To the Editor: “Is the public likely to benefit if practicing physicians and medical educators must perform their duties amidst the clamor and striving of merchants seeking to increase the sales of drugs by conscripting ‘education’ in the service of promotion?” Charles May, MD,1 penned this in 1961, but it could just as easily have appeared today. The recent findings of Sierles and colleagues2 are both a cause for cautious optimism and a call for more aggressive action in the ongoing discussion of interactions between physicians and the pharmaceutical industry. Sierles and colleagues make an important distinction about where pharmaceutical marketing exposure is taking place: teaching sites outside the academic medical center (AMC). At the University of Washington, we surveyed first-year students placed in medically underserved settings for a summer clinical immersion. We learned that by the end of their first year, over one-third had already eaten an industry-sponsored meal. Further supporting the findings of Sierles and colleagues about off-campus exposure, we discovered that student exposure to pharmaceutical sales representatives was greater in rural than in urban settings. Timing of exposure is also an important consideration. Although Sierles and colleagues focus on third-year medical students, medical students can be exposed to off-campus pharmaceutical industry marketing much earlier—even before they matriculate. For example, the increased emphasis admissions committees have placed on prematriculation physician shadowing means that premedical students may be exposed to pharmaceutical marketing before they are equipped to evaluate the ethical implications of this entanglement between doctors and industry. After enrollment, office-based preceptorships and early clinical immersions are additional areas worthy of attention. Off-campus experiences in community settings may limit the impact of conflict-of-interest (COI) policies and place students in ethically uncomfortable situations. We echo Sierles and colleagues’ call for early and frequent training on the role of the pharmaceutical industry in health care, and we agree that AMCs should consider revising their relevant COI policies to extend to off-campus learning environments. David V. Evans, MD Rosenblatt Family Endowed Professor in Rural Health and associate professor, Department of Family Medicine, University of Washington School of Medicine, Seattle, Washington; [email protected] Laurel Desnick, MD Clinical associate professor, Department of Medicine, University of Washington School of Medicine, Seattle, Washington. Toby Keys, MPH Education specialist, Department of Family Medicine, University of Washington School of Medicine, Seattle, Washington.

BACKGROUND AND OBJECTIVES:Pharmaceutical marketing techniques are effective in changing the behavior of health care providers in ways that deviate from evidence-based practices. To mitigate the influence of pharmaceutical marketing on learners, academic medical centers (AMCs) have adopted policies to limit student/industry interaction. Many clinical experiences occur outside of the AMC. The purpose of this study was to compare medical students' exposure to pharmaceutical marketing in off-campus rural and urban underserved clinical sites.METHODS:The University of Washington School of Medicine Rural and Underserved Opportunities Program (RUOP) places rising second-year medical students in underserved clinical sites in five northwestern states. We surveyed RUOP students to evaluate their exposure to pharmaceutical marketing.RESULTS:Of 120 students, 86 (72%) completed surveys. Sixty-five (76%) did their RUOP rotation in rural areas. Students in rural locations were more likely to report exposure to pharmaceutical marketing. Distribution of free drug samples was reportedly three times higher in rural than urban sites (54% versus 15%). Doctors meeting with sales representatives were reported as four times higher in rural clinics (40% versus 10%).CONCLUSIONS:Students at rural sites reported exposure to pharmaceutical marketing more than those in urban settings. Rural medical educators should provide faculty development for community clinicians on the influences of pharmaceutical marketing on learners. Medical schools must review local clinic and institution-wide policies to limit pharmaceutical marketing exposure to learners in the rural learning environment.

Abstract Introduction For the past 14 years, the University of Washington's Rural/Underserved Opportunities Program (RUOP) has offered rising second-year students a public health community externsh...

Objective. Pain concerns are one of the leading causes of visits to primary care. However, practicing physicians find managing pain frustrating and complex. There is little information about how undergraduate medical students approach pain and its management. This study aimed to explore first-year medical students' perceptions of pain-related patient encounters in the primary care setting.Design. Qualitative analysis was used to explore first-year students' reflective journals written during an early clinical experience in primary care. Using iterative process for text analysis, entries referencing pain-related encounters were coded by two independent researchers with 94% inter-rater reliability. Themes and categories were sought by immersion crystallization.Results. Three themes emerged from the students' journals: positive, negative, and neutral perceptions of pain-related encounters. With further analysis of the journals, acute, chronic, end-of-life, iatrogenic, and emotional pain categories also emerged. Most journal entries were negative, and chronic pain generated the most negativity.Conclusions. First-year medical students identified pain as a major concern in their early clinical experience. Students' perceptions of pain-related encounters can inform curriculum design and may ultimately benefit both physicians and the patients.

The concepts and tools clinicians use to understand disease and treat patients are the direct product of basic and applied scientific inquiry. To prepare physicians to participate in this tradition of medical science, the University of Washington School of Medicine (UWSOM) created a research requirement in 1981. The objective was to provide students, during their clinical years of medical school, with first-hand experience in hypothesis-driven inquiry and an understanding of the philosophies and methods of science integral to the practice of medicine. A comprehensive curriculum review in 1998-2000 identified several limitations of this requirement. Although many students completed it successfully, others struggled to find mentors, funding, or time as coursework became more demanding. Other students found they had no interest in or aptitude for the research process itself. Accordingly, UWSOM has reaffirmed its commitment to independent inquiry but expanded the ways in which students can meet the requirement. Three research options are now available under the Independent Investigative Inquiry (III) program, generally completed the summer after students' first year of medical school. These are the hypothesis-driven inquiry, a critical review of the literature, or an experience-driven inquiry in community medicine. The goal of UWSOM is to shape new physicians who can manage rapidly changing medical science, information technology, and patient expectations in clinical practice and/or laboratories. The role of III is to teach students to develop personal methods of acquiring new knowledge and integrate it into their professional lives. Faculty support, program oversight, and funding have been increased.