Doctors underestimate their susceptibility to the sales pitches and perks offered by drug companies, and that isn’t good for patients.
The latest twist in the continuing debate focuses on promotion posing as continuing medical education. Most physicians say they can separate selling from science. Marketing, they believe, is a black art that sways only lesser mortals.
Yet a growing body of academic research shows that doctors are vulnerable to drug-company influence. Add the increasing volume and sophistication of industry promotion to that predisposition, and the result should have patients wondering whether a ghost writer is at work behind their doctor’s prescription pad.
“Doctors are like anybody else who is influenced and generally would deny it,” observes Robert Goodman, an internist at Columbia Presbyterian Medical Center in New York and a medical school teacher. They are “smart, tend to be a little bit arrogant, and are very naive about business,” adds Dr. Goodman, who founded a group called nofreelunch.org to persuade doctors to renounce drug-industry influence on their practices, teaching and research. The “more you think you’re immune, the more you’re willing to partake.”
Indeed, the drug industry has incurred physicians’ wrath when withdrawing even the smallest morsels from its largess. Several drug makers say the biggest backlash from its voluntary code curtailing of entertainment last summer came from doctors incensed they couldn’t bring spouses to drug-company dinners anymore.
How did it come to this? Part of the problem is deciding on the proper boundaries: Pharmaceutical presentations are an important and legitimate way that doctors learn about new drugs.
“A diversity of inputs should be welcomed, and what we strive for,” says Hugh Smith, a psychiatrist in private practice in West Bend, Wisc. “If I have a question about a medication, I can go to the scientific literature and scan it, and sometimes I even confront the reps with the information.”
The trouble starts when the drug firms offer treats for doctors that have nothing to do with the value of their wares. The perk habit starts early, as young doctors see their mentors accepting goodies. Soon enough, they feel entitled to whatever the pharmaceutical industry throws their way, whether it’s a fancy dinner, a sturdy stethoscope, or a free lecture to meet continuing education requirements. Their view: Becoming a doctor is hard work, from gaining admission to medical school to long hours as a poorly paid resident. So what’s the harm of token gift in appreciation? Plus, as people who chose a career in science, doctors scoff at the notion that anything but objective information would inform their decisions.
Ironically, they don’t have the same confidence in their peers. “Physicians believe that their colleagues are influenced, but that they themselves are not influenced,” says Michael Steinman, a fellow in geriatrics and health services research at the San Francisco Veterans Affairs Medical Center. In a study of medical residents published last year, Dr. Steinman found that 61% of residents believed that they were unaffected by industry promotion but that only 16% of their colleagues were similarly immune.
Even the hardliners crumbled in the face of temptation. Half of residents in Dr. Steinman’s study who classified social outings sponsored by drug companies as inappropriate, for instance, nevertheless said they had participated in one or would do so given the opportunity. Dr. Steinman says he hopes the findings serve as a reminder to doctors to look at themselves more critically.
In the end, most doctors believe that as scientifically trained professionals, they make judgments based solely on facts. This view forms the foundation for the claim that medicine is different from other professions, like law and journalism, that have institutional safeguards and deep cultural traditions designed to prevent undue influence. But what facts really affect doctors’ decisions?
Twenty years ago, Jerry Avorn and colleagues at Harvard Medical School studied prescription choices by Boston-area doctors to answer that question. More than two thirds of doctors said their own training and experience were very important in prescribing decisions. And 62% said the same about the role of scientific papers. The majority of those surveyed said drug industry ads and salesman were “minimally important.”
Yet, the results indicated otherwise. The researchers studied doctors’ assessments of a painkiller called Darvon and medicines that dilate blood vessels to treat senility. The commercial claims of these drugs’ effectiveness were belied by an established body of scientific evidence.
More than 71% of doctors said they believed that decreased blood flow in the brain which the dilating medicines supposedly could alleviate was a major cause of senility, a message championed by drug makers but contradicted by science. Half the doctors believed Darvon was more potent than aspirin, also a scientifically faulty conclusion.
The study is cited often because of its elegant design and powerful conclusion: marketing matters more than doctors realize. “Although the vast majority of practitioners perceived themselves as paying little attention to drug advertisements and [salespeople], as compared with papers in the scientific literature, their belief about the drugs revealed quite the opposite pattern of influence” Dr. Avorn and his colleagues wrote in 1982.
Not much has changed since then except the drug industry’s spending on promotion. Last year drug makers dropped $12.5 billion for sales and marketing, a 50% increase since 1998, according to Quintiles Informatics, Inc.
Suds salesmen are free to spend millions on uncouth beer ads, and the fact that they do says a lot about the effectiveness of marketing. Drug companies, too, are likewise free to pitch their wares to physicians and lately directly to patients.
How your neighbors decide on a cold beverage may be none of your beeswax, but the decision your doctor makes in writing a prescription certainly is your business. Patients deserve doctors who make the best clinical judgments. And the sooner physicians face up to the full extent and power of the drug industry’s marketing machine, the sooner they can do something about it.