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Undue Influence?

Gienna Shaw, for HealthLeaders Magazine, May 13, 2008
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As scrutiny of pharmaceutical companies' relationships with providers intensifies, should your hospital immunize itself against pharma marketing?

The debate over pharmaceutical companies' relationships with providers continues to escalate: Does pharma have an undue influence over physicians' prescribing habits? Or do the frequent visits from gift-bearing reps provide an important opportunity for physicians to learn about new drugs and treatments for their patients?

Further complicating the issue are patients who recognize well-dressed reps in their physicians' waiting room, who notice the pens and other doodads emblazoned with drug company logos around the office, and who are bombarded with direct-to-consumer drug company marketing on television and in print daily. Such patients perceive that these companies may not be entirely altruistic—and that negative impression could be contagious, spreading to your hospital by association.

Critics of pharmaceutical marketing point to research that shows physicians are swayed by gifts, free lunches, and sales pitches, even if that influence is subtle. In response, several healthcare organizations, particularly academic medical centers, have placed outright bans on pharma rep visits or gifts. The pharmaceutical industry and its supporters, meanwhile, say it's absurd to believe a well-paid physician could be swayed by a pen or a ham sandwich. Besides, they argue, the industry has reformed itself with a code of ethics that no longer allows the extravagant vacations and luxury gifts of the past.

But the argument isn't that simple, says Robert M. Sade, MD, professor of surgery and director of the Institute of Human Values in Health Care at the Medical University of South Carolina, Division of Cardiothoracic Surgery, in Charleston. For starters, he says, studies don't prove that the relationship between physicians and drug or medical device reps actually harm patients.

"I don't think that anything has really been proved at all, although there is evidence … that drug representatives and device representatives have some influence over physicians' choice of drugs and devices," he says. But the evidence, he adds, is circumstantial. The data are often extrapolated from other studies that have no controls and, in fact, aren't specific to physicians and their prescribing habits. The evidence doesn't rise to the level of scientific proof, he says.

"Healthcare professionals are specially trained to be aware of and take into account influences that are inappropriate in a patient care context," Sade notes. "There probably is a problem. The question that I have is how big is the problem, how significant is it, and what should we do about it?"

The time was right
Some practices, hospitals, and health systems have responded to that question by eliminating even the appearance of conflict. SMDC Health System in Duluth, MN, banned all pharmaceutical company gifts, from pens to whiteboards, stopped allowing pharmaceutical companies to exhibit at continuing medical education events for physicians, and placed restrictions on sponsoring healthcare personnel training sessions. The system also put most of its physicians on a drug rep do-not-call list. (Physicians can opt out of that list if they choose to take calls from and meet with reps.)

"We wanted to get rid of that perception for patients that we were in the back pocket of the pharmaceutical industry," says Kenneth Irons, SMDC's chief of community clinics. It was a large but well-organized undertaking. And the key to its success was, of course, getting physician buy-in. "It can't come from senior leaders. It just won't work," Irons says. At SMDC, a group of 15 multispecialty physicians sat down to talk and began to develop a rationale for change. The group thought that the literature that showed people tend to reciprocate favors—even in an unknowing or subtle way—made sense. Patients were becoming more aware about the controversy over direct-to-consumer advertising and high-profile recalls. The reputation of pharmaceutical companies and their representatives, thanks to national press coverage, was taking a nosedive. The group wanted to inoculate SMDC from those negative impressions.

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