MDs for Sale

A retrospective study recently published in the Journal of the American Medical Association¹ reviewed 538 studies involving "the relationship between physicians and the pharmaceutical industry and its representatives, and its impact on the knowledge, attitudes and behavior of physicians." Ultimately, 29 studies were analyzed and revealed some disturbing results:^2-30

"More than $11 billion is spent each year by pharmaceutical companies in promotion and marketing, $5 billion of which goes to sales representatives," the study's author pointed out. "It has been estimated that $8,000 to $13,000 is spent per year on each physician." The 'interactions' between drug company representatives and medical physicians begin in medical school and continue at a rate of "about four times per month."

Regarding the interactions between MDs and drug company representatives, the study found that:

"There was an independent association between meetings with pharmaceutical representatives and formulary addition requests for the drug of the representative's company, both with respect to control physicians who did not meet representatives and with respect to requests for other companies' drugs. Interactions with pharmaceutical representatives were also found to impact the prescribing practice of residents and physicians in terms of prescribing cost, nonrational prescribing, awareness, preference and rapid prescribing of new drugs, and decreased prescribing of generic drugs. Exposure to pharmaceutical representatives was highly associated with a perception of the benefits of such an interaction and the appropriateness of other interactions."

The author categorized these interactions into several categories and presented the effects established by the reviewed studies:

Gifts - Receiving a gift, and the number of gifts received, correlated with the belief that pharmaceutical representatives have no impact on prescribing behavior; receiving gifts of high relevance to practice was also associated with a positive attitude.

Samples - Accepting samples was associated with awareness, preference and rapid prescription of a new drug, and a positive attitude toward the pharmaceutical representative.

Industry-Paid Meals - There was an independent association between benefiting from sponsored meals and formulary addition requests for any drug that was clearly dose-related.

Funding for Travel or Lodging to Attend Educational Symposia - Accepting funding to attend a symposium was independently associated with increased formulary addition requests for the sponsor's drug. This interaction still affected hospital-prescribing practices two years after two groups of physicians accepted all-expenses-paid trips to a drug-sponsored symposium.

CME Sponsorship - Drug company continuing medical education (CME) sponsorship affected presentation content. The sponsor's drug was always preferentially highlighted, although the same drugs were discussed in each event. Changes in prescribing practice (self-reported) in favor of the sponsor's drug were also found.

Honoraria, Research Funding, Employment - Accepting a drug company honorarium to present data on a new therapy and receiving research support were independently associated with a formulary addition request for the sponsor's drug and any other drug.

In addition, the study noted:

"The frequency with which physicians benefit from industry-sponsored meals and samples decreases as they enter practice, while frequency of receiving honoraria, conference travel, and research funding increases. One study found that residents receive six gifts a year.

"Residents and physicians have similar attitudes about pharmaceutical representatives. They believe that representatives provide accurate information about their drugs and are equivocal in their beliefs that representatives could provide accurate information on established or alternative drugs. Most believe that representatives prioritize product promotion above patients' welfare and are likely to use unethical practices.

"Most deny that gifts could influence their behavior and are equivocal about the ethics of such a practice, with residents more likely to admit that without gifts, their interactions with pharmaceutical representatives would be reduced. Samples, CME, and conference travel funding exert more influence (40 percent to 55 percent) than promotional material does (22 percent). Each interaction elicited ethical concerns; travel funding generated the most concern (48 percent to 75 percent). Most physicians also agree that pharmaceutical representative speakers should be banned."

The study concluded:

"Although some positive outcomes were identified (improved ability to identify the treatment for complicated illnesses), most studies found negative outcomes associated with the interaction. These included an impact on knowledge (inability to identify wrong claims about medication), attitude (positive attitude toward pharmaceutical representatives; awareness, preference, and rapid prescription of a new drug), and behavior (making formulary requests for medications that rarely held important advantages over existing ones, nonrational prescribing behavior, increasing prescription rate, prescribing fewer generic but more expensive, newer medications at no demonstrated advantage)."

One comment made by the author summarizes the situation:

"The present extent of physician-industry interactions appears to affect prescribing and professional behavior and should be further addressed at the level of policy and education."

The pharmaceutical companies will continue to wield their influence on the medical community. The publication that featured this paper (JAMA) contained 21 full-page advertisements paid for by drug companies. This leaves the patient in the uncomfortable position of having to ask: "Did you prescribe that drug because I need it, or because the drug company sales rep. just bought you lunch?"

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