Sunday, December 17, 2006

Gift-Giving to Physicians & its Repercussions on a Preventive Approach to Medicine: Identification of a Public Health Problem – Meghan McCutcheon

The manner in which public health is intervening upon the pharmaceutical industry influence on physician prescribing patterns needs to be altered in order to affect greater change and ensure the public is receiving comprehensive preventive care. Pharmaceutical promotion should not guide clinical practice. Regrettably, this is occurring within the practice of medicine and a different approach to intervention needs to be enacted to protect the public from pharmaceutical influence through the physicians’ pen – notably emblazoned with the brand-name drug and provided by the last pharmaceutical detailer to visit the office.

The number of detailers, or representatives, from pharmaceutical companies has grown at an alarming rate in comparison with that of physicians. Since 1995, the physician population has grown just 15%, according to the American Medical Association (AMA); however, over the same period, the number of pharmaceutical reps has grown 94% (MD NetGuide). The discovery by a McKinsey Consulting study that high-prescribing physicians receive “three to five times as many calls from sales reps as they did 10 years ago” (MD NetGuide) adds additional evidence to the escalating presence and influence of pharma on physicians. A more striking example is exhibited by the sheer data on expenditure for this influence by the industry. Drug companies spent more than $7 billion (not including drug samples) in 2003 on one-on-one marketing to doctors, which represents a 78% increase over 1999 levels and works out to about $8,400 to $15,400 per doctor per year (Consumers Union).

The purpose of pharmaceutical detailing is to influence physician behavior and prescribing practices, and medical literature suggests that doctor’s prescribing behavior is influenced by this promotion (Wazana). Additional reviews of the literature have confirmed a direct relationship between the frequency of contact with reps and the likelihood that physicians will behave in ways favorable to the pharmaceutical industry; physicians who spend more time with reps are less likely to prescribe rationally (Howard). Physicians not only need to engage rationally with their patients, but act in the utmost best interest of the individual in order to provide an optimal health outcome. Physicians need to get to the root cause of a patient’s health issue and increase behavioral interventions that will provide a healthier, long-term life solution. The quick fix of having the patient pop a pill is not the most efficacious solution. The fiduciary relationship between both parties warrants the physician to hold to a higher criterion of conduct. Gift-giving of pharmaceutical detailers to physicians undermines the doctor-patient relationship and creates a level of impropriety.

To date, the provision of evidence-based prescribing information to physicians has been the answer most applied to this current public health problem. However, according to medical literature, providing doctors with knowledge on how to treat diseases in accordance with research evidence and guideline recommendations seldom changes the way doctors prescribe drugs (Lagerlov). This educational outreach process known as “academic detailing” or “counterdetailing” needs to be altered through the use of social and behavioral sciences evidence and theory in order to more effectively address this public health issue of patients not being provided accurate, preventive care by their physicians.
This paper will address three aspects of this intervention change and prove the necessity of evoking behavior change in physicians so that a greater focus is subsequently on effective patient behavior change toward a more positive, healthy way of life.

The Dominant Model of Disease Today is Biomedical and it Leaves No Room Within Its Framework for the Social, Psychological, and Behavioral Dimensions of Health

A change from the current biomedical model to a biopsychosocial model is imperative in order to ensure that all aspects of treatment for a patient’s illness will be examined and included, such as behavior modification. If physicians focused on this model, their mindset would be concentrated more on what is best for the patient by taking into account a health psychology perspective. This approach considers the biological, cognitive, behavioral, emotional, social, psychosomatic and environmental factors as they relate to health, illness and health care at the level of individuals (Wikipedia). In identifying patient experiences and behaviors affecting the cause of illness, physicians could more effectively tailor treatment based on behavior change for the patient. With this change in medical model, physicians would not simply look to implement a medication treatment for patients or be as influenced by the latest pharmaceutical detailing visit.

For example, if a physician took a health psychology approach to her patient experiencing high cholesterol, she could talk to the patient about his current eating and exercise habits, educate the patient on the healthy, life benefits of a low-fat diet or a regular exercise regimen and suggest these behavioral changes that will not only aid in the reduction of high cholesterol, but also provide the patient with a more health-conscious way to live life. If the physician simply followed the biomedical approach, she would have easily prescribed a statin, such as Lipitor if a detailer from Pfizer had recently met with the physician.

According to a physician, who is also experiencing life as a patient with cancer, “…mind (and stress) affect the body-machine and how so many of the illnesses people suffer stem from behavioral causes with physiological correlates” (Dyer). Ignoring behavior change in patient treatments is clearly detrimental, as it excludes what could be the most important factors in the cause of illness. The health of the public is on the line, and it in great part depends on how the physician determines treatment, and ultimately what treatment is selected.
The affect physicians have on their patients is immense. “We know that when a doctor recommends something, patients start doing it…there’s almost nothing as powerful as a doctor’s advice,” states Tim Church, MD, PhD, MPH, Medical Director of the Cooper Institute of Dallas (Heubeck). This potential influence of behavior change would have a direct correlation with increasing healthy activities and quality of life in a population by getting to the root of the illness and attacking negative health issues through a more preventive approach.

The Deterioration of Trust in the Doctor-Patient Relationship Can Lead to Negative Health Seeking Behaviors (i.e. Less Patients Seeking Services and Following Recommended Treatments)

Trust is a fundamentally important aspect of medical treatment relationships, and studies have established that patient trust predicts instrumental variables such as use of preventive services, adherence, and continued enrollment (Thom). In addition, an article in The European Journal of Public Health states that “without trust patients may well not access services at all…” (Rowe). Research clearly shows that public health is in jeopardy if there is an erosion of trust in the fiduciary relationship with physicians.

The physician commitment to the well-being of the patient can be compromised, and the doctor-patient relationship undermined, by pharmaceutical detailing practices. Physicians have a professional and ethical duty to their patients. If they choose to disregard behavior modification in prescribed treatment and succumb to the influence of pharma and medication treatment, physicians also choose to disregard their fiduciary obligations to their patients. A physician ignoring preventive, behavioral interventions for his patients is an immense detriment to the patients’ overall health and way of life, as the physician is most easily compelled to put his pen to the prescription pad.

According to medical literature, 70% of subjects involved in a study on patients’ attitudes about pharmaceutical company gifts to physicians believed that gifts sometimes or frequently influence a physician’s prescribing of medication (Blake). If patients view a strong relationship between their physician and the pharmaceutical industry, they would be left to believe that their physician is not acting in their own best health interest. These personal beliefs and attitudes would lead to an increased lack of trust for the physician, and the public could consciously choose to forgo care based on its change in attitude toward physicians.
As an example that exhibits the significance of trust within the doctor-patient relationship, one can look to a study conducted on the influence on trust and the acceptance of and adherence to antiretroviral therapy, as presented in the Journal of Acquired Immune Deficiency Syndromes. Antiretroviral therapy (ART) has resulted in reduced AIDS incidence and mortality, which adds to the worth and value of those aspects that contribute to acceptance of and adherence to this treatment for infected patients (Altice). The literature in JAIDS concerning the highly important therapy found that the acceptance of (80%) and adherence to (84%) ART among the group studied was high and that acceptance was associated with trust in physician (8% increase for each unit increase with trust in physician scale) (Altice). The study concluded that trust and the therapeutic relationship between patient and physician remain central in the ART initiation process (Altice).

Current Intervention (i.e. Evidence-Based Prescribing Information) is Ineffective Because It Fails to Take Into Account the Importance of Physician Self-Efficacy

As previously stated from medical literature, the provision of evidence-based prescribing information to physicians, which has been the most applied public health intervention on the issue of pharmaceutical detailing influence, does not necessarily promote a high level of change in physician prescribing patterns. To reiterate the specific point: Providing doctors with knowledge on how to treat diseases in accordance with research evidence and guideline recommendations seldom changes the way doctors prescribe drugs (Lagerlov). Improved knowledge does not…necessarily lead to a corresponding change in behavior (Lagerlov).
Research has shown problem based learning, or “problem first learning,” which places the emphasis on the learner’s own initiative to discover problems and how to improve, to be effective in altering prescribing behaviors by physicians. This example of how self-efficacy can play a role in physician prescribing behavior has been explored in a study conducted in Norway by Lagerlov and colleagues that initially derived quality criteria of prescribing by discussing guideline recommendations that formed the basis for the physicians to judge their treatment of individual patients as acceptable or unacceptable (Lagerlov). Presented with feedback on their own prescribing, they learned what they did right and wrong, which provided a foundation for improvement and resulted in the physicians providing better quality patient care (Lagerlov).

Through the discussion and comparison of actual practices to established guidelines within peer review groups, the individual doctor’s self-efficacy, defined as one’s ability to organize and execute a course of action required to produce given results, was substantially increased (Lagerlov). The process documented in this Norwegian study is a prime exhibition of the Theory of Self-Efficacy, in which the basic premise is that the expectation of personal mastery and success determines whether or not an individual will engage in a particular behavior (Salazar). Expectations of personal self-efficacy are based on four major sources of information with the most dependable being performance accomplishments, referring to the learning (successful mastery) that results through personal experience (Salazar). Performance accomplishment tends to increase perceived self-efficacy (Salazar). This aspect of performance accomplishment relates directly to the study conducted by Lagerlov and his colleagues. As physicians investigate their own individual prescribing pattern, their personal motivation to master and succeed takes hold and therefore influences them to change their behavior toward a higher level of patient care and instituting better health actions within the public if they find prescribing was unwarranted for certain patients.

In conclusion, this paper has established that the current approach and intervention on pharmaceutical detailing on physician prescribing practices and provision of preventive care is not the most effective means in order to achieve the ultimate health outcome of patients living healthier lives through positive behaviors. The health of the public would increasingly benefit from a greater focus on health psychology and a biopsychosocial medical model, the establishment of trust in the doctor-patient relationship, and a self-efficacy approach for physicians in order to more positively change their prescribing behaviors.

References
Altice, F.L., Mostashari, F., & Friedland GH. (2001). Trust and the Acceptance of and
Adherence to Antiretroviral Therapy. Journal of Acquired Immune Deficiency
Syndromes, 28, 47-58. Information retrieved December 5, 2006, from http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=11579277&query_hl=4&itool=pubmed_docsum.
Blake, R.L. Jr. & Early, E.K. (1995). Patients’ Attitudes About Gifts to Physicians From
Pharmaceutical Companies. The Journal of the American Board of Family Practice, 8,
457-464. Information retrieved December 5, 2006, from
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=8585404&query_hl=2&itool=pubmed_docsum.
Consumers Union. (2005). Requiring Drug Companies to Disclose Marketing Expenditure to
Physicians. Retrieved November 17, 2006, from
http://www.consumersunion.org/campaigns/learn_more/001813indiv.html.
Dyer. A Helicopter Named Icarus: Essays on Health, Healing, Medicine and Spirituality – The
Need for a New Medical Model. Retrieved November 17, 2006 from http://faculty.etsu.edu/dyer/books/icarus/newmed.html.
Health Psychology. (2006). Wikipedia. Retrieved November 17, 2006, from http://en.wikipedia.org/wiki/Health_psychology.
Heubeck, E. (2005). Clinicians Lack Confidence in Prescribing Exercise. DOC News, 2, 11, 6.
Information retrieved November 17, 2006, from http://docnews.diabetesjournals.org/cgi/content/full/2/11/6.
Howard, B. (2005). The Company We Keep: Why Physicians Should Refuse to See
Pharmaceutical Representatives. Annals of Family Medicine, 3, 82-85. Information
retrieved November 17, 2006, from http://www.annfammed.org/cgi/content/full/3/1/82.
Lagerlov, P., Mitchell, L., Marit A., & Hjortdahl, P. (2000). Improving Doctor’s Prescribing
Behavior Through Reflection on Guidelines and Prescription Feedback: A
Randomised Controlled Study. Quality in Health Care, 9, 159-165. Information
retrieved November 17, 2006, from http://qhc.bmjjournals.com/cgi/reprint/9/3/159.pdf.
MD NetGuide. The “e”volution of Pharmaceutical Marketing. Retrieved November 17, 2006,
from http://www.mdng.com/specialty_editions/marketer/v1n1/pharmmarket.htm.
Rowe, R. & Calnan, M. (2006). Trust Relations in Health Care – the New Agenda. The European Journal of Public Health, 16, 1, 4-6. Information retrieved November 17, 2006, from http://eurpub.oxfordjournals.org/cgi/content/extract/16/1/4.
Salazar, M. K. (1991). Comparison of Four Behavioral Theories. AAOHN Journal, 39, 3, 128- 135.
Thom, D. H., Hall, M.A., Pawlson, L.G. (2004). Measuring Patients’ Trust in Physicians When Accessing Quality of Care. Health Affairs, 23, 4, 124-132. Information retrieved November 17, 2006, from http://content.healthaffairs.org/cgi/content/abstract/23/4/124.
Wazana, A. (2000). Physicians and the Pharmaceutical Industry: Is a gift ever just a gift?
JAMA, 283, 373-80. Information retrieved November 17, 2006, from
http://www.nofreelunch.org/changingbehavior.htm.

3 Comments:

Blogger Michael Siegel said...

This is a really interesting perspective on a previously overlooked implication of the influence of pharmaceutical company marketing practices on the public's health. While previous commentaries have addressed the effect on physician prescribing behavior and some of the ethical implications, this is the first I am aware of to address broader public health implications in terms of the undermining of the emphasis on prevention and the potential deterioration of the physician-patient relationship. It also raises the idea that perhaps public health groups should be detailing physicians, giving them gifts, sponsoring lunches, and trailing them around to keep a constant focus on prevention and behavior change approaches to medical care.

11:23 AM  
Anonymous Anonymous said...

This critique is really a great unearthing of a business practice that is influencing public health indirecting via health practitioners. In addition, it examines the influence of doctor's self-efficacy, and I think it does a really great job of considering the contextual factors influencing an individual's health outcomes!

6:40 PM  
Anonymous Juliane Scrivens said...

This is such an important topic. I think it is largely ignored that physicians may be prescribing drugs because they are being courted by pharmaceutical companies. This problem needs to be addressed. I feel like I am constantly talking to people who feel like a friend or family member is being over-medicated and wonder if it's because it's somehow to the advantage of the physician. You did an excellent job of describing how and why modifying behavior should always be something that comes before prescriptions.

2:38 PM  

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