A principal underlying assumption regarding limits on and ethics guidelines addressing pharmaceutical promotion is that smaller gifts are unlikely to exert influence on prescribing decisions. Nonetheless, a substantial body of marketing and psychology literature suggests that even trivial doctor gifts can exert influence irrespective of economic value.
Adding a small gift such as personalized mailing labels, a pen or a coffee mug to a solicitation for donations has been shown to significantly increase donations. These types of gifts can also influence prescribing behavior, according to a study that appears in The Archives of Internal Medicine. (Arch Intern Med. 2009;169(9):887-893).
The experiment found that exposure to these items results in more favorable attitudes toward marketed products and that medical school policies that restrict pharmaceutical marketing mitigate this effect. The study was designed to measure the influence of exposure to branded promotional items on relative attitudes toward 2 lipid-lowering statins.
Lipitor is among the most promoted brand-name statins in the United States while simvastatin is available generically and considered to be nearly equally effective. The study outcomes included measures of implicit and self-reported (ie, explicit) attitudes. Implicit attitudes were evaluated with the Implicit Association Test, a widely used tool in marketing and psychology research that is thought to be resistant to social desirability bias among research participants.
The experimental procedure involved assigning study participants to a control or primed condition based on their day of enrollment. Participants assigned to the “primed” condition were exposed to Lipitor (atorvastatin) branded promotional items immediately prior to completing a computer-based study instrument. These exposures included Lipitor logos on a clipboard (used when signing in to the study room) and notepaper (used to provide participants with their study identification number).
Participants assigned to the control condition completed the same procedures but with a plain (nonbranded) clipboard and notepaper. Differences in attitudes toward Lipitor and Zocor (simvastatin) in the exposed (Lipitor promotional items) and control groups were examined. The experiment debunked the belief of many physicians that because they are medical experts, believe they are not susceptible to these influences. In one survey, just 8% of physicians believed they were susceptible to influence by marketing items such as branded pens, whereas 31% of patients felt these items could influence physicians.
The guidelines of the American Medical Association regarding doctor gifts from industry reflect this belief of lack of susceptibility by permitting “gifts of minimal value.” Participants were third- and fourth-year medical students at the University of Pennsylvania School of Medicine (Penn) and the University of Miami Miller School of Medicine (Miami). These institutions were selected because of their differing policies regarding interactions between trainees and pharmaceutical company representatives.
The University of Pennsylvania has restrictive policies in place that prohibit most gifts, meals, and samples while Miami continues to permit such marketing practices. Perhaps not surprisingly, students at Miami had more positive attitudes toward marketing and exposure to a branded promotional item primed more positive implicit associations.
At Penn, exposure to the branded items produced less favorable implicit attitudes, possibly because the strong school policy provided an external warning about specific persuasion tactics underlying pharmaceutical marketing. The findings regarding the influence of even small gifts has implications for legislation proposed in the Senate Finance Committee known as The Physician Payments Sunshine Act of 2009.
The law would require makers of pharmaceuticals, medical devices and biologics to publicly report money they give to doctors over $100 every year. The Senate Finance Committee seeks input on whether a de minimis threshold for payments and transfers of value should be implemented or an annual aggregate reporting doctor gifts threshold of $100 per recipient. The proposed law would also establish a nationwide standard requiring drug, device and biologic makers to report payments to doctors to the Department of Health and Human Services and for those payments to be posted online in a user friendly way for public consumption. It would establish penalties as high as $1 million for knowingly failing to report the information.
The proposal incorporates many of the new recommendations of the Medicare Payment Advisory Commission, an independent congressional agency which advises Congress on issues affecting the Medicare program. The Physicians Payment Sunshine Act will apparently be incorporated into the Health Care Reform Bill of 2009.
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