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November 1, 2000

Gifts to Physicians in the Consumer Marketing Era

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JAMA. 2000;284(17):2243. doi:10.1001/jama.284.17.2243-JMS1101-4-1

Many physicians are concerned about the rise of direct-to-consumer (DTC) advertising of prescription medications. However, with an annual budget of more than $5 billion supporting 59 million sales representative visits to physicians and hospitals, drug detailing remains a cornerstone of the of the pharmaceutical industry's marketing strategy.1,2 Although often viewed as different issues, concerns about consumer-directed marketing may also apply to physician-directed marketing—in particular, gifts to physicians from the pharmaceutical industry.

A majority of physicians believe that DTC advertising can have an inappropriate effect on prescribing.3 This contrasts with physicians' mixed feelings about the effect of gifts from the industry. Studies show that most physicians believe that gifts do not influence their prescribing; however, the same physicians often believe that gifts influence their colleagues.4,5 Limited data suggest that these concerns may be well founded. One study of faculty physicians found that accepting a free meal was independently associated with self-reported change in their prescribing practices.6 Another study found that physicians who requested that drugs be added to a hospital formulary were more than 10 times as likely as their colleagues to have received financial support from the companies that manufacture those drugs.7

Other physicians worry that DTC advertisements erode public trust in physicians. Patients may lose faith in their physicians when advertising messages conflict with professional advice.3 However, gifts to physicians may also undermine patient confidence in the profession. Surveys show that as many as 70% of patients believe these gifts significantly impact prescribing, and as many as two thirds believe they increase the overall cost of medications for the public.8 Furthermore, 24% of patients reported that their perception of the medical profession changed after learning about drug company gifts to physicians.9

Another concern about DTC advertisements is that patients lack the sophistication to properly interpret companies' DTC marketing claims. However, physicians who view pharmaceutical representatives as a useful source of information may face similar challenges.10,11 Studies suggest that the information provided by representatives can be biased or even incorrect, and that physicians often cannot distinguish true statements from false ones.11 Moreover, many physicians appear unaware of the extent to which commercial sources of information shape their prescribing practices.12

Physicians' awareness of the consequences of gift-giving may be limited by the lack of policies and educational programs that address this topic.5,10 Many residency training programs have no policy regulating interactions with pharmaceutical representatives.13 Policies that do exist are poorly publicized and largely unknown to residents.14 As many as 90% of physicians feel they received insufficient training about how to interact with industry representatives,15 and guidelines from organizations such as the American Medical Association are not widely known. Perhaps more importantly, drug company gifts are an accepted social norm,4,9 and colleagues may be unsupportive of physicians and medical students who challenge these practices.

Despite their concerns about the marketing of drugs to consumers, physicians are not exempt from the ethical issues raised by pharmaceutical marketing. Issues of influence, patient-physician distrust, and a susceptibility to marketing ploys apply to caregivers as well as to patients. By highlighting these parallels, the debate over DTC advertising may be a useful way for the medical profession to reflect on its own relationship with the pharmaceutical industry.

Funding/Support: This work was supported in part by the Veterans Affairs National Quality Scholars Fellowship Program.
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