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Healthy Skepticism International News

November 2002

Patient’s perceptions of doctors’ relationships with pharmaceutical companies.

ABSTRACT:

Objective: Our aim was to pilot a study looking at patient’s perspectives of doctor’s relationships with pharmaceutical companies within a general practice setting. We also wished to make a direct comparison between patient’s and their doctor’s responses and evaluate whether patient’s wish to be better informed about the nature of this relationship.

Methods: A short eight-question survey of patients in the waiting rooms of two general practice clinics and a separate survey for their doctors. Obtained a sample of 147 patients and 5 doctors

Measurements: Patient’s and doctor’s perspectives on the frequency, appropriateness and possible influence of drug company gifts to doctors

Results: The patient survey had a response rate of 85% and showed that 18% of patients were unhappy about doctors accepting gifts from drug companies and 30% agreed that drug companies should be banned from giving gifts to doctors. However 60% of respondents agreed that patients should be better informed about the nature of gifts given to doctors by drug companies. Of the 18% of respondents who were not happy about doctors receiving gifts from drug companies 87% agreed that patients should be better informed and of the 30% of respondents agreed that drug companies should be banned from giving gifts to doctors 81% agreed that patients should be better informed.

Conclusion: While patients are aware doctors receive gifts from pharmaceutical companies 60% agree that patients should be better informed about the nature of gifts given to doctors by drug companies. The need for research in this area seems to be validated by the difficulty in finding doctors willing to allow their patients to be surveyed. With the change in the doctor-patient relationship in recent times to that of more of a partnership we feel doctors may need to take into account the will of their patients more often and be prepared to inform their patients about their interactions with pharmaceutical companies.

INTRODUCTION:

Relationships between medical practitioners and the pharmaceutical industry raise serious concerns and controversy within the medical profession and the general community[1, 2.]  This relationship includes both apparently desirable aspects (e.g., drug samples to low-income patients and research funding) and less clearly ethically justifiable ones (e.g., acceptance of lavish gifts and allowances for travel). The relationship between medical practitioners and the pharmaceutical industry involves a lot more than just giving of gifts. This relationship involves interactions in a variety of different areas that are involved within the day to day tasks of a medical practitioner. These include research funding, advertising in magazines and journals, surgery visits for drug presentations, gift giving, subsidized travel and accommodation to conferences and sponsorship of continuing medical education events and activities.

Doctors and pharmaceutical companies do share a number of common interests such as encouraging the effective and responsible use of existing drugs as well as innovative research into developing new ones. This is especially important as drug companies currently fund 70% of drug research and development costs[3] which is a $6 billion a year industry. Much of this research would not go ahead with out this funding. Heavy funding of both leading university and research laboratories by Pharmaceutical companies brings about the possibility of a conflict of interest. DeAngelis [4] highlights this point in the fact that over half the advisers to the Food & Drug Administration in the US, who are in charge of approving drugs for public use, have financial ties to pharmaceutical companies. Also that investigators doing research in an area related to their sponsors are more likely to favour their sponsors and produce research of lower quality.

In spite of these common interests and benefits of cooperation ethical concerns such as this have been expressed both within the medical profession and the general community. These concerns are based around the possibility that drug promotion and doctor’s exposure to drug companies may inappropriately influence doctor’s clinical judgment and prescribing choices. These concerns have been identified by a number of professional bodies and organizations, which have issued guidelines to help ensure that their members maintain mutually acceptable relationships [5-9].  However these are self-regulatory codes of conduct and adherence to these codes has been shown to be somewhat questionable [5-12]. 10% of statements made in pharmaceutical company presentations to promote their drug are factually inaccurate [10] and even when complaints are brought up against pharmaceutical companies due to their presentations more than 50% of sanctions are usually just to withdraw the current presentation[11]. Taking into account misleading presentations, and advertisements that ignore the shortcomings of drugs, as well as those aimed at “making the hippocampus – the prescription writing centre of the brain – react positively to the product”[13], it would appear that the relationship is based on deception rather than anything else. 

Drug promotion and marketing make up a considerably large part of the activities of drug companies and totals more than US$11 billion each year in the United States alone [14].  Gift giving is a widespread drug-promotion strategy and although doctors deny that gifts influence their behavior [15,16], there is clear evidence to the contrary [16,17].  A study by Chren and Landefeld [18] found that requests by doctors to have drugs added to a hospital formulary were strongly associated with the physicians’ interactions with the companies manufacturing those drugs. Not only were physicians who saw pharmaceutical company representatives more likely to add drugs to the formulary but they were also likely to favour the companies they interacted with.

Some studies have focused upon what patient’s perceptions are of these interactions between medical practitioners and pharmaceutical companies. A study by Mainous, Hueston and Rich 2 which surveyed over 600 patients found that while the public is aware of these interactions and the practice of giving gifts and the like they are generally uninformed about personal gifts from pharmaceutical companies to doctors.

Another study by Gibbons et Al 1 surveyed doctors and their patients about appropriateness and influence of 10 pharmaceutical gifts. These ranged from pharmaceutical company labelled pens and paper through to dinners at expensive restaurants. Patients were shown to perceive all of the gifts as less appropriate and more influential than their doctors did.

Most of these studies have been limited in that they only collected data from areas outside of general practices. Either by telephone surveys or through outpatient clinics in hospitals previous studies have not touched on general practice the area of medicine that is most often the first contact point and the closest relationship between doctor and patients.

Our aim with this study was to pilot the format for a patient and doctor survey within a general practice surgery looking at patients perceptions of the doctor-pharmaceutical company relationship. By getting responses from both patients and doctors we would be able to make accurate comparisons and show whether patients perceptions of their doctors relationships with pharmaceutical companies was accurate. With other studies showing that a large proportion of the community having knowledge of this relationship but not accurate or informed we also aimed to find if patients thought they should be better informed about the nature of this relationship.

METHODS

Setting: Our initial methodology for finding an appropriate sample was changed a number of times. Several practices were approached with the aim of having a sample from a number of practices covering suburbs all around Adelaide and within a variety of socioeconomic areas. After several practices declined to participate in the study and having only six weeks to complete the study we decided to concentrate on just a single area. The township of Gawler was chosen as we thought that this might provide the study with a range of patients with different socioeconomic backgrounds and bordering on a cross section of rural and urban patients. However this did not eventuate and in the end we had to settle for a sample of convenience with patients from a selection of doctors at the University of Adelaide run practice in the northeastern suburb of Highbury and from a practice in the township of Mount Barker. A bonus of this was the added variable that we could still compare rural and urban responses.

Before we commenced our data collection at these two practices we firstly piloted our questionnaire at a separate practice in the southern suburb of Aldinga to ensure clarity and accuracy. The results of this pilot gave us a good indication for modifications that the questionnaire required.

The patient’s questionnaire was administered whilst the patients were waiting to see the doctor.

RESULTS:

The sample consisted of 147 patient respondents and 5 doctor respondents from the two practices combined. This was obtained with a response rate of 85% and 71% respectively.

The demographic characteristics of the sample are shown in Figure 1.

Fig. 1 Demographics


Urban

Rural

Mean age

40.7

48.6

% Male

47.5

34.9

% Female

52.5

65.1

The patient’s perceptions of how often doctors received gifts from pharmaceutical companies was evaluated as gifts valued under $25 and gifts valued at $25 and over. Their doctors responses were compiled in the same categories and respective graphs for each are shown in Figure 2 and Figure 3.

Fig. 2 How often do you estimate doctors receive gifts valued at less than $25 from drug companies?

Patient’s Answers

Doctor’s answers

Fig. 3 How often do you estimate doctors receive gifts valued at more than $25 from drug companies?
Patients Answers

Doctor’s answers

In relation to these gifts eighteen percent of patients were not happy for their doctors to accept them when offered by pharmaceutical companies and thirty percent did not think companies should be allowed to offer them in general whereas the majority were more tolerant about doctors receiving gifts. However, sixty percent of patient respondents thought they should be better informed about the nature of the doctor-pharmaceutical company relationship. Of those who responded that they were no happy about doctors receiving gifts, eighty percent agreed that patients should be better informed. 

In addition to the perceptions of the patients, correlation of other variables such as gender, age, and location were done. Most showed no statistical significance with people in rural areas just as likely to want to be better informed as urban patients (p = .25), likewise with 40 and over and under 40 (p = .95). Male patients were more likely to want to be better informed about the nature of the doctor- pharmaceutical relationship (p = .05).

DISCUSSION:

From this study we were able to draw conclusions from both our results and from our observations. From our results we found that while patients are aware that doctors receive gifts from pharmaceutical companies the majority agreed that patients should no more about the frequency and value of these gifts. Therefore the perceptions of this relationship are based on uncertainty about how often doctors actually receive gifts. Patients views toward acceptance of gifts seems very tolerant but this may have been a result of respondents not being able to answer separately for things such as drug samples and free dinners. The fact that patients agreed that they should be more informed suggests that the current level of tolerance could change in response to more information. 

From our observations of performing a study of this nature we feel that the need for further research in this area is validated by the responses we received from doctors before we had collected any data while trying to find a practice to distribute our questionnaires in. Even after receiving ethics approval by the Research Ethics Committee some of the doctors we approached still claimed that our study was controversial and that the wording of our questionnaire was inflammatory in nature. Over ten practices declined to allow a survey of this topic to be shown to their patients almost leaving us to a study of which general practice surgeries, if any, would allow the surveys to be handed out.

One of the guidelines mentioned in the introduction quotes “A useful criterion in determining acceptable activities and relationships is: Would you be willing to have these arrangements generally known?” The number of doctors who were not comfortable with letting their patients participate in a survey of this nature makes us wonder what general practitioners’ attitudes genuinely are to this topic. Further research at a statewide level with a randomized sample would give a better indication of the average patients perceptions and a better comparison with more doctors. With the change in the doctor-patient relationship in recent times to that of more of a partnership we feel doctors may need to take into account the will of their patients more often and be prepared to inform their patients of their interactions with pharmaceutical companies.

Appendix 1 PATIENT’S QUESTIONNAIRE
Please tick the most appropriate boxes

q     Male

q     Female

Age: _____ years old

1)    How often do you estimate doctors receive gifts valued at less than $25 from drug companies?

q     About once a year

q     About once a month      

q     About once a week

q     About once a day

 

2)    How often do you estimate doctors receive gifts valued at more than $25 from drug companies?

q     About once a year

q     About once a month      

q     About once a week

q     About once a day

3)    Do you think this amount of gifts is?

q     Too little

q     About right

q     Too much

4)    Are you happy for your doctor to accept gifts from drug companies?

q     Yes              

q     Makes no difference to me

q     No

5)    If a doctor received gifts from drug companies at least once a week:

a) would this influence the doctor’s choice of medication?

q     Not at all

q     Occasionally

q     Often

b) would the cost of these gifts to the drug company cause an increase in the cost of the medication?

q     Yes

q     No

c) would this have a negative effect on the quality of health care provided?

q     Yes

q     No

6)    Do you think that drug companies should be banned from giving gifts to doctors?

q     Yes              

q     No

 

7)    Do you think patients should be better informed about the nature of gifts given to doctors by drug companies?

q     Yes              

q     No

 

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Far too large a section of the treatment of disease is to-day controlled by the big manufacturing pharmacists, who have enslaved us in a plausible pseudo-science...
The blind faith which some men have in medicines illustrates too often the greatest of all human capacities - the capacity for self deception...
Some one will say, Is this all your science has to tell us? Is this the outcome of decades of good clinical work, of patient study of the disease, of anxious trial in such good faith of so many drugs? Give us back the childlike trust of the fathers in antimony and in the lancet rather than this cold nihilism. Not at all! Let us accept the truth, however unpleasant it may be, and with the death rate staring us in the face, let us not be deceived with vain fancies...
we need a stern, iconoclastic spirit which leads, not to nihilism, but to an active skepticism - not the passive skepticism, born of despair, but the active skepticism born of a knowledge that recognizes its limitations and knows full well that only in this attitude of mind can true progress be made.
- William Osler 1909