Issue 31 / 25 August 2014

A RECENT research article found that medical students and junior doctors exposed to information from pharmaceutical companies were more likely to refer to drugs using their brand names.

The authors used a survey to show that for each 10% increase in exposure to pharmaceutical promotion there was an associated 15% lower adherence to published prescribing guidelines.

While doctors often seem to think they are immune to pharmaceutical industry marketing, the reality is that none of us are. The influence of marketing on prescribing habits is well established, but it is not the only influence.

External influences add to a range of factors that impact on our decisions about which medications to prescribe in different contexts. Ideally, as clinicians, we are primarily influenced by evidence-based guidelines and consideration of efficacy, mechanism and side effect profiles. In reality, influences that are less sound often win out.

For example, in the UK, researchers found that when it comes to antimicrobial prescribing behaviour, culture and etiquette were the main determinants.

Prescribing etiquette can have an impact on doctors at all levels of experience. We are often reluctant to alter medication regimens initiated by colleagues and frequently make prescribing decisions based on common practice at our hospital, or suggestions and requests from nurses, allied health staff and patients. It follows that these influences could disproportionately affect junior doctors, who have less experience and confidence in their medical decision making and who are often keen to please senior medical, nursing and allied health colleagues.

In fact, external influences begin shaping our medical decision making from the start of our time at medical school.

A number of US medical schools came under public scrutiny after students from Harvard Medical School found that some of their lecturers were being funded by pharmaceutical companies and that the material they were teaching was influenced as a result.

While the relationships between Australian medical schools and pharmaceutical companies may be less obvious, I distinctly remember learning suturing and “best practice” wound care from a company representative using only brand names and being told by the representative that there were no appropriate alternatives to their wound care products.

It seems grossly unethical to teach biased information, particularly to junior students who are less equipped than their senior colleagues to critically appraise that information. This has the potential to influence the way junior doctors prescribe and practise throughout their entire careers. Indeed, medical students from universities with less stringent regulations on the influence of pharmaceutical companies have been found to be more likely to prescribe high-cost, low-value medications.

Of course, it is not only industry that can exert undue influence on the prescribing habits of doctors and certainly not only junior doctors who are affected. One-off events like high profile media stories or journal articles can also alter patient and doctor perception of the evidence for or against certain medications and thus influence prescribing.

So, what should we be doing about all of this?

First we must recognise that these and other factors are major influences on the way we prescribe and practise medicine. Our prescribing will always be influenced by external factors, but we should try to ensure they are the right external factors.

Regulations restricting pharmaceutical advertising are useful and it is admirable that many individual health professionals try to limit pharmaceutical industry influences by, for example, not meeting with drug representatives or attending pharmaceutical industry-sponsored conferences. However, there are clearly other factors which are less immediately apparent yet perhaps just as important.

To promote change, we could start by following the lead of the observant Harvard students and critically examine and prioritise the influence of various external factors on our prescribing habits.

 

Dr Zoe Stewart is an Australian junior doctor and a clinical research fellow in metabolic medicine at the University of Cambridge. She has an interest in medical research and its translation into policy and clinical practice and is supported by the Gates Cambridge Trust and Jean Hailes for Women’s Health.

4 thoughts on “Zoe Stewart: Under the influence

  1. University of Tasmania says:

    A timely article.  Much easier for those of us purely in hospital practice to avoid the advertising pressure from the pharmaceutical industry and adhere to agreed standards and only prescribe using generic names.  But I am constantly reminded by my students that brand name dispensing is the norm in private practice – the argument being that the GPs and their patients find that easiest (exactly what the pharmaceutical companies want!)

    It is not at all unusual to see hospital patients confused by having been prescribed medications with a different brand name to what they normally use – even to the point of unintentionally (and potentially dangerously) taking additional medication.

    Maybe it’s about time to adopt “plain packaging” for pharmaceutical products.  It’s been done for cigarettes but maybe the government is more scared of “Big Pharma” than they are of the tobacco companies?

  2. Marcus Aylward says:

    Hard to discern health benefits from plain packaging Peter, perhaps as opposed to tobacco. And lots of assumptions round generics: bio-equivalence assumed but never tested for. Personally, if a patient, I will always take the branded product – only beneficiary  from a generic is the pharmacist’s margin.

    And hospital pharmacies should be held accountable for the confusion caused when they alter a patient’s named medication: this is a real issue and overdosing is not that uncommon.

  3. University of Western Australia Library says:

    There is nothing particularly new in this article. However, there is always the assumption that Pharma marketing is positive for their products. In my experience (and I suspect I am not alone), over-vigorous, inaccurate and perhaps even deceitful promotion can have an adverse effect on the prescriber. It’s a complex issue and less relevant in Australia vs the US given the PBS.

  4. Ian Napier says:

    Just a small point. Treading with caution is always advisable when trying to apply research in other markets to Australia. We have a much more restrictive advertising ecosystem in Australia, so the statistics are really not indicative.

    I know doctors would like prescribing decisions to be evidence-based and with that read and analyse all the literature on every ailment they are presented with, but the cost and time associated does make that impossible. Advertising to doctors in person or at conferences does help drug companies get their TGA approved medicines to patients. If drug companies didn’t exist and researchers didn’t discover, doctors would have very little to offer…

    Disclosure: I work in health advertising. Yes, I’m one of those.

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