.0%-22.9%; 2014: 10.0%; 95% CI, 7.6%-13.0%; P .001). The percentage of members with a conflict of interest who voted on protocols with which they have a conflict has not changed, although the percentage who said they always disclose relationships increased significantly from 54.9% in 2005 (95% CI, 42.2%-66.9%) to 80.0% in 2014 (95% CI, 65.3%-89.4%) (P = .01). We also found evidence of anti-industry bias in the presentation of protocols to the IRB.The results show significant positive progress in the reporting and management of conflicts of interest among IRB members in academic health centers since 2005 after adjusting for other factors. Additional attention should be focused on deterring IRB members from inappropriately voting on or presenting protocols in a biased manner.

When the US FDA approves a new prescription drug there is still a great deal remaining to be learned about the safe and proper use of that product. When new information addressing these topics emerges post-approval, the FDA may issue a Drug Safety Communication (DSC) to alert patients and physicians. The effectiveness of the communication-how drug safety messaging conveyed in FDA DSCs changes patient or prescriber behavior-may depend on multiple factors, including the way physicians and patients learn about the information, their understanding of the issues conveyed, and their perception of the importance of the information. In 2013, the FDA issued two DSCs addressing critical new warnings related to products containing the sedative/hypnotic zolpidem.In this article, we describe a core set of research initiatives that can be used to study how zolpidem-related DSCs affected subsequent physician and patient decision making.These research initiatives include analyzing drug utilization patterns and related health outcomes; comparing zolpidem-containing products against a comparator with similar indications [eszopiclone (Lunesta)] not covered by the 2013 DSCs; and surveying patients and qualitatively evaluating the dissemination of information regarding these drugs in traditional and social-media channels.Using an integrated, multidisciplinary approach, we can obtain information that can be used to optimize regulatory communications by seeking to understand the impact of the information contained in FDA risk communications.

Context:Interest in the measurement of organizational culture that supports patient safety has grown among health care providers.Objective:To review available quantitative instruments for the assessment of patient safety culture.Methods:Surveys were identified through a systematic review, which incl

A productive and ethical relationship between the pharmaceutical industry and physicians is critical to improving drug discovery and public health. In response to concerns about inappropriate financial relationships between the pharmaceutical industry and physicians, national organizations representing physicians or industry have made recommendations designed to reduce conflicts of interest, legal exposure, and dissemination of biased information. Despite these initiatives, the prescribing practices of physicians may be unduly influenced by the marketing efforts of industry and physicians may inadvertently distribute information that is biased in favor of a commercial entity. Moreover, physicians may be vulnerable to prosecution through federal anti-kickback and false claims statutes because of potentially inappropriate financial relationships with pharmaceutical companies. Since academic medical centers have a critical role in establishing professional standards, the faculty of Yale University School of Medicine developed guidelines for the relationships of faculty with the pharmaceutical industry, which were approved in May 2005. Input from clinical faculty and from representatives of the pharmaceutical industry was utilized in formulating the guidelines. In contrast to existing recommendations, the Yale guidelines, which are presented as an Appendix here, ban faculty from receiving any form of gift, meal, or free drug sample (for personal use) from industry, and set more stringent standards for the disclosure and resolution of financial conflict of interest in Yale's educational programs. The growing opportunities for drug discovery, the need to use medications in a more evidence-based manner, and preservation of the public trust require the highest professional standards of rigor and integrity. These guidelines are offered as part of the strategy to meet this compelling challenge.

Clinical trials are also becoming larger and more complex, with an increasing number of trials enrolling thousands of patients across multiple centres in multiple countries. To comply with the requirements of the Declaration of Helsinki, all experimental procedures that involve humans must be assessed and approved by an appropriately constituted research ethics committee (REC). 2 As the amount

The transfer and subsequent application of academic research results has demonstrable benefits for health care, researchers, universities, companies, and local economies. Nonetheless, at least three general concerns exist: bias in the reporting of results, limited revenues from these activities, and the lack of data to evaluate technology transfer activities. Future efforts with regard to technology transfer in the life sciences will need to recognize its importance without ignoring concerns or overestimating benefits. Next steps include better monitoring of university-industry relationships, the development of a better data system, the dissemination of best practices in technology transfer management, and evaluation of national technology-transfer policies.

A survey of 306 homeless adult smokers in Boston shows that they spent a mean of $44 per week on tobacco, which represented about one third of their total income. Higher levels of nicotine dependence were associated with greater difficulty meeting basic needs for subsistence.

Background The authors’ previous study found that despite caring for many patients with addiction, most Massachusetts General Hospital (MGH) internal medicine residents feel unprepared to treat substance use disorders (SUDs) and rate SUD instruction during training as fair or poor. This follow-up study evaluates the impact of an enhanced curriculum on resident perceptions of the quality of instruction, knowledge base, and self-perceived preparedness to diagnose and treat SUDs. Methods Based on the findings of the earlier study, an enhanced SUD curriculum was designed and delivered to MGH medicine residents. Impact of the curriculum was evaluated using the same Web-based survey that was administered in the earlier study to compare pre- and posttest results. Results The authors’ earlier study found that 75% of residents felt prepared to diagnose and 37% to treat SUDs and 45% of residents rated the overall quality of SUD instruction as good or excellent. Following the curriculum intervention, 87% of residents reported feeling prepared to diagnose ( P = .028) and 60% to treat ( P = .002) SUDs. Three quarters of residents rated the overall quality of instruction as good or excellent ( P < .001), and 98% reported residency curriculum had a positive impact on their preparedness to care for patients with a SUDs. Residents who reported receiving an adequate amount of SUD instruction were more likely to feel prepared to diagnose and treat addiction ( P < .001). Thirty-one percent of residents still rated the overall amount of SUD instruction as too little. The intervention did not significantly improve answers to knowledge questions. Conclusions An enhanced SUDs curriculum for medicine residents increased self-perceived preparedness to diagnose and treat SUDs and educational quality ratings. However, there was no significant change in knowledge. Implementation of a more comprehensive curriculum and evaluation at other sites are necessary to determine the ideal SUD training model.

Aaron Kesselheim and colleagues compared US medical students' survey responses regarding pharmaceutical company interactions with the schools' AMSA PharmFree scorecard and Institute on Medicine as a Profession's (IMAP) scores. Please see later in the article for the Editors' Summary, Background Professional societies use metrics to evaluate medical schools' policies regarding interactions of students and faculty with the pharmaceutical and medical device industries. We compared these metrics and determined which US medical schools' industry interaction policies were associated with student behaviors. Methods and Findings Using survey responses from a national sample of 1,610 US medical students, we compared their reported industry interactions with their schools' American Medical Student Association (AMSA) PharmFree Scorecard and average Institute on Medicine as a Profession (IMAP) Conflicts of Interest Policy Database score. We used hierarchical logistic regression models to determine the association between policies and students' gift acceptance, interactions with marketing representatives, and perceived adequacy of faculty–industry separation. We adjusted for year in training, medical school size, and level of US National Institutes of Health (NIH) funding. We used LASSO regression models to identify specific policies associated with the outcomes. We found that IMAP and AMSA scores had similar median values (1.75 [interquartile range 1.50–2.00] versus 1.77 [1.50–2.18], adjusted to compare scores on the same scale). Scores on AMSA and IMAP shared policy dimensions were not closely correlated (gift policies, r = 0.28, 95% CI 0.11–0.44; marketing representative access policies, r = 0.51, 95% CI 0.36–0.63). Students from schools with the most stringent industry interaction policies were less likely to report receiving gifts (AMSA score, odds ratio [OR]: 0.37, 95% CI 0.19–0.72; IMAP score, OR 0.45, 95% CI 0.19–1.04) and less likely to interact with marketing representatives (AMSA score, OR 0.33, 95% CI 0.15–0.69; IMAP score, OR 0.37, 95% CI 0.14–0.95) than students from schools with the lowest ranked policy scores. The association became nonsignificant when fully adjusted for NIH funding level, whereas adjusting for year of education, size of school, and publicly versus privately funded school did not alter the association. Policies limiting gifts, meals, and speaking bureaus were associated with students reporting having not received gifts and having not interacted with marketing representatives. Policy dimensions reflecting the regulation of industry involvement in educational activities (e.g., continuing medical education, travel compensation, and scholarships) were associated with perceived separation between faculty and industry. The study is limited by potential for recall bias and the cross-sectional nature of the survey, as school curricula and industry interaction policies may have changed since the time of the survey administration and study analysis. Conclusions As medical schools review policies regulating medical students' industry interactions, limitations on receipt of gifts and meals and participation of faculty in speaking bureaus should be emphasized, and policy makers should pay greater attention to less research-intensive institutions. Please see later in the article for the Editors' Summary, Editors' Summary Background Making and selling prescription drugs and medical devices is big business. To promote their products, pharmaceutical and medical device companies build relationships with physicians by providing information on new drugs, by organizing educational meetings and sponsored events, and by giving gifts. Financial relationships begin early in physicians' careers, with companies providing textbooks and other gifts to first-year medical students. In medical school settings, manufacturers may help to inform trainees and physicians about developments in health care, but they also create the potential for harm to patients and health care systems. These interactions may, for example, reduce trainees' and trained physicians' skepticism about potentially misleading promotional claims and may encourage physicians to prescribe new medications, which are often more expensive than similar unbranded (generic) drugs and more likely to be recalled for safety reasons than older drugs. To address these and other concerns about the potential career-long effects of interactions between medical trainees and industry, many teaching hospitals and medical schools have introduced policies to limit such interactions. The development of these policies has been supported by expert professional groups and medical societies, some of which have created scales to evaluate the strength of the implemented industry interaction policies. Why Was This Study Done? The impact of policies designed to limit interactions between students and industry on student behavior is unclear, and it is not known which aspects of the policies are most predictive of student behavior. This information is needed to ensure that the policies are working and to identify ways to improve them. Here, the researchers investigate which medical school characteristics and which aspects of industry interaction policies are most predictive of students' reported behaviors and beliefs by comparing information collected in a national survey of US medical students with the strength of their schools' industry interaction policies measured on two scales—the American Medical Student Association (AMSA) PharmFree Scorecard and the Institute on Medicine as a Profession (IMAP) Conflicts of Interest Policy Database. What Did the Researchers Do and Find? The researchers compared information about reported gift acceptance, interactions with marketing representatives, and the perceived adequacy of faculty–industry separation collected from 1,610 medical students at 121 US medical schools with AMSA and IMAP scores for the schools evaluated a year earlier. Students at schools with the highest ranked interaction policies based on the AMSA score were 63% less likely to accept gifts as students at the lowest ranked schools. Students at the highest ranked schools based on the IMAP score were about half as likely to accept gifts as students at the lowest ranked schools, although this finding was not statistically significant (it could be a chance finding). Similarly, students at the highest ranked schools were 70% less likely to interact with sales representatives as students at the lowest ranked schools. These associations became statistically nonsignificant after controlling for the amount of research funding each school received from the US National Institutes of Health (NIH). Policies limiting gifts, meals, and being a part of speaking bureaus (where companies pay speakers to present information about the drugs for dinners and other events) were associated with students' reports of receiving no gifts and of non-interaction with sales representatives. Finally, policies regulating industry involvement in educational activities were associated with the perceived separation between faculty and industry, which was regarded as adequate by most of the students at schools with such policies. What Do These Findings Mean? These findings suggest that policies designed to limit industry interactions with medical students need to address multiple aspects of these interactions to achieve changes in the behavior and attitudes of trainees, but that policies limiting gifts, meals, and speaking bureaus may be particularly important. These findings also suggest that the level of NIH funding plays an important role in students' self-reported behaviors and their perceptions of industry, possibly because institutions with greater NIH funding have the resources needed to implement effective policies. The accuracy of these findings may be limited by recall bias (students may have reported their experiences inaccurately), and by the possibility that industry interaction policies may have changed in the year that elapsed between policy grading and the student survey. Nevertheless, these findings suggest that limitations on gifts should be emphasized when academic medical centers refine their policies on interactions between medical students and industry and that particular attention should be paid to the design and implementation of policies that regulate industry interactions in institutions with lower levels of NIH funding. Additional Information Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001743. The UK General Medical Council provides guidance on financial and commercial arrangements and conflicts of interest as part of its good medical practice document, which describes what is required of all registered doctors in the UK Information about the American Medical Student Association (AMSA) Just Medicine campaign (formerly the PharmFree campaign) and about the AMSA Scorecard is available Information about the Institute on Medicine as a Profession (IMAP) and about its Conflicts of Interest Policy Database is also available “Understanding and Responding to Pharmaceutical Promotion: A Practical Guide” is a manual prepared by Health Action International and the World Health Organization that medical schools can use to train students how to recognize and respond to pharmaceutical promotion The US Institute of Medicine's report “Conflict of Interest in Medical Research, Education, and Practice” recommends steps to identify, limit, and manage conflicts of interest The ALOSA Foundation provides evidence-based, non-industry-funded education about treating common conditions and using prescription drugs

We evaluated whether primary care physicians (PCPs) from urban and rural practices differ on attitudes and behaviors related to quality improvement (QI) activities, patient relationships, and professionalism/self-regulation.Data from a national survey that assessed physician attitudes and behaviors based on the Physician Charter on Medical Professionalism were used. Of the 1,891 survey respondents, N = 840 were PCPs (n = 274 family medicine (response rate = 67.5%); n = 257 general internal medicine (60.8%); and n = 309 pediatricians (72.7%)). Using Rural-Urban Commuting Area (RUCA) codes, PCPs were classified as urban and rural according to their practice ZIP code.A total of n = 691 physicians were urban and n = 127 rural. Attitudes regarding participating in QI did not differ by practice location; however, rural PCPs were more likely to have reviewed an other physician's records for QI than urban PCPs (65.6% vs 48.0%, P.001). Rural physicians were more likely to agree that physicians should talk with their patients about the cost of care than urban PCPs (40.5% vs 29.2%, P = .02). While all PCPs endorsed attitudes regarding the importance of professional behaviors (eg, reporting impaired/incompetent colleagues, disclosing medical errors) at generally similar levels, their behaviors differed. More rural physicians had a personal knowledge of an impaired/incompetent physician than urban physicians (20.7% vs 12.7%, P = .02).PCPs from rural and urban areas share similar attitudes regarding the importance of participating in QI and fulfilling professional responsibilities. However, certain behaviors (eg, knowledge of impaired colleagues) do differ. These results should be confirmed in larger studies of rural PCPs.

Purpose. To understand the effect of market competition on patient-oriented research at U.S. medical schools and teaching hospitals. Method. From a multi-stage stratified, random sample, the authors surveyed 3,804 research faculty at 117 U.S. medical schools. The questionnaire assessed five variables, the type of research conducted by the respondent, changes in patient-oriented and non-clinical research in the preceding three years, amount of time spent on patient care, market stage of the respondent's institution, and research productivity. Results. Of the 2,336 faculty who responded (62%), 84% of those conducting patient-oriented research and 80% of those engaged in non-clinical research reported conducting the same amount of research or more in 1996–1997 than in the preceding three years. However, both patient-oriented and non-clinical researchers in the most competitive health care markets and those with high levels of patient care duties were most likely to report decreases in the amounts of such research conducted in the previous three years. Further, researchers reporting such decreases had been as productive in recent years and over their careers as had those who did not report a decrease. Conclusions. This study provides additional evidence of the negative relationships that exist between high levels of market competition and patient care services on the patient-oriented and non-clinical research missions of teaching hospitals.

This paper addresses research in the life sciences, responsible for significant national expenditures for scientific investigations funded by both the federal government and industry. Our investigation examines faculty members' involvement with industry in “entrepreneurial” ways that is, involved in translating their research into potentially marketable knowledge or products. First, this study examines whether there are differences in entrepreneurial behaviour between clinical and non-clinical faculty in the life sciences with industry relationships, and, second, to discover any linkage between entrepreneurship and secrecy or productivity in different ways for clinical and non-clinical faculty. The study is based on survey responses of a national sample of 4,000 clinical and non-clinical life sciences faculty in 49 U.S. research universities. The results show non-clinical faculty as more involved at the back end. The more entrepreneurial end of commercialization while clinical faculty are involved at the back end. The more entrepreneurial faculty (non-clinical) are more likely to be secretive about their research. Clinical faculty are less likely to have been denied access to research results or products. Entrepreneurial faculty are not less productive in their faculty roles. This investigation is preliminary in that it addresses one large area of academic research but excludes fields with longer historical relationships with industry.

Academic industry relationships (AIRs) in biotechnology are part of the modern life science economy. They cannot and should not be prevented. But their benefits should not be exaggerated, nor their risks minimized or ignored. It is essential that these relationships be understood, monitored, and managed in a manner that protects the investments and the integrity of involved individuals, institutions, and science in general. Failure to do so could result in loss of public confidence and support for research enterprise - a priceless resource whose integrity and independence are critical to the future of the scientific endeavor.

The sharing and withholding of research results is a topic of intense debate within the scientific community. However, few studies have addressed this issue. This study examines how frequently academic scientists are denied access to other investigators' research results and the characteristics of faculty who are most likely to have this experience. This paper is based on data from a mailed survey of a stratified, random sample of faculty in 117 US medical schools (n=2366, response rate 62.2%) conducted in 1996–1997. The results show that 12.5% of researchers in medical schools have been denied access to other academic investigators' data within the last 3 years. Researchers who were most likely to be victims of data withholding were those who have withheld research results from others, published more than 20 articles in the last 3 years, to have applied for a patent, or spent more than 40 hours per week in research activities.