Drug companies may be calling the shots

The strategies used by the pharmaceutical industry to influence doctors’ prescribing and treatment practices have come under a great deal of scrutiny in recent years.

Now: A recent survey shows that doctors are less likely than in the past to accept gifts or other financial incentives from drug or medical device companies, but there is still room for improvement.

The survey, which was completed by 1,891 primary care physicians and published in Archives of Internal Medicine, showed that a number of “relationship-building” incentives are still widely used. Overall, 83.8% of doctors reported some type of relationship with the industry in the year prior to the 2009 study. About 18% were reimbursed by drug companies for professional meetings and continuing medical education. In addition, 70.6% of the doctors surveyed received food and beverages from drug companies.

To learn more about the pharmaceutical industry’s continuing influence over doctors, Bottom Line/Health spoke with Carl Elliott, MD, PhD, a leading medical ethicist who has extensively studied drug companies’ relationships with doctors.

How do drug companies inform doctors about their products? As most people know, pharmaceutical companies employ armies of salespeople. Few people realize, however, the amount of influence that these drug reps can have over doctors. Many physicians are willing — and sometimes eager — to spend time with these reps. They are typically young, personable, smart and fun to be with. They also tend to be very good-looking.

Drug reps show up at doctors’ offices, hospitals and medical conferences. Their job is to get a few minutes with as many doctors as possible to talk about their products. If the rep is successful over a long period of time and persuades doctors to write a lot of prescriptions, the rep may even receive a bonus or commission.

During their brief meetings with doctors, the reps leave behind small gifts — coffee mugs, note pads, etc. Doctors don’t prescribe a different drug because of free mugs, but they are often influenced simply because such gifts are one way of creating goodwill between drug reps and doctors.

How do we know this? To test whether doctors are influenced by pharmaceutical companies, researchers at the Cleveland Clinic had the clever idea to compare doctors’ prescribing habits before and after they had gone on free trips sponsored by drug manufacturers. For one drug, the number of prescriptions written after a trip was awarded was 10 times higher than it was before.

What about the scientific studies that are conducted to determine a drug’s effectiveness? Doctors will tell you that they prescribe certain medications because studies prove that they’re superior or because leading experts recommend them. But the drug reps are often the ones who provide the drug research to the doctors. And even the doctors may not realize that the expert opinions and the studies themselves may be tainted by hidden sales strategies.

What are some of these hidden strategies? One is “ghost authorship.” This can occur in articles that are published in some prestigious medical journals or research that is presented at medical conferences. In each case, the information is linked with the names of prominent physicians.

However, the famous name (or names) at the tops of these articles may have only reviewed the material and provided suggestions. The real author, known as a “ghost,” isn’t listed anywhere in the article. He was probably a medical writer who was paid by a pharmaceutical company.

This practice deceives readers because an article that appears to come from, say, Harvard may, in fact, come from a pharmaceutical company. Though some journals have become more stringent and created policies against this, the practice still goes on at some publications.

Additionally, when a drug company wishes to establish a market niche for its drug, it may do so by publishing articles about a competing drug’s deficiencies.

For example, one of my colleagues was asked to review an article that would highlight the dangers of a popular blood-thinning medication. Later, she was sent a completed manuscript with her name on it. Only then did she realize that the company was developing a competing drug. Part of its marketing strategy was to insert negative references about the competition into the medical literature.

Are there any other ways that drug companies influence scientific research? Yes. With so-called “review articles,” a doctor summarizes the status of knowledge about a particular treatment. The author — again, a well-known physician who is widely respected — uses information from studies.

What’s interesting, however, is that some or even all of the background material for the review article may have been provided by the pharmaceutical company, which might omit “negative” material about a particular drug.

The author may have been approached by a pharmaceutical company because he is known to have a point of view that’s favorable to the company. As a “thought leader” in the field, this physician is in a unique position to influence the prescribing habits of other doctors.

Can’t physicians detect — and resist — industry influence? Most try, but it’s tricky. Just as the drug companies give small gifts to doctors, the pharmaceutical companies also provide the vast majority of funding for scientific research. Without this money, medical researchers can’t work — or get a salary. Industry influence is built into the system.

Even though grants from the National Institutes of Health and other government agencies are free from industry influence, these grants — given current budgetary constraints — are especially hard to get.

In fact, as a stipulation of grants from some pharmaceutical companies, the studies may be designed by the drugmakers themselves, not by the researchers. There are many ways to design a study so that a new drug appears better than it really is.

For example, suppose that a pharmaceutical company is funding a study that will compare an older drug with a new and “improved” drug. The study can be designed so that participants taking the older drug are given a lower dose — this is known as “under-dosing” the competition. The new drug will appear to have stronger effects.

Or suppose that a company has developed a new drug that will be advertised as having fewer side effects. Participants will be given a higher dose of the competing drug (“over-dosing”), which will exacerbate its side effect profile.

Don’t medical journals look out for such ploys when deciding which research to publish? They should — but you would be surprised at how many articles with questionable research are approved for publication in peer-reviewed journals. Studies can be manipulated in complex ways that require statistical expertise to spot.

What can medical patients do to protect themselves? If you’re concerned that your doctor’s prescribing practices may be influenced by drug companies, consider consulting ProPublica, http://Projects.ProPublica.org/docdollars, a nonprofit organization that has assembled a database listing payments from pharmaceutical companies to doctors. Patients can search for the name of a doctor. Receiving payments isn’t necessarily wrong, but it could indicate that a doctor may be biased in prescribing a certain drug.

Are there any specific questions you can ask a doctor to determine whether he has been influenced by the pharmaceutical industry? You can ask your doctor whether he accepts payments or gifts from pharmaceutical companies, and if so, whether the payment has anything to do with the drugs he is prescribing you. Remember: These influences are complex, and even your doctor may not be fully aware of how his decisions may be affected. But asking the question will prompt him to at least think about it.