Industry Influence Can Be Mediated by Understanding Theory Behind It

Aaron Levin

Social science research can help understand the marketing practices of pharmaceutical and medical device manufacturers, but might also plausibly be used to help doctors form independent judgments about therapies and diagnostic tools, according to two Georgetown University physicians.

However, doctors must first understand the techniques used to influence their choices.

“Industry uses principles of social psychology to manipulate prescribing behavior; physicians unaware of such subtle influences will not try to avoid the resulting conflicts of interest,” wrote Sunita Sah, M.D., M.B.A., Ph.D., an assistant professor of business ethics at Georgetown and a research fellow at the Ethics Center at Harvard University; and Adriane Fugh-Berman, M.D., an assistant professor of pharmacology and physiology and of family medicine at the Georgetown University Medical Center. Their article appears in the August issue of the Journal of Law, Medicine, and Ethics.

Earlier studies showed that physicians believe they are not personally influenced by industry but their colleagues are.

“Physicians think they are making their own independent choice of therapeutics for their patients and don’t realize the extent to which they are affected by drug reps,” said Fugh-Berman in an interview. She is also director of PharmedOut, a Georgetown University Medical Center project that advocates evidence-based prescribing and educates health care professionals about pharmaceutical marketing practices. “Overconfidence and naivetȳ are a dangerous combination.”

One understanding of the industry’s techniques may lie in the principles of influence and persuasion set out by social psychologists like Robert Cialdini, Ph.D., a professor emeritus of psychology and marketing at Arizona State University, as cited by Sah and Fugh-Berman.

For a start, reciprocity might be the tenet most familiar to medical professionals. That pizza or fancy dinner provided by the drug rep sets up an implicit obligation to return the favor.

Commitment to even a small goal (like prescribing that new drug to just a few patients) is amplified by a desire later to justify that choice with future consistency.

Conformity (or “social proof”) is doing what others do, especially those with more prestige or authority. Industry’s use of “high-status, respected, academic physicians” to act as “key opinion leaders” is such a time-tested tactic.

“The effect on trainees of observing trusted mentors accepting hospitality and funds from industry may be more powerful than the influence of institutional policies or formal curricula,” said Sah and Fugh-Berman.

However, Fugh-Berman said she has noticed a change in the last five years as attitudes toward speakers with heavy industry support have become less favorable, especially among medical students.

Finally, there’s simple likeability. Drug reps are hired at least as much for their social skills as for their scientific knowledge. And flattery, whether it’s a pleasant conversation over that archetypal pizza or an invitation to speak at a prestigious meeting, gets them everywhere.

“Some of that social science thinking might be turned around to help medical students and trainees think the way they have already learned to read the peer-reviewed literature,” said former APA President Carolyn Robinowitz, M.D., special associate provost for health science at George Washington University in Washington, D.C. “They could learn to recognize marketing techniques and begin to question more critically drug reps or speakers at those dinner meetings.”

Like Sah and Fugh-Berman, Robinowitz believes that educating physicians, trainees, and medical students is the best way to minimize any biases in marketing messages.

“We need to look to our leadership to help us learn this approach and help doctors make decisions based on the best evidence,” said Robinowitz.

However, like it or not, the reality is that corporations exist to produce profits as well as products, she added. “Drug companies perform a useful function, and they must make money or they won’t invest in our field.”

Somewhere out there between the bathwater and the babies lies a place where industry can make medicines and equipment while health professionals can find unbiased information about them.

“Educational interventions have been able to move the needle on whether other physicians are affected by industry influence,” said Fugh-Berman.

If enough physicians can learn to avoid the social obligations that industry cultivates and if academic medicine maintains its distance from industry, she said, “a new social norm may emerge that rejects transactions fraught with conflicts of interest.” ■