Physicians have frequent contact with pharmaceutical firms and their sales personnel, who spend substantial sums in the form of gifts, free meals and travel, and sponsored educational programs. The implications of these practices and attitudes about the physician-industry relationship were examined by conducting a MEDLINE search for English-language articles published since 1994. An internet database also was searched, and five key informants were interviewed. Of 538 articles providing relevant data, 29 that were published in peer-reviewed journals were analyzed. Sixteen of them dealt with the extent of physician-industry interactions. The same number of articles identified physician attitudes, and 16 of the articles examined the effect of the interaction on the practitioners. A majority of studies used a self-reporting cross-sectional survey design. Response rates ranged from 30 percent to 100 percent.
Interactions began as early as medical school. Most physicians met with pharmaceutical company representatives approximately four times a month starting in the residency years. As physicians left residency and began practicing, industry-sponsored meals and samples were replaced to some extent by honoraria, conference travel, and research funding. Both residents and physicians believe that the representatives provide accurate drug information, but they also reported believing that they place product promotion ahead of patient welfare and are likely to use unethical practices. Most physicians deny that gifts might influence their behavior. They see drug samples, continuing medical education, and conference travel funding as having more influence than promotional materials. Interactions with pharmaceutical representatives seemed to influence the prescribing practices of residents and physicians. Those accepting gifts professed to believe that the representatives have no effect on their prescribing behavior. Samples, in general, were associated with positive attitudes toward industry. Accepting funds to attend a symposium correlated with increased requests for the sponsor's drug. Physicians participating in sponsored continuing medical education programs changed their prescribing practices in favor of the sponsor's drug. Accepting an honorarium to present information on a new treatment and receiving research support correlated with requests for the sponsor's drug but also for any drug.
This survey suggests that interactions between resident and postresident physicians and the pharmaceutical industry do influence prescribing behavior. These issues should be addressed at both the educational and policy-making levels.
JAMA 2000;283:373-380
(At many levels, the interaction between the pharmaceutical industry and the medical profession is controversial. Approximately $10,000 per physician per year is spent by sales representatives as a trickle-down to physicians. The expenditure includes free meals, travel subsidies, and sponsored meetings, with the hope of having an impact on prescribing behavior (T Randall, JAMA 1991;265:440).
A. Wazana conducted a MEDLINE search from 1994 to 1999 to address the factors affecting drug prescribing; 29 of 531 studies were analyzed. The physicia's interactions with pharmaceutical representatives began in medical school and continued at an encounter rate of four times per month after graduation. Continuing medical education programs many times highlighted sponsors' drugs; compared with other continuing medical education programs, sponsors' programs were associated with increased prescription rates of sponsors' medications. The authors concluded that the present extent of physician-industry interaction seems to affect prescribing and professional behavior (JAMA 2000;282:373).
Some of the physician-industry interaction is helpful. Most physicians and residents believe that conferences, lunch rounds, sponsored symposia, and visiting professors would decrease markedly without industry-paid meals and/or honoraria and expenses paid to the speakers. However, a powerful vehicle for prescribing seems to be conference travel funding, which influences prescribing habits more than promotional material does (TS Caudill et al., Arch Fam Med 1996;5:201).
To provide quantitative data about the accuracy of information provided to physicians by pharmaceutical representatives, Ziegler et al. analyzed 106 statements about drugs made during 13 presentations by pharmaceutical representatives. Statements were considered inaccurate if they contradicted the 1993 Physicians' Desk Reference or material quoted or handed out by the sales representative. Twelve (11 percent) of 106 statements were inaccurate. All 12 inaccurate statements were favorable in promoting the drug, whereas 39 (49 percent) of 79 accurate statements were favorable. None of the 15 statements about competitive drugs were favorable, but all were accurate. In a survey of 27 physicians who attended these presentations, 7 (26 percent) recalled any false statement made by the pharmaceutical representative, and 10 (37 percent) said that the information influenced the way they prescribed drugs. The authors concluded that approximately 11 percent of the statements made by pharmaceutical representatives about drugs contradicted information readily available to them and that physicians generally failed to recognize the inaccurate statements (JAMA 1995;273:1296).
The American College of Obstetricians and Gynecologists (ACOG) Committee on Ethics believes that the pharmaceutical industry does assist fellows and junior fellows in pursuit of their educational goals through financial support of various medical education programs. The ACOG clearly states that advertising or marketing practices must not influence the accuracy, completeness, or balanced presentation of medical advice given to patients. Physicians should go beyond the information provided by the advertising or the approach of the sales representative, and physicians must maintain a standard of professional conduct that is not influenced by the provision of gifts, parties, trips, and services (ACOG Committee Opinion, Committee on Ethics. Washington, DC: ACOG, 1997;182).
Continuing medical education is the cornerstone of life-long learning; physicians do need access to comprehensive and reliable product information that will in the end assist physicians in providing state-of-the-art patient care. Medical schools should train medical students and program directors, and institutions should have specific programs for residents regarding ethical issues that may arise in respect to relationships with industry and to physician-prescribing practices. Residents and physicians should understand that the cost related to marketing to physicians is ultimately borne by the patients.-RCC)