The first study looked at what drugs doctors prescribed when they were offered all-expenses-paid trips by drug companies to conferences sponsored by the drug company. (Orlowski and Wateska. 1992)

This was done by checking the doctors’ prescribing patterns with the hospital pharmacy inventory. The prescribing of two drugs was looked at.

The prescribing patterns were tracked for 22 months before each conference and 17 months after each conference.

Ten doctors invited to each conference were interviewed about how likely they thought that such an incentive might affect their prescribing patterns.

There was a significant increase in doctors prescribing both drugs after the all-expenses trips to the conferences.

This alteration took place even though the majority of physicians who attended the symposia were sure that such incentives would not alter what they prescribed.

The second study was the first large-scale study of its kind (Halperin et al. 2004).

It demonstrated that:

1. gift-giving in radiation oncology was endemic;

2. each physician was likely to consider himself or herself immune from being influenced by gift-giving;

3. he/she was suspicious that the “next person” might be influenced.

There was a correlation between the willingness of individual physician to accept gifts of high value and their sympathy toward this practice.

From these two studies, it sounds as if medical decision-makers worry that others are too easily persuaded and are very confident that they themselves can’t be – even though their own behaviour suggests that something quite different may be happening, and that the more it happens to them, the more they accept it as normal.

Orlowski and Wateska.
Chest. (1992; 102:270-273.
“The effects of pharmaceutical firm enticements on physician prescribing patterns”
URL: http://www.ncbi.nlm.nih.gov/sites/entrez?db=PubMed&cmd=Retrieve&list_uids=1623766&dopt=Abstract)

Halperin et al.
International Journal of Radiation Oncology, Biology and Physics:
2004 Aug 1;59(5):1477-83
“A population-based study of the prevalence and influence of gifts to radiation oncologists”
URL: http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15275735)

I think if I was to give the talk again, I’d focus on the notion that doctors are free to keep the company of whomever they may choose in their own time, but in allowing them to be part of educational functions, we allow them into a space that is communal and, in a way, sacred. It is asking a lot from a doctor who may feel uneasy about receiving drug company hospitality to refuse a sandwich as this will aslo mean that they miss out on time spent with their peers, which can be very valuable. So drug company hospitality would best be restricted to meetings that are opt-in, rather than our current set-up, which is opt-out.

Personally I feel like the issue is tangential; yes, accepting lunch and clocks and pens and all that from people who are working very hard to be your friend is likely to have unfortunate effects on your practice, but declining lunch doesn’t go nearly far enough to correct the situation while offering a dangerous feeling of self-rightousness entirely out of proportion to the action. What’s needed here is better research practices and a more scientifically literate public; refusing a sandwich isn’t even a drop in the ocean.

I’ve been lurking but haven’t said anything til now.

How did your opposition go over?

It looks to me like you struck just the right tone; balanced, not too preachy and did not demonize Pharma. I admire you.

I wish I knew exactly where my pdoc stood on this issue. The pens/clocks/pads etc. are obvious and I know he’s given one drug talk. I don’t know why, but I feel funny bringing the subject up with him.

I didn’t realize Pharma marketing is a big deal over there as well.

http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0040150

on the PLoS, that gives details of how reps manipulate doctors emotionally so that they feel guilty and feel obliged to prescribe the rep’s drugs.

It sounds as if the deliberate manipulations of sales reps are designed to “trigger” guilt in doctors (who are probably going to be very conscientious and perhaps are a bit more susceptible to that kind of thing than other groups would be). If the sales rep intimates that they feel disappointed in the doctor because the doctor said they would prescribe and then did not, the doctor could end up berating themselves. “I’m not good enough, I have disappointed him, he feels let down, I might harm patients if I don’t prescribe this drug, the nice friendly sales rep will be disappointed in me, I’ll have let everyone down”.

I wondered whether such guilty ruminations might then combine to make the doctor look for and focus on the symptoms of patients that might fit the drug, and then simply be less aware of symptoms that did not fit, because he is more actively looking for justifications to prescribe the drug, in order to relieve himself of the pain of the guilt of letting the drug rep down, in having said he would consider prescribing it, and having done this when he was invited to lunch, so feeling under a sense of obligation, and the rep perhaps suggesting that he might be letting his patients down if he did not. Does this mean a doctor would feel less likely to “hear” evidence from the patient that did not support the case to prescribe it? It is just human nature – not deliberate deception or malpractice. The doctor might be more “primed” – because of guilt – to notice evidence that suggested he should prescribe it. The “rule” would be: “In order to please the sales rep, I need to find cases where I can safely prescribe this drug.”

In the end I got rather sick of them, and there’s no doubt it does skew the likelihood of a child being prescribed methylphenidate or atomoxetine. After all, if on one side there’s a pair of pushy parents loudly insisting that all that parenting classes stuff is bollocks and demanding you sort out their little monster, and on the other side there’s a set of smooth-talking drug reps telling you their wonders over a tasty sandwich…and in the middle is a stressed-out child psychiatrist…then it’s clearly going to increase the likelihood of that psychiatrist thinking, “Sod it, let’s give the meds a try.”