Within a two-week period, two sales representatives from
competing pharmaceutical companies visited the office of an orthopaedic
group practice. One representative was elated that the group had
been steadily prescribing his company’s new arthritis medication.
The physicians assumed that the representative was speaking about
the number of sample packs used by their office. Several days later,
a competing drug representative visited the office and complained
that several physicians in the group were "not thinking
of my company’s medication first." The physicians
were perplexed and asked him how he had come by that information.
After multiple attempts at evading the question, the representative
explained that pharmaceutical companies pay the drugstores for such
data. Although unwilling to disclose the details of the arrangement,
he did inform the physicians that the pharmaceutical companies know
exactly which physicians are writing which prescriptions. He assured
the physicians that patients’ names are not disclosed.
The physicians spoke to several pharmacists and other pharmaceutical
representatives, who confirmed the practice.
This case raises several subtle ethical issues. The orthopaedic surgeon
who is surprised to learn that drug-company representatives know
his or her prescribing patterns feels violated, as if some private
domain has been breached. However, while patients have rights of
confidentiality that must be protected, patient-identification information
has not been shared with the drug companies and patient confidentiality
has not been violated by this practice. The question that arises
is: to what extent does this practice of providing physicians’ prescribing
patterns to pharmaceutical companies infringe upon the doctor-patient relationship?
Traditionally, in ethical discussions regarding the doctor-patient
relationship, the focus has been on the patient’s right
to privacy and confidentiality. In fact, the assurance of privacy
and confidentiality is implicit to the trust that patients place
in their physicians. But what about the doctor’s right
to privacy in the rendering of medical care? Does the right to privacy
extend to the treating physician as well?
It is true that selling the records of physicians’ prescribing
patterns to pharmaceutical companies does not disclose patient information—but
does the practice have the potential to alter physicians’ decisions
about their patients’ treatment? In the above scenario,
the drug-company representatives knew exactly how many prescriptions
that each physician had written for each medication. Can that knowledge be
used to subject physicians to major coercive influences? A simple
illustration may help to clarify this issue.
A well-respected senior physician with an excellent position
at a major medical center resisted joining his institution’s
managed-care plan because he valued his clinical autonomy. However,
all around him, his colleagues were discussing the coercive pressures
on their medical practices. About a year into the institution’s
managed-care experience, this physician received his annual summary
of the laboratory services that he had ordered. When he compared this
summary with similar previous reports, he noticed that the number
of laboratory services that he had ordered had decreased by more
than one-third even though his patient population had remained the same.
While it could be argued that the change was for the good, the frightening
point of this story is that this observant, thoughtful, and scrupulously
honest man had not noticed a major change in his own practice pattern.
He was not participating in the managed-care plan, he had no concerns about
the security of his position, and no pressure was being exerted
upon him by administrative bureaucrats. He was moved, so to speak,
only by the talk in the air.
If the person who is least vulnerable to psychological coercion can
be moved, then those who are more vulnerable to the incentives in
the environment can be moved even more easily. And, while everyone
feels immune to the effects of the pressures in the medical environment
(such as managed care, drug-company advertising, and the attention
of the warm, friendly detail representative), no one notices when or
how they are affected. The effects are often invisible, but those
who deliberately insert the coercive forces into the environment
are well aware of their effectiveness and value.
According to a front-page article in The New York Times on
November 16, 2000, pharmaceutical companies still spend most of
their advertising dollars in targeting doctors. Of the 13.9 billion
dollars that drug companies spent promoting their products in 1999,
87%, or about $12 billion, was aimed at health-care providers,
including physicians, nurse practitioners, and physician assistants.
Without question, these marketing dollars serve an important function
in helping to educate doctors about prescribing drugs more appropriately. New
drugs become available all of the time, and physicians depend upon
marketing information to educate themselves regarding the use of
these drugs.
But if medical education is the sole purpose of these marketing dollars,
then why is there the need to obtain data on the specific prescribing
practices of individual physicians? According to the newspaper article
cited above, pharmaceutical marketers admit that they use these reports
to help determine which doctors should be offered certain perks.
Lawrence Gostin, an expert in health-care privacy at the Georgetown
University Law Center, believes that prescribing profiles raise
important policy questions about physicians’ privacy as
well as about the commercial influence on physicians. He considers
these profiles to be a fundamental violation of privacy, and he
raises the question as to what extent physicians’ practices
are influenced by commercial concerns.
Because doctors cannot help but behave like ordinary mortals, propelled
by the psychological powers of gratitude, friendship, and affection,
are they likely to alter their prescribing patterns when targeted
by pharmaceutical representatives? It is exceedingly difficult to
acknowledge that coercive forces can work on each of us, but studies
show that we are indeed susceptible. In a recent article in the Journal
of the American Medical Association, Ashley Wazana of McGill
University reported a definite association between physicians’ meeting
with pharmaceutical representatives and a rapid change in their
awareness about, preference for, and prescription of new drugs over
previously prescribed generic drugs. Wazana concluded that, with
or without our awareness, we are influenced by these encounters.
So the question remains: is the selling of data on physicians’ prescribing
patterns to pharmaceutical companies ethical? Certainly, no patient
information is exchanged or disclosed in the sale, nor does there
appear to be any violation of patient or physician autonomy. Many
physicians feel that they are responsible for their own decisions
and that profiles and databases have nothing to do with their ethical
behavior. The edict of benefit to the patient—the physician
acting for the patient’s good—does not seem to
be violated and, in fact, may even be improved if the physician
gains information and insight into a potentially helpful new drug.
So what is the ethical issue raised by the practice of selling data
on physicians’ prescribing patterns?
We believe that the ethical issue that is raised is twofold.
The first concern involves the violation of privacy. Why are the
data on individual physicians collected without their knowledge
or consent? In medicine today, we are surrounded by issues of full
disclosure. Every author who is published in The Journal must
disclose any source of support, funding, gifts, payments, or benefits
received. The Journal’s readership and
the public in general are entitled to such information. Why are
we then not afforded the same right by the companies buying our
prescription profile? If there is no ethical issue, then why are
the companies not informing the physicians that they are tracking
every prescription that the physicians write?
The second concern raised is one of coercion. With our prescribing profiles
in the hands of the pharmaceutical companies, do we as physicians
become more vulnerable marketing targets? Can subtle incentives
be directed our way in an attempt to alter our prescribing patterns,
whether they be in the form of gifts, office lunches, pens and pads, dinner
lectures, or weekend courses at resorts? According to psychologists
and pharmaceutical marketing representatives, we are indeed influenceable.
As physicians, we are all familiar with pharmaceutical representatives.
They are often a tremendous asset in providing us with information
regarding new drug products, surgical equipment, and prosthetic
implants. However, they can also exert powerful, coercive forces
that could potentially alter our medical decisions. And if they
have obtained information regarding our practice patterns without
our knowledge, we may become even more selective targets for their
attention. Although the practice of selling data on physicians’ prescribing
patterns may be legal, we believe that it raises some important
ethical issues and that, at the very least, physicians should be
made aware of them.
Avorn J, Chen M, Hartley R. Scientific versus commercial sources
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Roughead EE, Harvey KJ, Gilbert AL. Commercial detailing
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Wazana A. Physicians and the pharmaceutical industry:
is a gift ever just a gift? JAMA. 2000;283:373-80.
Stolberg SG, Gerth J. High-tech stealth being used
to sway doctor prescriptions. New York Times. 2000
Nov 16;Sect A:1.