Doctors Under the Influence
Impact of drug marketing denied for selves, but not for others
New York, NY, April 10, 2007. A new study concludes that stricter policies limiting interactions between physicians and sales representatives are needed; while physicians acknowledge the conflicts of interest caused by direct-to-doctor pharmaceutical marketing, they employ a series of classic psychological techniques to resolve the contradiction between marketing influence and conflict-free patient care.
Published this month in the Journal of General Internal Medicine by Columbia University researchers, the report is based on focus groups with physicians from around the country. Co-authors of the report include David Rothman, associate director of The Prescription Project, president of the Institute on Medicine as a Profession and professor of social medicine at the Columbia College of Physicians and Surgeons and Susan Chimonas, also of Columbia University and The Prescription Project.
“Left to their own devices, doctors ignore the inherent conflicts created by drug industry marketing even when given research findings about how these practices influence them,” said Rothman. “Doctors use denial and rationalization to maintain the belief that the friendly relationships and gifts are not influencing the choices they are making for their patients even while they say others are being influenced.”
This report builds on an article published in the Journal of the American Medical Association last year in which Rothman and Chimonas, among others, called on academic medical centers to take the lead in instituting reforms to control conflicts of interest. The pharmaceutical industry spends $12 billion a year marketing directly to physicians, for an average of $13,000 per doctor. With approximately 90,000 pharmaceutical company representatives – one for every five doctors – promoting drugs and nearly 60% of continuing medical education sponsored by pharmaceutical companies, it is not surprising that research shows that exposure to promotion influences prescribing and creates a sense of obligation and reciprocity in doctors toward drug companies.
“When a physician refers to the PhRMA code as the ‘Doofus Code’ you know it is time for medical institutions and professional societies to take steps to effectively change behavior. Voluntary regulations just aren’t going to be effective,” said Chimonas.
According to the report, the doctors who participated in the study often expressed self-contradictory points of view, known psychologically as “cognitive dissonance,” about whether or not the drug firms’ marketing was educational, influenced their prescribing practices, or influence their colleagues.. Among the contradictory views held by physicians:
Doctors say they seek education…
Yet they do not trust information from companies
“They just tell you about your product and you learn about it. A lot of the things I know about the new drugs, I learned from the pharmaceutical representatives.”
“I don’t think it’s a conflict of interest. It’s a way of getting you to learn about a product.”
“Ninety percent of what they’re telling you is propaganda. I don’t mind hearing their spin. I just take it with the appropriate grain of salt.”
“I take a lot of it with a grain of salt. It presents information but it’s always going to be in their best interest.”
Doctors say they are not influenced…
Yet there is an impact
“You accept the perks that are offered, but personally it never made any difference in what I have or have not prescribed.”
“We get the lunches, the house staff may enjoy it, but I haven’t seen it influence.”
“I just prescribe the medication that is best for the patient.”
“They’ve got you because they gave you the samples, you dispensed [them], you start a patient on the samples.”
“They’re dropping off pens and pads because drug reps want sales.”
“There are doctors that, if they’re wined and dined, they’re going to prescribe out of loyalty.”
A significant finding in the research was the physician’s dislike of ethical codes of conduct.
As one doctor complained: “We’re not allowed to bring our significant others to dinners. I think it’s ridiculous, insulting… not to be able to spend an extra hour or two with our wives while we’re getting an education.”
Most medical organizations, including the American Medical Association, urge physicians to judge for themselves if a gift is appropriate. However, the authors conclude that the techniques physicians use to manage cognitive dissonance prevent them from self-regulating effectively. Stricter, enforceable policies on gifts and other interactions between physicians and sales representatives are needed, they say.
Several prominent AMCs, including Stanford University, the University of Pennsylvania, and Yale University, have enacted reforms consistent with those recommendations in the JAMA article.
“Doctors have clearly rationalized their way into thinking they are immune to marketing tactics,” said Robert Restuccia, Executive Director of the Prescription Project. “This is why our team is looking to not only change policies at Academic Medical Centers, but encourage state and federal agencies, private payers, consumer groups and others to advocate for changes that minimize the influence of pharmaceutical marketing.”
Rothman and Chimonas are continuing their work through the Prescription Project, a partnership between IMAP and the Boston-based Community Catalyst. The Prescription Project, a two-year campaign funded by a $6 million grant from the Pew Charitable Trusts, seeks to manage conflicts of interest caused by marketing and to promote evidence-based medicine through reforms and policy initiatives in the public and private sectors.
About The Prescription Project
The Prescription Project is led by Community Catalyst in partnership with the Institute on Medicine as a Profession. Funded by the Pew Charitable Trusts, the Project seeks to eliminate conflicts of interest created by industry marketing by promoting policy change among academic medical centers, professional medical societies and public and private payers. In addition the Project will advance state and national level policy solutions.
The Institute on Medicine as a Profession seeks to shape a world inside and outside of medicine that is responsive to the ideals of professionalism. IMAP supports research on the past, present, and future roles of professionalism in guiding individual and collective behavior. It aims to make professionalism relevant to physicians, leaders of medical organizations, policy analysts, public officials, and consumers. IMAP’s programmatic agenda is carried out through the Center on Medicine as a Profession of Columbia University.