Any company making a product for sale must and does engage in marketing practices to support the sale of that product. There is little that “sells itself” in the marketplace. So pharmaceutical manufacturers advertise to their customers—physicians. But society should nonetheless be bothered by the various attempts by pharmaceutical companies to influence the behavior of academic and community physicians.
The rationale often offered for many of the marketing practices directed at physicians is that they are a form of education, not marketing. And physicians, whose first and foremost ethical and professional responsibility should be to serve the best interests of their patients, need to be well educated in the enormous complexities of medicine in order to do so. So of course any rational patient wants his or her physician to be as knowledgeable as possible about conditions and possible treatments. The enormous push for “evidence-based medicine” in recent years reflects this convergence of physicians’ responsibilities and patients’ interests.
But, as Angell correctly argues, it is absurd to think that drug companies are well positioned to carry out this education in the service of evidence-based medicine. Drug companies are indeed in the drug business, not the education business. Their goal is to convince doctors that their products are better than those of any of their competitors, not to conduct unbiased comparison studies of their and their competitors’ products, and to present objectively the evidence of those studies to physicians.
That is the fundamental reason why the financial entanglements that Angell details between physicians and the drug companies are not in the public or patients’ interest. Companies foster relationships with physicians in order to distort, not to maximally and objectively inform, their decisions about how best to take care of their patients. I believe it follows that the public interest is best served by limiting or eliminating any entanglements designed to distort physicians’ decisions about the care of their patients. Angell notes two important examples in her recommendations regarding faculty acceptance of financial payments and of gifts from drug companies.
What other common entanglements between medicine and drug companies should be straightened out? One is advertising in professional journals, which has made many journals financially dependent on these companies. This can subtly influence the editorial practices of those journals in conscious and unconscious ways, and, as the advertisers know, readers will be influenced just by the repeated viewing of advertisements for the latest product. A central purpose of professional medical journals is to educate physicians. Drug ads in those journals make no contribution to that purpose, indeed they are in conflict with it.
Increasingly, drug companies reach out to physicians via advertising to patients: “ask your Doctor about whether . . . might be right for you” is a common theme of such ads. But the ads take this form because patients cannot directly purchase at their pharmacy medicines available only by prescription. When prescribers are influenced by their patients in response to these ads, they are again deflected from an informed and objective assessment of what will best serve their patients’ needs.
Another important marketing practice relies on what are known as detail persons. Often attractive young women, they visit doctors’ offices to promote their company’s products, an important component of which is to leave free samples of those products for distribution to patients. The typical rationale for detailing is, again, education. But, as I noted earlier, it is unlikely that a physician educated by people with strong conflicts of interest and no incentive to provide objective, unbiased information will really learn best practices. This is also why the current regulations to keep continuing medical education free of industry bias, while still allowing industry funding of that education, are inadequate. Doctors are well-paid professionals and, as Angell says, should fund their own education.
Even if visits from detail persons toting free samples are not a good means to educate physicians, the practice is often defended as serving the interests of patients because it facilitates access to drugs. With samples available, patients can start taking medications sooner than if they had to wait to fill a prescription. More importantly, samples enable poor patients without prescription drug coverage, of whom there will still be many even with the recently passed health insurance reform, to obtain medicines they otherwise could not afford.
Improving the accessibility of drugs is a laudable goal, but it comes at an unnecessarily high cost when accomplished using free samples. Typically, these are samples of expensive alternative drugs. To the degree that the samples inspire prescription, they counterproductively drive up health costs, and they may divert doctor’s judgments from the medications that would best serve their patients. We should find less conflicted ways to make drugs available to patients.
Cloaked in promises of educating physicians, drug-company marketing can worsen patient outcomes. As such, it requires rigorous regulation to ensure that it is as unbiased as possible. At the same time, medicine as a profession needs to strengthen its own commitment to unbiased education so that physicians feel less compelled to rely on industry marketing. As Angell describes and these examples reinforce, industry sales practices corrupt physicians’ commitments to serve their patients’ best interests. These advertising-as-education schemes are no part of reasonable pharmaceutical marketing.