The Invisible Influence of Industry Inducements

According to a front-page article in The New York Times, pharmaceutical companies spend about 87% of their advertising budget in targeting doctors. In 1999 that amounted to about $12 billion aimed at healthcare providers (Stolberg and Gerth 2000), and a portion of that budget is spent on gifts to doctors. In their discussion of gifts to physicians from the pharmaceutical industry, Dana Katz, Arthur L. Caplan, and Jon F. Merz (2003) ably note the central problem that such favors create. Whereas physicians typically believe in their own immunity to such inducements, those who provide the tokens rely on data that show the efficacy of such tokens in affecting physician prescribing patterns. The most frightening factor associated with pharmaceutical largesse is that the effects are invisible to each physician and the influence of the largesse is therefore hard for physicians to monitor or protect against in their own decision making. Katz, Caplan, and Merz identify the psychological and social factors that contribute to the efficacy of gift-giving in influencing physician behavior, and they argue that these factors make the acceptance of small as well as large gifts an imprudent and ethically hazardous practice for medicine.

What Katz, Caplan, and Merz, as well as many statements by medical societies overlook, however, is the fact that other practices of pharmaceutical companies and medical equipment manufacturers that do not involve gifts place physicians in a similarly precarious situation. For example, the distribution of pharmaceutical samples, provider profiling, and corporate sponsorship of medical education all raise similar problems. In each of these cases the impact is at least as significant as the influence of gifts, yet addressing the problems might be more complicated and irremediable. In each of these cases the obvious concern is the corruption of physician judgment in ways that might compromise medical care.

Drug company representatives who visit doctor's offices are usually young, bright, and personable. It's hard not to like them, and the industry's public relations experts know the importance of these personal contacts. Even when drug representatives do not leave gifts for physicians, they do leave drug samples along with information about new drug products. The product information makes it simple for doctors to learn about new drugs, and samples allow physicians the freedom to easily start patients on new medication and to assess their performance and side effects. Giving samples to patients also allows physicians to experience their gratitude and often helps physicians to ease the financial burdens on underinsured patients by providing some of the medications without cost. Although drug samples provide no immediate personal contribution to the doctor, they do empower physicians with the means to address wrenching problems of patients who lack adequate means to access needed treatment. Samples that doctors can pass along as medication also ingratiate doctors with their patients. These results, in turn, promote responses of gratitude, friendship, and affection for the drug representatives, just as gifts do. Although cutting off the supply of drug samples to doctors would prevent their unwanted influence on physician decision making, it would also curtail the good that they allow doctors to pass along to their patients.

Prescriber profiles is another related problem. Many people are unaware of the practice, but drugstores sell pharmaceutical companies information on the drugs that individual physicians prescribe. While confidentiality concerns protect patient information from disclosure, the drug representatives who visit doctors in their offices with gifts, samples, and product information come well-supplied with information on the drugs that doctors prescribe and changes in their prescription patterns. This information allows drug representatives to target remarks so as to reinforce or redirect physician behavior. And even when nothing is said, physicians knowing that their prescribing patterns are being monitored will want to help and avoid harm to their friendly benefactor drug representative. Again, these factors exert a powerful but unnoticed...