Prescribing under the Influence
E. Haavi Morreim
Gifts to doctors from drug companies have implications for patient interests.
It’s morning report in the Department of Pediatrics at an academic medical center. A senior faculty member is working through a case with a group of residents and interns. "First we saw these symptoms. Now that the laboratory results are back, how does that change what we think?"
In the back of the room, there’s a table with bagels and juice. On the table is a supply of pens, notebooks, and little stuffed toys, all with a pharmaceutical company logo prominently displayed. Next to the table is a representative from the drug company.
When you ask doctors whether this kind of drug marketing is effective, the answer is always the same: "It doesn’t influence me at all. They’re not going to buy my soul with a laser pointer." In a recent syndicated newspaper column, one doctor commented, "I blame the pin-striped MBAs, who mistakenly believe that physicians are going to prescribe certain medicines because the company plies them with pens."
The truth is, the physicians may need to reconsider. This kind of advertising is crucial to sales. A doctor is not going to prescribe something he or she has never heard of, and it’s the drug representative’s job to get the products’ names in front of the physicians. Maybe the drug representative does that while the resident is slathering cream cheese on a bagel; maybe it’s while the intern is saying, "Oh, what’s this cute little stuffed bear?" Either way, the doctor stops and spends a moment.
In private practice, the little gifts are often even more important. If you’re a drug representative, physicians are usually not interested in talking to you unless you have something to catch their attention. Then you can get your three sentences in: "We’ve got such and such on the hospital’s formulary now." Or "The new form of this drug can be given once a day instead of four times a day. The patients will love it." It’s a way to get in the door so that your information rather than somebody else’s reaches the doctor’s brain.
Marketing at Work
A recent letter in the Journal of the American Medical Association illustrates how effective drug advertising can be. It describes a patient who came into the hospital with an infected insect bite. The intern who first saw the patient first sensibly wanted to prescribe a nice, inexpensive penicillin, which is the drug of choice for a minor infection. But the resident overruled the intern and favored a more "modern" choice for this "severely" ill patient. He decided the patient had to have a brand-new antibiotic…at $183 a day.
The attending physician who supervised the house officers checked into the incident. It turned out the resident had just been wined and dined by the drug representative whose company made the new antibiotic. Think marketing doesn’t do any good? Think again.
The evidence is not just anecdotal. In a classic 1982 study, researchers explored physicians’ perceptions of two medications where there was a distinct discrepancy between what the company was touting as the virtues of the drug and what the science said.
The first group of drugs was cerebral and peripheral vasodilators. The drug company representatives were suggesting that these medications might be a good treatment for dementia. The theory was that if you increased the circulation to the brain—if you oxygenated it—you could alleviate senility. The scientific literature, however, said that not only were vasodilators no good for dementia, but they could actually make it worse because if you dilate the vascular beds throughout the body—which these medications do—you may actually decrease the flow of blood to the brain.
The other medication studied was propoxyphene (Darvon). The drug representatives were promoting the use of Darvon for pain from fractures and major surgery. The scientific literature said, "At best, Darvon is as effective as aspirin."
The study focused on physicians’ perceptions, so the researchers conducted a telephone survey of internists in the Washington area. All the doctors in the study probably thought, I get my information from Science; I don’t listen to those drug representatives. But it turned out that 71 percent of those interviewed believed that inferior cerebral blood flow was a major cause of dementia, and almost a third of them found vasodilators useful in managing geriatric patients. For Darvon, almost half of them believed that it was more potent than aspirin. The physicians could not possibly have gotten this misinformation from the scientific literature.
Another study tracked the prescribing patterns of two groups of 10 physicians who had been taken by pharmaceutical companies on all-expenses-paid trips to luxury resorts. Each day, the doctors participated in seminars for several hours. The rest of the time, they enjoyed the amenities of the locale.
All 10 doctors on each trip were interviewed, and the majority of them insisted that they were in no way influenced in their prescribing habits. Several said, "Maybe I was indirectly influenced by important scientific information that I might not otherwise have heard, but nothing else would influence me."
The study then compared the physicians’ prescription patterns for almost two years prior to the trip with their prescriptions for almost a year and a half after the trip. The first group had been hosted by the makers of an intravenous (IV) antibiotic—Drug A. The second heard about an IV cardiovascular medication—Drug B.
The prescriptions for Drug A increased from 81 units before the trip to 272 units afterwards; in other words, they more than tripled. Drug B went from 34 units to 87 units, more than doubling. In the case of Drug B, the use those doctors made of the medication went well beyond the nationally agreed-upon standard of care.
And the drug companies are getting more and more sophisticated about their marketing techniques. Now they can go to the American Medical Association and buy biographical data on individual doctors including their prescription license numbers. Then they can buy information from pharmacies about what a particular physician is prescribing and keep track of what tends to influence him or her: This guy goes for gold address labels. That doctor likes to be taken out for vegetarian food.
The pharmaceutical companies are also making increasing use of samples. Admittedly, the samples can be very useful. They are a way to see whether the patient does well or poorly on a particular drug; they provide a time cushion for people to get to the pharmacy for the rest of the prescription; they can be used to help poor patients; and, in general, patients tend to be pleased to get them—"This is the only thing I’ve ever gotten from a doctor that’s free."
But in the long run, the samples aren’t free. The drug representatives only leave samples for the very latest, most expensive drugs. Once you finish the sample, the doctor almost never shifts you to a less expensive drug. So the samples are often a way of getting you launched on the newer, more expensive medication. That’s a problem not only because you end up spending a lot more money than you might need to, but also because some of the newer drugs have not been out long enough for us fully to appreciate the potential side effects.
This is not to say that profit is evil or that business is evil. The pharmaceutical industry has done some great work, developing a host of marvelous drugs in the past 20 or 30 years. They’ve been a godsend for thousands and thousands of people, who in many cases, can save money by avoiding costlier, more invasive treatments.
You’re not going to get this kind of vigorous productivity if you’ve got some government bureaucrat dictating five-year plans for drug research; you need a free market. And if the companies are going to continue to produce new drugs, they have to sell the ones they’ve developed, which means they have to market them.
The Role of Physicians and Consumers
On the other hand, there are some questionable things going on, and both physicians and consumers need to be part of the solution. Physicians need to avoid being naïve. They need to quit protesting that because they’re scientists, marketing doesn’t influence them. They need to understand that the pen and the golfing trip are not designed to buy their souls; these "perks" are designed to foster familiarity and comfort with the drugs and sometimes create a gift relationship and the gratitude that goes along with it. That makes them very effective marketing tools.
Consumers also have to be more realistic. So many people feel entitled to the latest, greatest, hottest medications and treatments, but most of us are financially insulated by our insurance from the cost of this care, We’re not willing to spend more, but by golly, we want our health plan to cover everything under the sun. That can’t go on. The economics won’t work.
A classic example was bone marrow transplants for breast cancer. In one particularly famous case, a woman with advanced breast cancer was told that her only hope was a bone marrow transplant. When her HMO denied the treatment, she sued and got the court to mandate coverage. In similar scenarios all over the country, many other insurers started to cover it.
Several years later, when there were finally randomized, controlled trials of bone marrow transplants for breast cancer, this treatment proved to be no better than conventional chemotherapy. By that time, 30,000 women had had bone marrow transplants at a cost of $3 billion. That’s $3 billion while 44 million Americans are pounding on the door trying to get any access to health care at all. Ultimately, we all need to become more savvy about the medical and economic dynamics of the wondrous new drugs that are touted to cure what ails us.
E. Haavi Morreim is Professor of Human Values and Ethics at the College of Medicine, University of Tennessee. This article is excerpted from her presentation for the Markkula Ethics Center Lecture Series.