Healthy Skepticism International News
May 2007
Is it insulting to suggest that health professionals are influenced by drug promotion?
by Peter R Mansfield
Director, Healthy Skepticism
One of the most important barriers to healthy skepticism about drug promotion is the belief that to suggest that health professionals are influenced is to insult them. I will present some arguments for overcoming that barrier below. I have found these arguments to be effective for use in presentations to health professionals.
I will focus on doctors because we have been the subjects of many studies of our beliefs and behaviours[1]. These studies suggest that doctors are human. We have the advantages of being human including capacities for compassion, intuition and humour. Consequently we have to accept that we also have the disadvantages of being human. There has been less study of other health professionals. If they are human, then the following may apply to them also!
Many doctors are confident that they are not much influenced by drug promotion or not influenced at all. However many of us are not so confident about our colleagues[2].
On 23 February 2007 an Australian newspaper for GPs presented a front page story about new ethical guidelines for interactions with drug companies produced by the Royal Australian College of General Practitioners. The report quoted a GP who described the new guidelines as “humiliating… We are highly professional people… this is all going too far. No doctor prescribes because of a pharmaceutical rep. If we think a product has no benefit for a patient, no gift in the world is going to influence us to prescribe it.”[3]
Other Australian GPs have asserted that:
- “It is an insult to doctor’s integrity to think they are going to prescribe a drug because the pen being used is emblazoned with the drug’s name.”[4]
- “Doctors have the intelligence to evaluate information from a clearly biased source.”[5]
A drug company employee has defended drug promotion as harmless because “doctors, who were obviously highly educated, could sort the chaff from the wheat.”[6]
In a 1963 speech an advertising executive asserted that “the medical profession is distressed to find its high opinion of itself not shared by writers of [prescription] drug advertising. It would be a great step forward if doctors stopped bemoaning this attack on their professional maturity and began recognizing how thoroughly justified it is.”[7]
It seems that to suggest that doctors are influenced by drug promotion is to insult their professionalism, integrity, intelligence and education.
In the 1840s doctors did not understand the risk of invisible microbes so were offended by the suggestion they should wash their hands. Nowadays the existence of invisible microbes is well accepted so the idea that we should wash our hands is not regarded as a personal insult. We are now going through a similar paradigm shift towards understanding the risk of invisible unintended bias from exposure to industry influence techniques. Just as professionalism, integrity, intelligence and education provide little protection against invisible microbes they also provide little protection from invisible bias.
To help understand this lack of protection please consider the example of a space shuttle commander. Space shuttle commanders are the elite of elite pilots. They are highly intelligent and very well trained. However, space shuttle commanders have to trust the experts in mission control to tell them if all systems are go for launch or not. They do not have the time to get out of the cockpit and check all the systems themselves. Nor do they have all the specific skills required. If mission control is wrong then they will be misled and they and their crews may die.
Intelligence and education do not protect people from being misled when they trust a source of information that happens to be wrong. Intelligence and education give us the ability to see through some promotional techniques some of the time. However, we rarely have the time and specific skills required to see through them all.
Doctors do receive many years of training. However few of us have advanced training in all of the following disciplines, all of which are useful for evaluating treatment decision making in general and drug promotion in particular:
- Medicine and Pharmacy
- Pharmacology, Epidemiology, Public Health, Evidence Based Medicine, Drug Evaluation, Pharmacovigilance
- Social sciences
- Psychology, Economics, Sociology, Anthropology, Management, History, Politics, Communication Studies
- Humanities
- Logic, Ethics, Rhetoric, Epistemology, Linguistics, Semiotics, Literature, Art, Religion
- Professions
- Marketing, Public Relations, Education, Advocacy, Regulation Policing, Law, Accounting
- Statistics
For example many doctors know little about epistemology and semiotics. Epistemology is the study of how we know what we know. Epistemology is relevant to evaluation of whether what we “know” is made more reliable by exposure to drug promotion. Semiotics is the study of signs and symbols including study of the meanings conveyed by images in advertisements. Whilst it is reasonable to be uncertain about the conclusions of semiotic analyses this field of study is clearly relevant.[8]
Even if we have a good critical appraisal radar, drug promotion often goes under the radar to work despite us giving it little or no attention. For example, advertising may create a small link in the mind between a drug and good feeling. In fact, promotional claims may be more effective if we are not fully aware of them because if we gave them more thought we would reject them.
In my personal experience over the past 25 years the disciplines listed above have all provided insights that are relevant to evaluation of drug promotion. However the more I learn, the more I realize how little I know and how much more there is to learn. Consequently, I have become less confident in my ability to resist being influenced by drug promotion. I still occasionally discover that I have unjustified beliefs about drugs that could only have come from drug promotion. For example one of my colleagues has a special interest in pain management and was amused to discover that I had some unjustified beliefs about oxycodone. I don’t know where I picked up those beliefs. I don’t see drug sales representatives so I guess I was influenced by an advertisement in a medical journal or from some other source that was influenced by promotion of that drug. It is difficult enough to remember everything we “know” let alone where we “learned” it. I am only human.
After considering all the issues mentioned above, I don’t feel insulted by the suggestion that I am influenced by drug promotion.
If you have any comments, suggestions or questions please contact: .(JavaScript must be enabled to view this email address)
Acknowledgement
Special thanks to Robyn Clothier for constructive criticism of the first draft.
1. www.healthyskepticism.org/library/topics/doctors.php
2. Steinman MA, Shlipak MG, McPhee SJ. Of principles and pens: attitudes and practices of medicine housestaff toward pharmaceutical industry promotions. Am J Med. 2001 May;110(7):551-2.
3. Eccles K. Gift guidelines ‘humiliating’. Medical observer 2007 Feb 23:1
4. Parrish R. Accusations of GP bribery by reps an insult. Medical Observer ( Australia) 2006 Jun 9; 25
5. Richards D. Guess who’s coming to dinner. Australian Doctor Weekly. 2004 Jan 23; 19-21
6. Riggert E. Doctors seduced by drug giants: Drug companies’ tactics spark rethink by doctors. The Courier Mail. ( Brisbane) 1999 Jul 26; 1-2
7. Garai PR. Advertising and Promotion of Drugs. In: Talalay P, Editor. Drugs in Our Society. Baltimore: John Hopkins Press; 1964. Available at: www.healthyskepticism.org/publications/editions/2003/10.php
8. Mansfield P. Accepting what we can learn from advertising’s mirror of desire. BMJ. 2004 Dec 18;329(7480):1487-8. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=15604193
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