When I started college, I worked in a grocery store. As I prepared food for sale each day, I became familiar with patterns of production, marketing, and our day-to-day product sales. When I helped customers, I did so superficially, helping them find what they needed but rarely advising or influencing their purchasing. It was, as is typical in a supermarket, a self-serve operation—you found what you wanted, you paid, and you left. And when you couldn't find something, there I was with more.
In medicine too, patients buy products, and frequently those products are drugs. However, as a medical student, I have found the process of prescribing drugs is far from the simple product sale I had previously experienced. Rather, it involves a nuanced series of assessments and decisions to be made by doctors and patients that, as a medical student, I am just beginning to understand. The “supermarket” version of product sales provides a very enticing delivery model for the big pharmaceutical companies. For many, this conjures up a troubled image—one of metformin and warfarin being pulled off a grocer's shelf without a doctor's advice. But this model is becoming a fact. It has become clear through their direct-to-consumer marketing practices that pharmaceutical companies envision access to drugs so easy one could stroll down aisle seven and pick up some Lasix or Lipitor—no doctor required, of course. Aggressive marketing by big pharma represents an attempt to circumvent the intellectual role of our nation's doctors in the diagnosis and prescription process. Through direct-to-consumer advertising, the pharmaceutical companies systematically prey on patients' fears and encourage self-diagnosis to the detriment of overall patient care and satisfaction.
The pharmaceutical companies have long sought to take doctors out of the equation by marketing directly to the consumers. Our television airwaves are jam packed with ads for the newest drugs, usually ending with the refrain, “Ask your doctor.” Suffering patients are easy prey when a new drug claims relief from pain or freedom from disease, and this hope leads them to raise it in conversation with their doctors.1 In an age of increased patient autonomy, when more and more health care decisions are being left up to patients, doctors routinely incorporate patient preferences into their recommendations. Functioning optimally, this marketing model needs no doctor. The analytical role physicians play in this process serves only to interfere with a sale.
One could argue, however, that doctors will always write the prescriptions and thus have ultimate control over any drugs their patients take. Although this is undoubtedly true, this counterargument has two faults. Firstly, most physicians, when confronted with a choice between two drugs, will likely defer to patient preference in the absence of other discernible factors. In fact, it has been shown that four out of five times when patients ask for drugs, they get them.2,3 Secondly, it is imperative not just to analyze which party makes the final decision but the prescribing process as a whole. The influence of pharmaceutical advertising ultimately wrests no direct power from the doctor but is far more insidious. Rather, this strategy seeks to circumvent us intellectually—that is to say, it diminishes our role as respected consultants in the health care decision process. It is an attempt to reduce us from “health care providers” to “product providers,” thus enabling greater sales with less physician interference or critical thought.
Better yet, big pharma's consumerist vision of self-serve medical practice has taken diagnosis straight to the patient. With ads that begin with inquisitions about vague symptomatology—such as “Are you ever anxious?” or “Do you have trouble focusing at work?”—it is hard for viewers not to feel that the drug could be of potential value (these two examples are especially pertinent in our current social climate of increased pressure in the workplace, at home, and in schools). Marcia Angell,4 in her book, The Truth About the Drug Companies, notes their strategy succinctly: “The way to sell drugs is to sell illness . . . every marketer's dream is to find an unidentified or unknown market and develop it, that's what we were able to do.” Pharmaceutical companies have again altered the role of doctors. Patients no longer need to bring a complaint to the attention of a doctor who will assess the constellation of symptoms to come to a diagnosis. Much to the delight of big pharma, consumers are more than willing to self-diagnose, potentially because they mistrust their doctors, and immediately demand drugs as a quick fix, heading straight to the neurologics in aisle six of the “pharmacologic supermarket” for some Adderall or Paxil.
All these practices have served the pharmaceutical companies extremely well. Drug advertising in the U.S. has exploded. Laws were loosened five years ago, and last year pharmaceutical companies spent $2.5 billion on advertising—and drug sales are soaring. This situation is damaging to our profession and, more importantly, is compromising the care of our patients in favor of profits. Though the government is loathe to intervene in the health care industry, especially against the entrenched interests of big pharma, without some checks and balances the situation could deteriorate further. What is the role of pharmaceutical advertising in our society? Could drug ads go the way of tobacco or cigarette ads? Clearly, there is a correlation between drug ads and prescription habits, otherwise the pharma companies wouldn't run them. But is there a correlation between harmful or adverse effects of a drug and advertising? One need only look at one of the more famous cases of drug side effects—Vioxx, where a drug was prescribed after heavy marketing and little long-term data follow-up with disastrous results.5 Perhaps it is not in the public interest to have such information provided by pharmaceutical companies themselves. Short of a total ban, it is reasonable to envision a governmental regulatory body that could provide some measure of control in terms of accurate product portrayal. A government agency has been used successfully in Canada to curb pharmaceutical advertising (though even there the laws are under attack from the pharmaceutical companies that want them loosened).6,7 Governmental action might be able to provide a limit on pharmaceutical advertising as a consumer safeguard.
However, this analysis would be incomplete if the positive aspects of product advertising were ignored. In a classic free market model, a consumer better informed about product options can make better consumption decisions based on that knowledge. No one would argue with the fact that patients need to know as much as possible about potential drugs and therapies. This is due to the fact that, despite the provision of the most compassionate care, patients' interests are always closer to their own hearts than their physicians'. Additionally, it is also conceivable that some mistrust of doctors or the medical profession leads patients to independently research their options. Clearly, though, there is a vast difference between information gathered through research and information fed to patients by advertising. We need to encourage active research into our patients' health—this serves everyone, as a better-educated patient is a healthier patient—while also discouraging passive intake of information provided by the big pharma companies. However, in America's very ad-friendly culture, it is difficult to break the mold of passive information gathering and, perhaps more importantly, the uncritical acceptance of that information that currently exists in the commercial marketplace.
My experiences in medical school have shown me how pervasive and subconscious the influence of the pharmaceutical companies can be. Now armed with some knowledge of drugs and their side effects, it is clear to me that the bottom line and profit come ahead of patient well-being in the marketing strategies of the big pharma companies. It is our responsibility as physicians to provide accurate information on drugs and to educate patients on how big pharma can manipulate them (just as we were educated on the topic) and to encourage active, rather than passive, research by patients. It is imperative to reassert our role as valued consultants. This may be especially important in those cases involving simple medical issues. While outwardly these do not seem to require a doctor's attention, in the long run, these simple medical problems are so amenable to the influence of big pharma that they require the greatest vigilance on the part of doctors. I feel confident that even my former supermarket coworkers would agree that there is an order-of-magnitude difference between the complexity of selling a product and providing health care. However, as doctors become more wary of, and resistant to, pharmaceutical marketing techniques, it is almost a certainty that direct-to-consumer advertising will become a more prominent weapon of pharmaceutical sales tactics. As a result, it will be of increasing importance to raise awareness among patients of this growing and critical trend with nothing less than our patients' lives hanging in the balance.
Dedicated to my late grandfather Ernie Avrith, pioneer of self-serve and low-cost shoe stores in the province of Quebec. Learning about his innovations in the shoe business led to the inspiration for this piece.
1 Pollack A. The troubling cost of drugs that offer hope. New York Times. September 8, 1988.
3 Mintzes B, Barer ML, Kravitz RL, et al. Influence of direct to consumer pharmaceutical advertising and patients requests on prescribing decisions: A two-site cross sectional survey. BMJ. 2002;324:278–279.
4 Angell M. The Truth About the Drug Companies: How They Deceive Us and What to Do About It. New York, NY: Random House; 2004.
5 Frantz S. How to avoid another Vioxx. Nat Rev Drug Discov 2005;4:5–7.
The 2008 National Essay Contest on the Relationship Between Medical Students and Pharmaceutical Marketing
In 2008, the Division of Pharmacoepidemiology and Pharmacoeconomics at Brigham and Women's Hospital, Harvard Medical School in Boston conducted a nationwide essay contest to gauge medical students' views of the influence of pharmaceutical marketing practices on their education and to seek out their ideas for how we ought to manage this complex issue. The contest was funded by a grant from the Attorney General Prescriber Grant Program.
Medical students were asked to respond to one or more of these statements: (1) How have your experiences as a medical student shaped your understanding of the interaction between the pharmaceutical industry and the practicing physician? (2) What have you learned in medical school about the relationship between pharmaceutical promotion and physician prescribing, and how could that aspect of your education be enhanced? (3) Describe a notable interaction with a drug sales representative that you have had or observed, and how that interaction will help influence your work as a physician. The contest received more than 130 submissions from 55 different schools of medicine and osteopathy. The country was divided into four regions, and a panel of expert reviewers selected one first-place finisher, three second-place finishers, and five third-place finishers from each region.
We are pleased that Academic Medicine can publish the first-place essays, submitted by Amanda Redig (Feinberg School of Medicine, Northwestern University), Viet Nguyen (University of Washington School of Medicine), Donna M. Kaminski (University of Medicine and Dentistry of New Jersey–School of Osteopathic Medicine), and Elliott Wakeam (Jefferson Medical College). All winning essays can be found on the Division of Pharmacoepidemiology's Website (www.DrugEpi.org).
Aaron S. Kesselheim, MD, JD, and Jerry Avorn, MD
Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.