How Aware Are Physicians of Commercial Influence on Prescribing?

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Image retrieved from on September 11th, 2013.

Dr. Jerry Avorn, Milton Chen, and Dr. Robert Hartley of Harvard Medical School developed a clever "gotcha!" for practitioners, which they published in 1982. They selected two drugs for which there was a clear disconnect between what the medical journals reported as the scientific findings and what was claimed for the drugs in commercial marketing. Propoxyphene (Darvon) was widely touted for relief of moderate pain, when the evidence showed it was no better than acetaminophen or aspirin. several drugs, cerebral vasodilators, were argued to improve the symptoms of dementia by improving blood flow to the brain, but no published studies had shown them to have any useful effect.
The authors did telephone interviews with one hundred internists and general practitioners in Boston. (Fifteen refused to participate for an 85 percent response rate.) Of those answering, 68 percent described the drug advertising as of "minimal importance" in their prescribing habits; 28 percent called it "moderately important"; and only 3 percent viewed advertising as "very important." Detail reps were considered some what more important, with respective figures of 54 percent, 26 percent, and 20 percent. By contrast, 62 percent claimed that scientific papers were "very important" in influencing which drugs they used.
Avorn and colleagues then asked about their target drugs. The physicians agreed by a 71 percent majority that "impaired cerebral blood flow is a major cause of senile dementia," and 32 percent said that they found cerebral vasodilating drugs useful in managing confused geriatric patients. Forty-nine percent stated that Darvon was more potent than aspirin; only 31 percent thought them equivalent.
In sum, these physicians seemed to believe that they were minimally influenced by drug ads and drug reps and instead used only scientific sources of information; yet they believed things that could never be found in medical journals and that could only be heard from company sources. And their own assessment of where they got their information (journal articles vs. drug reps or ads) was unrelated to what they believed to be true.
Dr James Orlowski and Leon Wateska, a pediatrician and pharmacist respectively at the Cleveland Clinic, performed a study at their medical center which has since been widely quoted. Leading physicians at the Cleveland Clinic were invited to attend a conference at a tropical beach resort, all expenses paid, to hear presentations from the company about each of the two drugs. Each drug was administered intravenously in a particular specialty unit, so that a relatively small number of physicians could greatly influence the rate at which the drug was prescribed.
Orlowski and Wateska looked at prescriptions for each drug in the twenty-two months prior to and the seventeen months after the resort trips. They found that the first drug was used at about three times the previous rate after the trip, and the second drug was used at more than twice the previous rate. Orlowski and Wateska then looked at utilization data for these drugs in all large U.S. hospitals during the same time period and found no comparable increases. They concluded that the increased prescribing could therefore not be due to any national trend.
The authors interviewed twenty physicians (ten from each resort trip group) and asked them if they thought they could possibly have been influenced in their drug prescribing behavior by these junkets. Seventeen of the twenty denied flatly that a resort trip could have any such influence. Three were less certain, but none of them felt it likely that they would be influenced.
Finally, a third paper (not strictly a research paper) provides some further clues as to how aware physicians are of the way in which they are influenced. A group based at the University of Toronto, headed by Dr. Neil H. Shear, set out to design an instructional intervention for physicians. They reasoned that the vast majority of physicians see drug reps, and so it made no sense to tell them not to. Instead they decided to see if they could train physicians how to use the visit with the rep to get their own educational informational needs better met.
Dr. Shear and his colleagues made use of a video made in Australia that depicted a physician being detailed on a fictitious antidepressant. The audience agreed that video was very authentic, matching closely their own experiences with drug reps. Shear and colleagues reported their surprise that when they pointed out the fairly obvious and typical selling techniques used by the rep in the video control and steer the interview, most physicians reacted as if becoming aware of these for the first time. Also, when they designed a checklist that allowed the physician to take charge of the interview and to get information on things that doctors needed to know about the medication, the direction the interview would take differed dramatically from the "normal" rep visit--showing again the error in the widely held claim by the industry that drug detailing is primarily an educational "service."

pp. 185-186, Hooked by Howard Brody (2007)

Darvon, prescription, pharmaceutical, drug reps