May 9th, 2013
Journal X: Not so Subtle Marketing Messages
Eric Lindley, MD
I was the rare resident who thought that conflict of interest issues in medicine were a bit overblown. I did not find (or ignored) the evidence that pharma played a role in prescribing habits very persuasive, at least not when it came to my personal prescribing habits. I was not alone among the house staff, however, in appreciating an occasional “free” lunch, and the much rarer sponsored dinners at places I couldn’t afford as a physician-in-training.
Now I’m a fellow, and my attitudes about the pervasiveness of pharma influence have changed. Am I older and wiser? I’d like to think so. But I owe most of my conversion to the fresh perspective of my three-year-old daughter. She refers to most things by their color, including a majority of my medical journals. For instance, my JACC journals: blue for the mother journal, red for heart failure, green for interventions, etc. But then she started calling the original JACC the “X” journal. When I asked her why, she pointed to the “X” in Xarelto (rivaroxaban). I realized that every issue of JACC is covered front to back with the “X”. The message was subliminal to me, but quite obvious to her.
How do you think all of our pharma marketing looks with naive eyes?
10 Responses to “Journal X: Not so Subtle Marketing Messages”
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A story that I heard at ACC a few years ago goes something like this:
In a roomful of interventional cardiologists, the speaker asks, “How many of you have ever put in a stent that was unnecessary?”
Two or three hands went up.
The speaker then asks, “How many of you have seen someone in this room put in a stent that was unnecessary?”
About half the room raised their hands.
I think there is something similar with respect to our attitude towards pharma ads and gifts. I know plenty of residents and fellows who firmly believe that ads and dinners do not affect their personal practice patterns. Whether or not this is true for any given individual, the fact that pharma continue to spend so much on these activities suggest that as a whole, we are probably more susceptible than we believe.
The effect of such influence has been well studied. Yes, it makes a difference, or (as suggested by Dr. Ye) the pharmaceutical companies would have stopped spending millions a year on gift items and dinners long ago. Many physicians greatly underestimate the influence of marketing on their prescribing choices. Also, germane to Dr Ye’s experience, a recent published survey found that approximately 35% of physicians believed that gifts affected their own prescribing, but over 50% thought it affected the prescribing habits of their colleagues.
Fortunately, some medical schools are beginning to discuss the topic of “conflicts of interest” for physicians, toward greater awareness of our inherent (if subconscious)potential for bias when the presence of inappropriate influence goes unrecognized. Based on existing medical and psychological literature, for residents, fellows or any other medical professional to believe that they cannot be so influenced is at best naive, at worst, denial.
Marketing is necessary. It is done to our politicians (lobbyists), laypeople (ads, coupons, and various incentives to induce people to buy something), professionals of all stripes (look in the technical journal of any discipline from analog circuits to zoology and see all of the advertisements),and anyplace else in America except maybe the jails. Marketing is the only way a manufacturer has to get people to know their products. Marketing even occurs in our military, that is how recruiters get promoted. I’ve seen the worst, most cruel and misstated marketing occur in political advertisements.
I never believed, nor do I believe now, that marketing attempts by pharma, device manufacturers, or anyone else for that matter has much influence on what we physicians recommend or prescribe.Most of these items “sell themselves” whether it be Xarelto as mentioned in the post, or penicillin when it first became available. Think, what would be your choice as an oral anticoagulant in a person allergic to warfarin sodium? It would have to be one of the three new, expensive medications on the market.
Conflicts of interest are truly a problem when a physician puts a particular brand and any personal gain associated with it ahead of patient interests. For example, I knew many fine academic specialists at a particular university who regularly prescribed Vioxx and Bextra to patients while they were being paid to speak at CME conferences on the subject of COX 2 inhibitors. This went on even after post marketing adverse events were reported. Some of these physicians are the same ones serving on professionalism committees at that same medical college creating policies barring pharmaceutical representatives from their respective facilities.
American industry has a long tradition of marketing, and professional marketing has its place. It is up to the individual physician to take information they have gleaned from salespeople and put it to good use. If a physician is unable to use proper discretion in making prescribing decisions, they probably should never have been admitted to medical school. Proper behavior is something that should be learned well before medical school, and I place the responsibility on the medical school admission committees to sift out the wheat from the chaff.
In conclusion, I feel that a well balanced approach to learning about new products is necessary to be well informed. The perspective from the manufacturer is necessary for us to make the correct decisions. I feel we have gone too far in our restrictions regarding industry sponsored events, especially events that benefit the local economies, create jobs, and otherwise make our lives less dull.I can honestly say that I never went to an industry sponsored event where I learned nothing. I may be the only Doctor to say this, and may be jeered for doing so, but I miss the many networking and learning opportunities that I once had complements of our manufacturers.
I spent 6 months of medicine electives as a student in england in 1985, remember, the dept head had to review and authorize the drug luncheon(with white linen/china) when the entire faculty, house staff and medical students were expected to attend, review/ discuss the new drug, pros/cons before it was approved for the hospital formulary. That was back in 1985 in england…we can learn a few from socialized countries.
As one overseas colleague noted on her visit to the States, americans are great at marketing, “you make shit
look attractive”…pardon my language.
I remember when doctors/hospitals/drugs when first started to be marketed on public media…don’t think it takes a rocket scientist to figure out marketing has huge influence if not subliminal!
We are finally examining our behavior…it is placing our economy at risk….
economics ultimately drives policies.
As my wife and I were heading to the country for the weekend, we passed a billboard (ergo: “the country” is not Vermont)advertising the excellence of a local orthopedic group. All 8 or 9 of the white coated colleagues stood together as a testament to their greatness. There is no reason to assume that they are not all well trained and well intentioned, but the mere fact that they (or their business managers) feel they have to advertise is a sign of the erosion of a profession.
Not long ago the notion of doctors advertising was not only frowned upon but was prohibited, for good reason in my view. Our profession has been following in the footsteps of our legal brethren for years. The ambulance chasing ad has given way to the ambulance directing ads of expanding medical networks that seem to becoming too big not to fail.
The direct marketing on TV of drugs, many soon destined to reveal their fatal adverse effects, has a particularly exalted position in the pantheon of odious developments in our profession. The naive audience also includes us. The drug ads are among the longest TV ads due in part to the required recitation of side effects, including elevated risk of death,and to the instruction to patients to “tell your doctor” lots of things about you that he/she should already know. For example, “Before the doc offers you something that may increase your risk of bleeding, inform the doc that you have a peptic ulcer.”
The ads imply that none of us is performing the role well enough and this may or may not have some factual basis, but they assault our professional integrity and perhaps reflect genuine public perceptions of us.
Sadly ironic that a 3 year old sees clearly what we deny. The bottom line has become the bottom line.
The fellow’s comment regarding (subliminal) effects of Pharma advertising (readily visible to his 3-yo daughter) will become an issue when she reaches med school.
We are all bombarded by advertising all the time. I suppose some of it is effective. But it is the responsibility of an intelligent adult to decide his/her habits. Blaming others for trying to influence you seems rather puerile. Does anyone think that s/he is going to live in a world without advertising?
Further, I do not see any evil prescribing the same drug which the physician personally uses (or the stent which s/he has received) to a patient (unless it has been superseded by a better version).
As for the recent tidal wave of resistance to Pharma representatives and Pharma free lunches by Medical Schools, I have yet to hear of Med schools turning away Pharma money for faculty research/salaries. Most of the efforts of Deans has been to reassure the public that free pizzas and sandwiches and textbooks for house staff will not be allowed to pervert their thinking. As for faculty, I suppose the Deans think that it is too late to alter their habits of mind.
Re: anonymous from several posts back, I agree that there is often a reverse issue, namely how to improve the uptake of new treatments that have found to be effective. My sense is that compared to the slow uptake of beta blockers for CAD patients in the 90s, we are better about this than before. However, I don’t think it’s true that pharma should be the only source or the only primary source of medical information. I would argue that the practices such as academic detailing (http://www.narcad.org) should be expanded and supported, and that pharma education events should have elements that foster transparency and accountability such as peer review.
Re: Dr. Mark, I would argue that the pharma-researcher relationship is quite different from that of the pharma-physician relationship. Certainly the former can be problematic and needs to have transparency and accountability as well, but bias or even appearance of bias due to pharma-physician interactions can harm the primary fiduciary duty of physicians, which is to the patients they care for. As a profession we must come to terms with this, as we can no longer pretend that we are not being scrutinized: http://www.propublica.org/article/dollars-for-docs-mints-a-millionaire
My college Dr. Ye makes some excellent points.
I agree with his contention that “bias or even appearance of bias due to pharma-physician interactions can harm the primary fiduciary duty of physicians, which is to the patients they care for”. However, if it was not for the capitalist urges of these companies, physicians would still, for the most part, be bleeding patients to treat disease. We would likely not have LVADs, ICDs, stents, or even Xarelto etc. etc.
Unfortunately, whether we like it or not, far less than ideal interests are always between the physician and the patients they care for, and some of these have nothing to do with drug companies.
That is why almost ever major academic center is making the flashiest cancer center and far more focus is given to placement of LVADs, ICDs, etc. than primary prevention.
If we want a more perfect world, why focus on just the drug/device companies? Is it any less different that we reward doctors far more for doing procedures than thinking critically about patients and trying to keep them from needing procedures? Why do certain centers at hospitals look like 5 star hotels, while others haven’t been renovated in decades?
I am curious to see what people think is the best answer to this complex issue.
Dear Tariq,
I disagree that improving marketing practices would return us to the day of the leeches. Pharma has an undeniably important role in innovation and bringing the fruits of medical advances to the greatest number of patients. Drugs and devices that are effective and safe SHOULD make a profit for the companies that make them.
But this is not what the argument is about. Let’s look at an example:
Suppose drug A has an excellent track record for safe and effective treatment of disease X. However, company Z creates drug B, and does an excellent job promoting it, using some of the tactics such as paid speakers and sponsored meals as described in the posts above to quickly gain a large market share. However, years later it turns out that not only drug B is more expensive, but it also causes harm for a large number of patients.
I would argue that even the most fervent believers of free market would be offended by the above, yet from Avandia to metallic hip implants, the above scenario has been repeating itself over and over. You might even argue that true innovation is being stymied in the current system, because these bad products that are nonetheless marketable and profitable are an inefficient allocation of R+D resources (from the perspective of the broad healthcare market).
As for your other points, I recognize that medicine is not practiced in a vacuum, that at every level of organization there are legitimate economic interests (and conflicts). I also agree that the current reimbursement system leads to distorted incentives. But I think recognizing these issues, and starting honest conversations about them (and perhaps changing a few minds), are part of process for improving our flawed system.
“Stranger than subliminal ”
Dear colleagues
If we open the home page of NEJM iPad app we have more than à subliminal picture about ForXi… A New antidiabetic!
The now well known half powder filled bottle appears flashing
Difficult To Forget this advertissment and. ‘X´ .