Abstract: Dealing with marketing pitches from drug companies is a routine part of practising medicine. But few medical students are aware of how this information can influence their decisions. Harvey Black meets two doctors who decided to help students take a fresh look at their free dinners. When Raquel S Watkins was a medical student, no one talked to her about how she would be targeted by drug marketers or how influential their efforts could be. As a result of her experiences as a student, Watkins, now an assistant professor of medicine at Wake Forest University Health Sciences School of Medicine, with her colleague James Kimberly, decided to create a course on how drug companies market their products, how effective that marketing can be, and how doctors can evaluate that marketing and make the best decisions for their patients. Watkins admits everyone is affected by marketing, but argues that if physicians were more aware of the marketing techniques used to sway them, and knew how to obtain drug information independently of sales representatives and adverts, they would be less vulnerable to the influence of marketing. Marketing efforts targeting doctors are intense. In the USA, the pharmaceutical industry spends more than US$11 billion a year on promoting their products, $5 billion of which goes to the support of sales representatives. Overall, somewhere between $8000 and $13000 is spent on each physician annually. Nevertheless, only one in four US medical schools provide courses to prepare their students to cope with these attempts to influence their practice. According to a survey conducted by Watkins and Kimberly at Wake Forest most residents are not aware that research shows doctors are susceptible to the blandishments of marketing nor are most of them aware to ethical guidelines on accepting gifts from marketers issued by various professional societies, including that of the American Medical Association. The Wake Forest programme, which begins its second year this fall, consists of four lunch-time meetings. The first meeting presents the residents with patients' views of the practice of doctors accepting gifts from drug companies. Watkins says this approach helps capture the residents' interested by showing that their patients have concerns about the issue, concerns that could well affect the doctor–patient relationship. The patients appear to have divided views on their doctors getting such gifts, on the one hand, says Watkins, “some patients were surprised their doctors were getting gifts, though they trusted their doctors to make the right decision”. A second session explores the statistical methods needed to evaluate research data presented by drug company representatives and covers how they can search the medical literature for information on their own. The third session focuses on finding out information about how much a drug costs. Doctors don't pay too much attention to drug costs, says Watkins. In the class, the residents learned where they could go, for example Thomson Micromedex (www.micromedex.com) to find out drug prices. The session also covers marketing strategies commonly used by drug reps. For example, drug reps often use an “appeal to authority” ploy to push their drugs, saying that “so and so, who's head of the pharmaceutical and therapeutics committee, is using this drug.” The fourth session covers professional guidelines on dealing with drug companies and accepting gifts. Watkins says it's important for residents to be aware that these guidelines can help doctors judge what's appropriate behaviour in their dealings with drug company representatives. Gregg Shepard, a resident who took the course, says he had felt vulnerable to drug company marketing tactics and was pleased to have learned more about them. “It's certainly not something that's addressed in medical schools”, he says. Arnold Relman, former editor of the New England Journal of Medicine and an outspoken critic of drug marketing tactics, says courses like the Wake Forest programme are a good idea, but be believes academic medicine should do a better job keeping its distance from the drug companies. Drug companies, for example, should have no role in continuing medical education, Relman argues. “That should be under the control of professional groups, not industry groups.” Mildred Cho, associate director of the Stanford Center for Biomedical Ethics at Stanford University (Palo Alto, CA), who studies the conflict of interest issues raised by drug company funding of clinical trials, says more medical schools should have courses like the Wake Forest programme and the courses should be begin at the outset of medical training. “Students are exposed to [marketing] influences right from the beginning”, Cho says. “They are already being contacted by drug reps, and they don't know what to do.” Robert Goodman, assistant professor of clinical medicine at Columbia University New York, NY, says there was little discussion in medicine about the influence of marketing, a situation, he says which led him to start “no free lunch” a website devoted to highlighting the potential conflicts of interest between drug companies and doctors. Drug companies have become increasingly aggressive in marketing in order to promote a large number of “me-too” drugs they have brought on to market, says Goodman. “Those are really identical drugs. The only way companies are going to get their market share are by out-promoting the other guy.” Much concern inevitably gets focused on the detailer, the drug company representatives who go door-to-door to pitch products to physicians in their offices, laden with pens, pads, and drug samples. Relman views detailers as an anathema. “I don't think it's a good way for physicians to learn about new drugs. Clearly the detail people have a job, and that's to increase the use of products that their company makes”, he asserts. But Jeff Trewhitt, a spokesperson for the Pharmaceutical Research and Manufacturers of America, says detailers provide important expertise that is of great use to doctors. “Yes, they are trying to draw attention to a product, but if they are going to do it, they are going to have to maintain their credibility and show that they are knowledgeable, and be able to answer important technical questions.” Trewhitt thinks critics are over blowing the influence of gifts given to physicians by drug company representatives. “We believe that when you give a modest gift that helps promote the medical practice of the health care professional involved, you are simply acknowledging that you are taking valuable time from a busy health care professional. Quite often all they are is pens and pads. It is entirely possible that a physician is going to have a pen and a pad from one company and then a pen and a pad from that company's main competitor. It's probably an insult to the vast majority of doctors to think they are going to be unduly influenced by a $1·18 pen with somebody's name on it”, he says. But for Cho, the price of a gift is hardly the issue. The low dollar value items such as pens and note pads, emblazoned with the name of a drug can be pernicious. “That in and of itself causes people to prescribe those drugs more often”, she says. “The more times someone is exposed to a name, the more likely they are to use that product.” Of course it's far too early to assess the impact of a course like the one at Wake Forest on physician behaviour in dealing with the marketing efforts of drug companies. A course can only have so much influence, Goodman says. “The didactic stuff alone isn't going to do anything if physicians and training programmes don't serve as better role models for the students and residents. A bit part of the problem is they're seeing everyone else doing it”, says Goodman. Goodman says after he finishes talking about these issues with residents, they then go to their preceptor's office “and the day starts with a lunch provided by a rep, who is sitting there giving out gifts and talking about their products and providing food.” “You see residents already with this sense of entitlement: 'If they want to give me food and gifts, I'm entitled to it. I work hard', and that's the attitude that you see”, says Goodman.
Publication Year: 2004
Publication Date: 2004-11-01
Language: en
Type: article
Indexed In: ['crossref', 'pubmed']
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Cited By Count: 7
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