DRUG COMPANY MARKETING & PHYSICIAN PRESCRIBING BIAS
We physicians tend to be a rather independent lot, and most of us would like to believe that we prescribe treatments to patients based purely upon the best available objective clinical evidence.
Although there are far fewer doctors who are accepting golfing vacations, or other expensive gifts, from drug companies these days, the pharmaceutical industry still spends billions of dollars every year on marketing outreach activities directed at physicians. These costly promotional activities include frequent sales rep visits to doctors’ offices, the sponsorship of free medical education activities for physicians, the provision of free meals to doctors and their staff, as well as free trinkets (including pens and other inexpensive items containing product logos), and, yes, the occasional vacation thinly disguised as a “continuing medical education” opportunity. Additionally, physicians with specialty expertise in certain areas are often compensated to deliver dinner lectures to other physicians, with the lecture content provided solely by the sponsoring drug or medical device manufacturer.
In years past, these sorts of interactions between physicians and the drug and medical device industries were considered to be completely acceptable, and both physicians and these industries blithely maintained that clinical treatment decisions were not being altered, in the least, by the cozy and often lucrative relationships that doctors enjoyed with these deep-pocketed companies. However, more recently, there has been a growing sense within the medical community that these costly marketing outreach activities by drug and medical device companies probably do influence physicians and surgeons to change their patient care decisions. These still-evolving views have been receiving increased exposure in recent articles and editorials in major U.S. newspapers, including the New York Times, and these reports have often focused upon individual and prominent physicians and surgeons who have apparently been swayed in favor of certain drugs and surgical implants by their fiduciary relationship with the very same companies that produce and market these medical products. As a result of the growing number of such reports (in both the lay press and the medical press), an increasing number of health care organizations and physician advocacy groups have recently come out on record as opposing physician participation in activities that involve the transfer of money or other “high-value” services or gifts from drug and medical device manufacturers. But old habits die hard, and many physicians continue to enthusiastically embrace drug company marketing activities, and the gifts that often accompany such activities.
An intriguing new study, just published in the Archives of Internal Medicine, adds to a growing body of research literature suggesting that even gifts of nominal value probably influence physician decision-making when it comes to prescribing medications. In this innovative randomized, prospective, controlled study, 352 third-year and fourth-year medical students at two different U.S. medical schools were selected to participate in an ongoing and prospective review of their drug prescribing attitudes. The two medical schools were specifically selected due to their very different policies towards drug company marketing and promotional activities. One of the medical schools had very restrictive policies in place that discouraged interactions with drug company sales reps, while the other medical school had very liberal policies in place regarding interactions between medical personnel and drug company sales reps.
Some of these medical student volunteers (the treatment group) were intentionally exposed to typical promotional activity interactions with drug company sales reps, including the distribution of inexpensive promotional gifts, such as ink pens and other typical logo-emblazoned drug company trinkets. During the course of this study, the medical students in the “treatment group” were not informed that their interactions with drug company sales reps were actually a part of the clinical research study of drug prescribing attitudes that they had volunteered to participate in!
The treatment group of medical students at each medical school was intentionally exposed to promotional visits from sales reps for the drug Lipitor, a cholesterol-lowering statin drug, while the other group of students (the control group) was not exposed to any such marketing visits. I should point out that Lipitor (atorvastatin) is still protected by patent, and as such, it is an expensive drug, while the other statin that was assessed in this research study, Zocor (simvastatin), has recently gone off patient, and is now available as a much less expensive prescription drug alternative to Lipitor.
The 352 medical students, from both the study’s treatment groups and control groups, were all subsequently tested for their attitudes towards prescribing either Lipitor or Zocor, using a previously validated test known as the Implicit Association Test.
Among the fourth-year students in the treatment group at the permissive medical school, exposure to promotional activities sponsored by Lipitor sales reps (including the distribution of inexpensive promotional items) significantly increased these students’ implicit preference, by a margin of almost 20 percent, for prescribing Lipitor over the less expensive generic statin drug (Zocor), when compared to the students at the same school who were in the control group.
Among the fourth year medical students attending the medical school that had strict policies in place regarding drug company marketing and promotional activities, the medical students exposed to the Lipitor sales rep’s marketing and promotion activities were actually significantly less likely to favor prescribing the more expensive statin drug over the generic Zocor (and by a margin of 30 percent!). (Third-year medical students, who were just beginning their clinical clerkships, did not appear to be swayed, one way or the other, by their interactions with drug company sales reps.)
The findings in this study, that physicians-in-training at medical centers with permissive attitudes towards drug company marketing activities were more likely to prescribe these same drug companies’ more expensive drugs, has been confirmed by previous research studies. The twist in this particular research study, however, are the novel findings within the group of medical students studying at a medical school where a more critical and restrictive approach towards drug company product marketing and promotion is enforced. Under these more stringent conditions, promotional interactions with drug reps were actually associated with a more negative view towards prescribing the more expensive drug being marketed by the sales reps!
Needless to say, the findings of this study strongly suggest that the pernicious influence of pharmaceutical drug reps on doctors’ prescribing habits can likely be minimized, if not reversed, by enacting strict limitations on marketing interactions with drug company sales reps, on the one hand, and senior medical students and resident physicians, on the other hand, while these physicians are still in training. At the same time, I believe that there is still an important role for ongoing interactions between physicians and representatives from the pharmaceutical and medical device industries. However, finding the proper balance in such relationships, and eliminating influences on physician prescribing and practice that are not supported by any available clinical evidence, is critically important, in my view.
Finally, a few more comments on this topic before I conclude this week’s column:
Many people reading this column might ask why a study such as this is even necessary, as our understanding of basic human nature would lead almost anyone to predict that exposing medical students and doctors to marketing and promotional activities by drug manufacturers would, inevitably, result in prescribing habits that are biased in favor of these same manufacturers’ drugs. However, another almost universal flaw in our nature, and one which is especially prevalent among physicians, is our unshakable belief that we can control the degree to which external forces influence our most important decisions. Indeed, this has long been the perspective of most physicians and physician advocacy groups. At the same time, drug and medical device manufacturers have understood, very well, that the prescribing habits of physicians can, indeed, be significantly influenced by costly marketing and promotional activities.
Over the past 5 years, as increasing research data has become available to confirm what most people would argue is really a matter of common sense, I have had to concede to myself that the pharmaceutical and medical device industries would probably not be spending millions and millions of dollars every year on free meals, cheap logo-embossed pens, and other freebies, if these activities did not favorably influence at least some physicians to preferentially prescribe their more expensive patent-protected medications, instead of equally effective and far cheaper equivalent generic drugs. As a result of my own soul-searching, I have stopped accepting frequent invitations to join drug company speakers’ bureaus, and I no longer regularly attend continuing medical education seminars sponsored by drug companies, particularly when the content of such lectures is provided directly by the sponsoring pharmaceutical company. This change in practice has brought me the twin benefits of a clearer conscience and fewer evenings spent away from my family. (A third potential benefit is that I am eating far fewer unhealthy meals at expensive steak houses these days….)
As I have already opined, however, there is an important role for an ethically clean relationship between physicians and medical industry representatives. In my own practice as a comprehensive Surgical Oncologist, for example, I often must rely upon representatives from medical technology companies to support my use of complex and emerging cancer treatment modalities, especially in the operating room. Like any relationship that has the potential for abuse, though, I find that I must constantly be vigilant to assure that I remain on comfortable ethical territory with regards to my interactions with these industry reps.
For other columns dealing with these issues, please click the following links:
Disclaimer: As always, my advice to readers is to seek the advice of your physician before making any significant changes in medications, diet, or level of physical activity
is an oncologic surgeon, a professor
of surgery, a widely published author, and the
Physician-in-Chief for Surgical
Oncology at the Kaiser Permanente healthcare system in Orange County,
(Anticipated Publication Date: March 2010)
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Robert A. Wascher, MD, FACS.
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