Does Pharmaceutical Industry Marketing to Medical Students Affect Their Prescribing Choices as Physicians?
Aaron Kesselheim, M.D., J.D., M.P.H., is an assistant professor of medicine at Harvard Medical School and a primary care physician based in the Division of Pharmacoepidemiology and Pharmacoeconomics at Brigham and Women’s Hospital. He is a 2009 recipient of the Robert Wood Johnson Foundation Investigator Award in Health Policy Research.
As a physician who studies trends in drug prescribing and seeks to promote evidence-based medicine, I have always been intrigued by the paradox related to the impact of pharmaceutical marketing on physicians’ behavior. Physicians are highly educated, and that preparation is intended to impart special insight when it comes to the medical literature and evaluating the data underlying potential treatment decisions. It is perhaps not surprising, therefore, that when physicians are surveyed, most report that pharmaceutical marketing does not sway their individual prescribing choices. Yet most objective studies show that marketing does indeed drive prescribing in non-evidence-based ways. And physicians, when polled, will generally not deny this effect, although they usually point fingers at their colleagues, believing them to be influenced by marketing, while claiming that they personally are not.
What’s going on? In numerous cases, pharmaceutical industry marketing has been shown to rely on distorted presentations of the medical literature, and many advertising campaigns improperly favor use of the particular drug being promoted in order to sell more product. Yet most physicians take seriously their professional ethical requirements, and I don’t doubt that all physicians try to apply their years of training to offer the best care they can to their patients. If so, why are physicians as susceptible to marketing messages from the pharmaceutical industry as ordinary consumers are susceptible to marketing messages they see on television?
One possible contributing factor is the perspectives and practices formed early in physicians’ careers. The socialization effect of professional schooling can be strong, exerting a powerful influence on how students behave after graduation. It is well known that medical students are frequently exposed to pharmaceutical marketing, even in their preclinical years. Some policymakers dismiss the relevance of these interactions; after all, medical students cannot prescribe drugs, so the potential for direct harm is limited. And medical students are often deeply in debt, and thus many sorely need the free supplies and books that might be distributed to them by pharmaceutical manufacturers.
To examine the extent of medical students’ relationships with industry – as well as the impact of these interactions – my colleagues, Kirsten Austad and Jerry Avorn, M.D., and I conducted a systematic review of the literature, examining all published studies on this topic and collecting the results from a total of 9,850 medical students studying at 76 medical schools. We confirmed that most students have some form of interaction with the pharmaceutical industry, and that such contact increases in the clinical years, with up to 90 percent of all clinical students receiving some form of educational materials. In the studies, medical students generally found industry-supplied materials useful, but agreed that the materials could be biased in self-serving ways. Almost two-thirds of students reported that they were immune to bias induced by promotion, gifts or interactions with sales representatives, although a substantial number agreed that others could be affected. It seems that physicians’ “them-but-not-me” attitude starts early.
Most importantly, we found that the extent of students’ contact with industry may be related to positive attitudes about marketing and skepticism toward any negative implications. In numerous studies, researchers have identified a direct association between exposure to the pharmaceutical industry and positive attitudes about industry interactions and the role of marketing strategies.
The studies in our sample took place in different locations and over multiple years. They also did not account for confounders, such as secular trends, that could be important in shaping students’ exposures and attitudes. But we believe these results suggest the importance of re-examining the extent of pharmaceutical industry marketing interactions in medical education, even in its earliest days. Students’ ability to learn to respect scientific principles and to critically review the literature informing evidence-based practices may not be compatible with simultaneous exposure to pharmaceutical marketing messages. These interactions indeed appear to serve as part of the “hidden curriculum” of professional schooling, which may influence the way students behave once they become practicing physicians.
In recent years, the medical profession has set new policies regarding disclosure of financial conflicts of interest with for-profit companies and funding of continuing medical education, in part to address growing concern over the negative effects that pharmaceutical marketing can have on physician prescribing choices. But we may not see real progress in this effort until we dig at the roots of the problem and look at the environment in which medical students learn to become doctors.
Read more about the RWJF Award in Health Policy Research.
Check out an RWJF Human Capital Web site story on a recent Aaron Kesselheim study on the impact of market incentives for drug manufacturers.
Listen to a May 2010 RWJF Clinical Scholars Health Policy Podcast featuring Aaron Kesselheim.
For an overview of RWJF scholar and fellow opportunities, visit http://www.rwjfleaders.org/.