Dermatology Online Journal

Drug representatives: Giving you lunch or stealing your soul?
Steven P Higgins MD
Dermatology Online Journal 13 (4): 5

Division of Dermatology, Department of Internal Medicine, Duke University Medical Center, Durham, NC. sph1@duke.edu

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Abstract

Pharmaceutical companies and their representatives attempt to influence the practice of medicine by giving gifts. Gifts, even those of trivial monetary value, impart a sense of obligation that conflicts with the provider's primary responsibility to the patient. Providers are less likely than their patients and peers to believe that gifts change their own prescribing habits, making them vulnerable to manipulation by industry. Providers who interact with drug reps must exercise caution to prevent compromise of the patient-physician relationship.

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The pharmaceutical industry is one of the most profitable in the US [1]. A distinctive feature of this business is its dependence on physicians to recommend its prescription products. This necessity is underscored by the promotional budget of pharmaceutical companies, over $27 billion in 2004, mostly targeted at physicians [1].

Gift giving is one way in which pharmaceutical companies and their representatives attempt to influence the practice of medicine. The impact of pharmaceutical representatives and gifts such as free lunches are increasingly popular topics in both the lay press and medical literature [2, 3, 4, 5]. Fearing a conflict of interest, medical professional societies have established guidelines to help healthcare providers decide which gifts are appropriate [6, 7]. Guidelines for the American Academy of Dermatology refer to those of the American Medical Association (AMA) [8]. The AMA guidelines are somewhat vague, for example, stating that gifts should be "of minimal value." An attempt to clarify the guidelines set limits on gift value, such as $100, that seem arbitrary [9].

Moreover, such limits ignore the importance of small gifts. Studies reveal that seemingly insignificant gifts can influence behavior. For example, a pharmacy that gave a keychain to all patrons noted a 17 percent increase in sales [10]. A charity fundraiser that employed direct mail solicitation had an increase in response rate from 18 percent to 35 percent when free address labels were included [10]. Gifts, even those of trivial monetary value, impart a sense of obligation that conflicts with the provider's primary responsibility to the patient. A physician who is the recipient of a gift may recommend products made by the gift-giver without due consideration of other cheaper or more effective options.

This potential conflict of interest is not lost on patients. Although physicians may balk at the suggestion that their integrity is compromised by the acceptance of trinkets such as pens and notepads, a third of patients surveyed believe that the receipt of any gift compels a physician to prescribe a particular product [11]. For all types of gifts except drug samples, patients are consistently more likely than physicians to think the gift is influential [11]. This could compromise trust in the physician-patient relationship, whether or not the gift ultimately influences the physician. Furthermore, time constraints of typical patient encounters dictate that most physicians are unlikely to disclose all drug company-related gifts to their patients.

Figure 1
Perceived influence of pharmaceutical representatives on prescribing practices. Percentage of residents (n = 102) who believe that pharmaceutical representatives influence the prescribing practices of other physicians (dark bars) and influence their own prescribing practices (light bars). Residents perceive themselves as less prone to influence than are other physicians (p < 0.0001 by McNemar's chi-square test). Reproduced from Steinman et al. [12], with permission from author.

Providers perceive that drug companies successfully manipulate practices of other practitioners, yet deny that the companies' promotional efforts impact themselves (Fig. 1). Although 33 percent of medicine residents acknowledge a significant effect on the habits of their peers, just 1 percent feel the efforts of pharmaceutical representatives greatly impact their own prescribing habits [12]. Similarly, 61 percent think the drug reps exert no influence on their own practice, while only 16 percent assume that other physicians are not influenced [12]. In addition, the likelihood that residents believe they are influenced by promotional items decreases with the number of items accepted [13]. Even when residents recognize gifts as inappropriate, they often take them anyway [12]. More than half of residents admit they would be unlikely to maintain the same degree of contact with pharmaceutical representatives if not for free lunches and other promotional items [13].

Residents are not the only physicians potentially swayed by pharmaceutical funding. Physicians in leadership positions, who influence the decisions of other physicians, may themselves be influenced by the pharmaceutical industry. Physicians recommending formulary additions are more likely to have received drug company money to attend or speak at symposia or perform research (odds ratio 5.1, 2.0-13.2) [14]. Over half of authors of clinical practice guidelines have preexisting relationships with companies producing drugs reviewed in the guidelines [15].

Pharmaceutical representatives often provide meals at which well-known physicians are paid to speak, in the name of education. The objectivity of these speakers is arguably compromised by their honoraria and a sense of loyalty to the industry representatives at the rear of the room. A physician who portrays the featured drug unfavorably will not have a future opportunity to "educate" other providers on behalf of the company. When representatives themselves give the lectures, all inaccurate statements are favorable to the drugs being promoted [16].

Lunches, pens, and other promotional items all play a role in drug marketing, but pharmaceutical companies spend over half of their promotional budget, 15.9 billion dollars in 2004, on samples [1]. Drug samples, seemingly a gift that would benefit patients, likely serve to make health care more expensive. Patients who finish their samples may fill costly prescriptions for the same products, unaware of inexpensive, generic alternatives. Resident physicians with access to samples are more likely to prescribe advertised medications and less likely to recommend generally cheaper over-the-counter options [17]. Medical institutions including Yale, Stanford, and the University of Pennsylvania have taken steps to limit relations between member healthcare providers and pharmaceutical companies [18, 19]. However, not all institutions have sought to create distance between themselves and pharmaceutical representatives. The Weill Medical College of Cornell University recently opened the Clinique Skin Wellness Center, mostly financed by a $4.75 million grant from Clinique, at which patients may make on-site appointments with Clinique representatives [20]. The ends may justify the means, as one of the stated goals of the clinic is educating patients on skin cancer prevention [20]. However, physicians at that institution may have a difficult time convincing patients and others that the care they deliver is unbiased.

Mounting evidence suggests that physicians are vulnerable to various pharmaceutical marketing strategies. The fact that industry annually spends billions of dollars on advertising geared to physicians implies that such advertising is effective. The most direct way for physicians to avoid a conflict of interest with pharmaceutical companies is to eschew all types of gifts from those companies. Some feel that interactions with pharmaceutical representatives are too useful to abandon. Those providers who continue to interact with drug reps should view all gifts with skepticism, avoid the appearance of impropriety, and exercise caution to prevent compromise of the patient-physician relationship.

Acknowledgment: I would like to thank the No Free Lunch organization, www.nofreelunch.org, for providing many useful resources including several of the references cited in this paper.

References

1. Kaiser Family Foundation. Trends and Indicators in the Changing Health Care Marketplace. Publication number 7031, updated February 8, 2006.

2. Saul S. Gimme an rx! Cheerleaders pep up drug sales. New York Times. 2005 Nov 28.

3. Saul S. Drug makers pay for lunch as they pitch. NY Times (Print). 2006 Jul 28;A1, C7. PMID: 16909492

4. Wazana A. Physicians and the pharmaceutical industry: is a gift ever just a gift? JAMA. 2000 Jan 19;283(3):373-80. PMID: 10647801

5. Brennan TA, Rothman DJ, Blank L, Blumenthal D, Chimonas SC, Cohen JJ, Goldman J, Kassirer JP, Kimball H, Naughton J, Smelser N. Health industry practices that create conflicts of interest: a policy proposal for academic medical centers. JAMA. 2006 Jan 25;295(4):429-33. PMID: 16434633

6. Coyle SL; Ethics and Human Rights Committee, American College of Physicians-American Society of Internal Medicine. Physician-industry relations. Part 1: individual physicians. Ann Intern Med. 2002 Mar 5;136(5):396-402. PMID: 11874314

7. American Medical Association Ethical Opinions and Guidelines Opinion 8.061, "Gifts to Physicians from Industry," Updated 26 Jan 2005, www.ama-assn.org/ama/pub/category/4001.html.

8. AAD Code of Medical Ethics for Dermatologists, Approved 12/3/05, Revised 11/4/06, www.aad.org/professionals/policies/ar.htm.

9. American Medical Association Opinion E-8.061: clarifying addendum, Updated June 2002, www.ama-assn.org/ama/pub/category/4263.html.

10. Katz D, Caplan AL, Merz JF. All gifts large and small: toward an understanding of the ethics of pharmaceutical industry gift-giving. Am J Bioeth. 2003 Summer;3(3):39-46. PMID: 14594489

11. Gibbons RV, Landry FJ, Blouch DL, Jones DL, Williams FK, Lucey CR, Kroenke K. A comparison of physicians' and patients' attitudes toward pharmaceutical industry gifts. J Gen Intern Med. 1998 Mar;13(3):151-4. PMID: 9541370

12. Steinman MA, Shlipak MG, McPhee SJ. Of principles and pens: attitudes and practices of medicine housestaff toward pharmaceutical industry promotions. Am J Med. 2001 May;110(7):551-7. PMID: 11347622

13. Hodges B. Interactions with the pharmaceutical industry: experiences and attitudes of psychiatry residents, interns and clerks. CMAJ. 1995 Sep 1;153(5):553-9. PMID: 7641153

14. Chren MM, Landefeld CS. Physicians' behavior and their interactions with drug companies: a controlled study of physicians who requested additions to a hospital drug formulary. JAMA. 1994 Mar 2;271(9):684-9. PMID: 8309031

15. Choudhry NK, Stelfox HT, Detsky AS. Relationships between authors of clinical practice guidelines and the pharmaceutical industry. JAMA. 2002 Feb 6;287(5):612-7. PMID: 11829700

16. Ziegler MG, Lew P, Singer BC. The accuracy of drug information from pharmaceutical sales representatives. JAMA. 1995 Apr 26;273(16):1296-1298 PMID: 7715044

17. Adair RF, Holmgren LR. Do drug samples influence resident prescribing behavior? A randomized trial. Am J Med. 2005 Aug;118(8):881-4. PMID: 16084181

18. Pollack A. Stanford to ban drug makers' gifts to doctors, even pens. NY Times (Print). 2006 Sep 12;:C2. PMID: 16972375

19. Coleman DL, Kazdin AE, Miller LA, Morrow JS, Udelsman R. Guidelines for interactions between clinical faculty and the pharmaceutical industry: one medical school's approach. Acad Med. 2006 Feb;81(2):154-60. PMID: 16436576

20. Singer N. Skin deep, a word from our sponsor. New York Times. January 25, 2007.

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