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Healthy Skepticism Library item: 15685

Warning: This library includes all items relevant to health product marketing that we are aware of regardless of quality. Often we do not agree with all or part of the contents.


Publication type: news

Mansfield PR.
Under the influence
ABC Unleashed 2009 May 25

Full text:

In the 1840s there was a big argument among doctors that led to a paradigm shift in understanding the need to avoid invisible microbial infections.

Today doctors are having a similar argument about avoiding invisible infection with bias from exposure to drug promotion.

The debate will be evident this week at the Royal Australian and New Zealand College of Psychiatrists Congress in Adelaide.

The original organisers of the Congress wanted to do without drug company sponsorship. They wanted to avoid having a reciprocal obligation to drug companies and avoid the promotional stalls. However another group from the College took over and accepted sponsorship from seven pharmaceutical companies. “Gold” sponsors include Eli Lilly, recently subject to record fines for misleading marketing of its anti-psychotic drug Zyprexa. Another sponsor of the event is pharmaceutical company AstraZeneca, recently accused of hiding adverse effects and negative outcome data about its anti-psychotic drug Seroquel.

Back in the 1840s, the context was a series of epidemics of fatal childbirth fever. We now know the cause was bacteria transmitted by doctors who got infected when they did autopsies. However the doctors got no symptoms so they did not know they were infected.

This century we have had several epidemics of inappropriate drug use. For example the Vioxx epidemic probably killed more Australians than the Victorian Black Saturday bushfires.

The epidemic of so-called hormone replacement therapy has accelerated breast cancer in large numbers of women. There have been many other similar epidemics, some ongoing.

Many of the drugs do more good than harm for a small group, but have been used for a larger group where they do more harm than good.

The common factor in all these epidemics is that doctors have caught invisible infections of bias when exposed to persuasion from drug companies. Of course, the companies can’t fool all of the doctors all of the time. However, doctors are influenced enough on average to provide good returns on investment.

Drug promotion would otherwise be illegal under the Corporations Act which requires that company staff rationally believe their business judgements to be in the best interests of their corporation.

By bias I mean genuinely held false beliefs. General practitioners didn’t prescribe Vioxx because they wanted to kill people or didn’t care. GPs prescribed Vioxx for joint pain because they genuinely believed it was a safer drug overall. They didn’t know that Vioxx caused heart attacks.

The company, Merck, had information that Vioxx caused more heart attacks than Naproxen, an older drug that was cheaper, safer and just as effective against pain on average. However, Merck’s promotion emphasised that the drug was safer for the stomach. That was true but it wasn’t the whole truth.

Back in the 1840s doctors didn’t know that microbes existed. The germ theory of disease had not yet been developed. Today few doctors know much about the psychology of persuasion and bias. There are several competing theories that have not yet been integrated. Perhaps the best is the Elaboration Likelihood Model.

This theory explains that persuasion often works under the radar. Persuasive messages can get in when we don’t give them the time and attention required to evaluate and reject them. Few health professionals have ever heard of this theory.

Doctors are not gods, nor computers. We are humans. We have the advantages of being human including capacities for intuition, imagination, humour and compassion. Those advantages come from brain processes that occur without conscious awareness. Those processes also make us vulnerable to persuasion that works under the radar.

In the 1840s when it was suggested to doctors that they might be unintentionally transmitting childbirth fever most felt offended. They perceived the idea as an attack on their characters. They made defensive denials to protect their self-esteem. Their self identity as scientists included believing only what they could see. They had rejected past beliefs in unseen forces as superstitions.nThey looked at their hands and could see nothing wrong.

Most current day health professionals respond in much the same way to suggestions that they may be infected with bias by exposure to persuasion from drug companies. They are confident that their intelligence and training protect them from being misled.

However intelligence and training give little protection. In fact, two of the three professions most at risk of being misled by internet fraud are the best trained at judging people: psychiatrists and psychologists.

The most likely explanation is that over-confidence increases the risk of being misled. Over-confident people are less likely to avoid persuasion, less likely to make the effort to reject misleading messages and less likely to double check afterwards. Many people believe that only other people are vulnerable to being misled. Some psychologists call this the illusion of unique invulnerability.

Also whilst doctors are get a lot of training, few of us adequately understand statistics.

Since the 1840s health professionals have gone through a paradigm shift. We now understand the germ theory of disease so don’t take suggestions that we could be carriers of infection as attacks on our character. Health professionals accept the need to wash their hands before delivering babies or doing surgery.

Your health may depend on doctors being assisted to make a similar paradigm shift to accept that we are all vulnerable to bias from misleading persuasion.

We can prevent transmission of microbial infections with technologies such as gloves and condoms. We can diagnose microbial infections with microscopes and we can treat many infections effectively with antibiotics.

By contrast, we don’t have proven methods currently for enabling anyone to be exposed to misleading persuasion without becoming biased. We don’t have any technology for diagnosing the presence, let alone the magnitude of, bias. We don’t have effective treatments for bias.

That’s why doctors need to avoid drug company influence – because we don’t have any other way to reduce the risk of bias.

Health care will improve when doctors decrease their reliance on education from drug companies and instead use sources of information that are less biased. That’s why Healthy Skepticism calls for a ban on pharmaceutical company involvement in medical education.

As a first step, to help inform people so that they can decide for themselves about this issue, we also urge the government to set up an inquiry into bias in postgraduate medical education.

Reducing bias in medical education will lead to better health and will also help the economy via improved productivity and reduced health care costs.


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