How other doctors (not you) are influenced by Big Pharma

The pharmaceutical industry spends billions of dollars each year on handing out free samples of their expensive brand name drugs to physicians, who in turn hand them out to their patients.  As I’ve written about here and here, the obvious marketing truth is that no company would be doing this unless the strategy resulted in a significant increase in sales of those drugs.  When you’re looking at a global market for pharmaceuticals expected to top $1.1 trillion by next year, that’s a substantial incentive to keep up this practice. Still, very few physicians believe that doctors accepting billions of dollars in free drug samples annually has the slightest bit of influence on the way they practice medicine. Except, of course, when it’s those other docs out there who are accepting the freebies. 

Some studies have reported this pervasive sense of righteous denial among medical professionals, including one undertaken by the American College of Obstetricians and Gynecologists (ACOG) and later published in The Journal of Medical Ethics.*

This study set out to assess the opinions and resulting practice patterns of obstetrician-gynecologists regarding the acceptance and use of free drug samples and other free incentive items offered to them by Big Pharma drug reps.

Over 92% of the physicians studied thought it proper to accept free drug samples. After all, patients love them, right?

But surprisingly, one-third (33%) of the same ACOG respondents admitted that their own decision to prescribe a drug would probably be influenced by accepting these drug samples. Other studies also confirm this admission: once the free samples of high-priced meds are used up by their patients, physicians who gave out those free samples in the first place are indeed more likely to pull out the prescription pad and order a (no longer free) course of the expensive brand name drug.

A well-known example is a 2005 study (Adair et al) out of the University of Minnesota in which physicians with access to free drug samples were not only found to be less likely to prescribe cheaper generic (non-advertised) drugs than those docs who did not have such access, but were also less likely to recommend over-the-counter medications that would have been appropriate alternatives to the expensive prescribed meds – thus paradoxically increasing total drug costs for patients who had started off with the free samples.

About 77% of physicians surveyed in the ACOG study also thought that accepting free “informational meals” provided by a drug company was just fine, roughly the same percentage (75%) who insisted that receiving a free anatomical display model (clearly branded with the drug company’s corporate logo, of course) was acceptable, too. And over half (53%) saw absolutely nothing wrong with becoming a well-paid drug company consultant (what the industry likes to flatteringly refer to as Thought Leaders” or “Key Opinion Leaders).

As bioethicist Dana Katz and his colleagues explained a similar observation in the American Journal of Bioethics in 2003:

“When a gift or a gesture of any size is bestowed, it imposes on the recipient a sense of indebtedness. The obligation to directly reciprocate, whether or not the recipient is directly conscious of it, tends to influence behavior.”

But just as we suspected,  the ACOG respondents were more likely to claim that the average doctor’s future prescribing habits would be far more  influenced by accepting these items than their own acceptance would be.

The established marketing practice of Big Pharma spending on free samples may in fact be slowing down. In 2007, drug companies spent $8.4 billion on samples to leave behind in doctors offices. But by 2011, these companies spent just $6.3 billion.

The reasons that doctors give out these samples seem obvious: about 94% of the ACOG docs who distributed drug samples to their patients told researchers that they did so because of patients’ financial need and for convenience (76%). Some doctors cite the usefulness of letting a patient try out a short trial of a new drug to observe potential side effects or efficacy.

But fewer docs list the reason as “physicians’ knowledge about the drug” – in other words, they did not know whether or not the sample product was the most appropriate treatment (63%).

In fact, we know that doctors admit to handing out free samples of specific drugs that may not actually be what they would choose to recommend to patients if they didn’t already have a drawer full of the samples on hand.

The ACOG study participants agreed, judging free samples to be “influential on future prescribing practices.”

In 2007, the Association of American Medical Colleges held a symposium at Houston’s Baylor College of Medicine called “The Scientific Basis of Influence and Reciprocity.”  This event was designed to explore how objectivity was affected by gifts, favors, and influence. One of the participants in the symposium presented the findings of an experiment using functional MRIs of the brain in people playing a “two-person trust game.”  The findings suggest that specific areas of the brain actually react when a person receives a favor or gift from another. In other words, accepting even a pen, pad, coffee mug or free drug sample may generate an unconscious bias toward trusting that what a drug company rep says about his or her product is true.

Despite the fact that the vast majority of the ACOG study’s physicians admitted accepting free stuff from their drug sales reps, one-third (34%) of them paradoxically agreed that these interactions with industry should be more strictly regulated.

The study authors’ conclusion:

“The widely accepted practice of receiving and distributing free drug samples needs to be examined more carefully.”

Canada’s University of Victoria drug policy analyst Alan Cassels is the author of the book Seeking Sickness: Medical Screening and the Misguided Hunt for Disease.  He concludes even more bluntly:

“The appeal of freebies is obvious: everyone loves something for free, especially those patients who feel good about skipping the pharmacy and saving themselves money. Doctors like satisfied patients, and helping out someone who maybe can’t afford their drugs probably feels good, too.

“With all the feel-goodery swirling around drug samples, society seems to act like a kid in a candy store when it comes to applying caution to how they’re used.

“In my opinion, we need to ban or severely restrict the use of free samples.”

Some academic and hospital facilities have indeed already prohibited their physicians from accepting free drug samples.  The University of Michigan Health System has banned free samples altogether, and the University of Pennsylvania and Stanford University medical schools have prohibited staff members from accepting them (though samples can be given to Stanford’s pharmacy for use in free clinics).

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9 thoughts on “How other doctors (not you) are influenced by Big Pharma

  1. In cluttered markets like antihypertensives or antidepressants, samples may tilt the doctor to starting a patient on what is in the cupboard – as there is little difference between many drugs. Drugs out of patent are never sampled nor are those where there is little competition. Doctors also like the notion of giving patients a “freebie“. For what it is worth I stopped accepting samples 8 years ago and my patients are no worse off in my view.

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    • Hi Dr. Joe – patients like the notion of getting those ‘freebies’, too. At least in the beginning . . . There is no marketing advantage in offering free samples of unbranded off-patent drugs – I guess that’s why there are no samples.

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  2. Hi Carolyn,

    The seeming disconnect between what doctors say they do and what they say others doctors will do reminds me of a finding from political science. As the economist Justin Wolfers at the University of Michigan has shown (among others), a very good predictor of who will win an election is not who people say *they* will vote for, but who they say *others* will vote for. Wolfers pointed this out before the recent US Presidential election, when there were (sometimes) conflicting data about whether Obama or Romney would (though the smart statisticians all had it right). And, indeed, at almost every point, the majority of Americans though that Obama would win, no matter who they intended to vote for.

    It makes me wonder whether we shouldn’t start asking this question in more domains of human economic and political life. Sure, sure: *You* would never do X. But what do you think other people like you (voters, doctors, students) will do? If the phenomenon is widespread — and I suspect it is (there’s probably a vast literature I’m not familiar with) — it would suggest, oddly, that we’d better predictors of our own behavior by imagining the behavior of others under similar circumstances.

    And then we might all stop and think, “Oh dear. Maybe I’m not as immune to these influences as I think I am.”

    –Ed

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    • Hi Ed – very interesting about the voting analogy. Wonder if it’s because voters try to make sense of externa community indicators (billboards/lawn signs/TV ads) along with what results radio talk shows and water cooler conversations generally hint at? Docs on the other hand, are likely aware at some level of the pervasive influence Big Pharma has on “marketing-based medicine”, so they may be willing to acknowledge pharma’s ability to influence prescribing behaviour of their colleagues while being less willing to admit to the same influence personally.

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  3. Hi Carolyn,
    I read your post with great interest because as you might have read in the press the “medicines war” goes on in the economic crisis ridden countries, my country Greece among them.

    Over-prescribing, directed prescribing and more accusations of doctors bad habits are the order of the day… The recently implemented e-prescribing is also conceived as a tool to put gates to prescribing by auditing the monthly medicines quotas of each doctor …

    To my knowledge sampling is also here limited to selected branded medicines. As prescribing by drastic substance and not by trade mark is mandatory (unless the patient is willing to pay the price!), it is expected that big pharma will have every interest to convince doctors, and by their intermediary patients, that branded medicines are more effective than unknown generics…The tool in this case will be, you guess what, free samples…

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    • Thanks for sharing your perspective from Greece, Kathi. As in Greece, free drug samples here are the expensive brand name drugs. There’s just not enough money in making low-cost generics to warrant the expense of providing freebies!

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  4. Reblogged this on EpatientGR's Blog and commented: Στο παρακάτω άρθρο από το blog ethical.nag αντιγράφω το άρθρο “Πώς άλλοι γιατροί (όχι εσείς) επηρεάζεστε από τις μεγάλες φαρμακευτικές εταιρείες”. Η συγγραφέας, Carolyn Thomas, είναι επαγγελματίας των δημοσίων σχέσεων και της επικοινωνίας αλλά και γνωστή blogger του http://www.myheartsisters.org στο οποίο γράφει για την εμπειρία της με το έμφραγμα στις γυναίκες, και του http://www.ethicalnag.org στο οποίο γράφει για θέματα διαφάνειας στην κλινική πράξη, τα φάρμακα και θέματα δεοντολογίας.
    Η διάθεση δωρεάν δειγμάτων στους γιατρούς από τις εταιρείες τα οποία οι γιατροί διανέμουν δωρεάν στους ασθενείς τους, είναι πρακτική που τούς ωθεί στη συνέχεια να συνταγογραφούν τα συγκεκριμένα φάρμακα;

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  5. Pingback: Profiles in Medical Ethics

  6. I hope this isn’t about the USA – i know this post is from 2013 — but the states pharma and device companies have not been able to give out any freebies in almost 10 years. Difficult to cite a 2005 study in such a dynamic environment.

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