How Industry Manipulates Physicians For Product Promotion

As an homage to May 4th, I wanted to highlight an AAP report that reminded me of Yoda telling Luke Skywalker: “If once you start down the dark path, forever will it dominate your destiny, consume you it will, as it did Obi-Wan’s apprentice.”

DS Diekema. AAP Committee on Bioethics. Pediatrics 2022; 149: e2022056549. Open Access. Health Care Clinicians and Product Promotion by Industry.

Background:

  • “In 2016, pharmaceutical companies spent $29.9 billion on marketing, of which $20.3 billion (68%) was directed toward health care clinicians in the form of prescriber detailing ($5.6 billion), free samples ($13.5 billion), direct physician payments related to specific drugs ($979 million), and disease education ($59 million)”
  • “In 2019, 615 000 physicians received payments or investment interests worth $3.6 billion (an average of $5854 per physician recipient), and 1194 teaching hospitals accepted payments totaling $2.63 billion”
  • “Despite their own sense of invulnerability to persuasive techniques, physicians do consider other physicians to be vulnerable.125  This phenomenon is what social scientists refer to as the “bias blind spot.”147  As a general rule, individuals underestimate the degree to which they are influenced by cognitive and motivational bias and overestimate the degree to which others are influenced by the same things.147 

Key points:

“In his book, Influence: The Psychology of Persuasion, Cialdini summarizes this literature and describes 6 basic categories of effective persuasive techniques.57

  • Commitment and Consistency…Industry representatives are trained to get health care clinicians to make a verbal commitment to use their products…once the health care clinician has tried the drug on 5 patients, he or she is more likely to continue to use the drug.7 
  • Social Proof…When told that almost all of the physicians in the region are now using drug A to treat disease B, a health care clinician will be hard-pressed not to join the group”
  • Liking… Humans tend to be more responsive and receptive to individuals who are friendly, likeable, and attractive”
  • Appeals to Authority…The use of opinion leaders and experts to give lectures supporting the use of a product”
  • Scarcity…Opportunities to engage in consulting and speaking opportunities fall into this category”
  • Reciprocation…A sense of obligation to reciprocate accompanies the receipt of any favor, gift, or kindness. Gifts can take many forms and need not be valuable.”

Reciprocation Elaborated:

  • “Much cognitive activity occurs without conscious awareness, and the most effective marketing and persuasion strategies are designed to engage the subconscious aspects of decision making…Decision making appears to rely on dual systems within the brain, a socioemotional system” and the cognitive control system.
  • “The socioemotional system tends to involve rapid, automatic processing that is often reactive, intuitive, unconscious, and sensitive to social norms…Effective marketing strategies, including the use of incentives and gifts and the nurturing of relationships, are designed to engage the socioemotional decision-making areas of the brain”
  • “The cognitive control system, on the other hand, tends to be consciously controlled, reasoned, and analytic and requires more time and conscious effort”
  • “Most health care clinicians believe they cannot be bribed and that they would never trade a small gift for changing their prescribing behavior…Gifts may subtly and subconsciously affect the way the receiver of the gift evaluates the information provided by the gift giver, and these feelings of indebtedness may ultimately lead to changes in prescribing behavior”

“With regard to the receipt of gifts from the industry, the American Academy of Pediatrics (AAP) has endorsed the AMA guidelines, which do not prohibit gifts outright but offer the following basic principles for managing them:198 

  • Physicians should decline cash gifts in any amount from an entity that has a direct interest in physicians’ treatment recommendations.
  • Physicians should decline any gifts for which reciprocity is expected or implied.
  • Physicians should accept an in-kind gift for the physician’s practice only when the gift is of minimal value and will directly benefit patients, including patient education.
  • Academic institutions and residency and fellowship programs may accept special funding on behalf of trainees to support their participation in professional meetings, including educational meetings, provided the program identifies recipients based on independent institutional criteria and funds are distributed to recipients without specific attribution to sponsors”

As a final incentive,  “in late 2020, the Department of Health and Human Services Office of the Inspector General issued a special fraud alert highlighting concerns … in connection with speaker programs.” The Office of the Inspector General warned both companies and health care professionals that such arrangements may, under certain circumstances, violate antikickback statutes.”

My take (from the report): “At a minimum, health care clinicians should be cognizant of the techniques used to attempt to alter their behavior and guard against them.”

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Short Take on Understanding Bias

A recent commentary (Rosenbaum L. NEJM 2015; 372: 1959-63) adds a couple of new terms to my lexicon regarding bias.

The author notes that there have been multiple concerns regarding industry-sponsored studies.  For example:

  • Industry-sponsored studies are more likely than government-sponsored ones to have positive results
  • Physicians who attend symposia funded by the pharmaceutical companies subsequently prescribe the featured drugs at a higher rate

While the Physician Payment Sunshine Act requires drug and device companies to disclose payments over $10, she notes that the long-term effects of this transparency are unclear.  With increased transparency, there could be a “phenomenon called ‘moral licensing’: once disclosure gets off your chest, you feel liberated and may feel licensed to behave immorally.  A corollary concern” for the audience, is that this disclosure may be interpreted as a sign of honesty or a sign of expertise rather than as a warning of potential bias.

Two new terms for me:

  • “‘Self-serving bias’: when we stand to gain from reaching a certain conclusion, we unwittingly assimilate evidence in a way that favors the conclusion.”
  • Bias blind spot“: “Studies suggest that we’re far more likely to think that drug promotions influence our colleagues than that they affect our own behavior.”

The author cautions that anti-industry bias could be detrimental as well.  If having ties to industry lessens the opportunity for individuals to voice their support (or opposition) for new drugs or devices, it could bolster individuals who may “overstate the risks and understate the benefits of these new treatments.”

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