A majority of physicians believe that DTC advertising can have an inappropriate effect on prescribing.³ This contrasts with physicians' mixed feelings about the effect of gifts from the industry. Studies show that most physicians believe that gifts do not influence their prescribing; however, the same physicians often believe that gifts influence their colleagues.^4-5 Limited data suggest that these concerns may be well founded. One study of faculty physicians found that accepting a free meal was independently associated with self-reported change in their prescribing practices.⁶ Another study found that physicians who requested that drugs be added to a hospital formulary were more than 10 times as likely as their colleagues to have received financial support from the companies that manufacture those drugs.⁷

Other physicians worry that DTC advertisements erode public trust in physicians. Patients may lose faith in their physicians when advertising messages conflict with professional advice.³ However, gifts to physicians may also undermine patient confidence in the profession. Surveys show that as many as 70% of patients believe these gifts significantly impact prescribing, and as many as two thirds believe they increase the overall cost of medications for the public.⁸ Furthermore, 24% of patients reported that their perception of the medical profession changed after learning about drug company gifts to physicians.⁹

Another concern about DTC advertisements is that patients lack the sophistication to properly interpret companies' DTC marketing claims. However, physicians who view pharmaceutical representatives as a useful source of information may face similar challenges.^10-11 Studies suggest that the information provided by representatives can be biased or even incorrect, and that physicians often cannot distinguish true statements from false ones.¹¹ Moreover, many physicians appear unaware of the extent to which commercial sources of information shape their prescribing practices.¹²

Physicians' awareness of the consequences of gift-giving may be limited by the lack of policies and educational programs that address this topic.^{5, 10} Many residency training programs have no policy regulating interactions with pharmaceutical representatives.¹³ Policies that do exist are poorly publicized and largely unknown to residents.¹⁴ As many as 90% of physicians feel they received insufficient training about how to interact with industry representatives,¹⁵ and guidelines from organizations such as the American Medical Association are not widely known. Perhaps more importantly, drug company gifts are an accepted social norm,^{4, 9} and colleagues may be unsupportive of physicians and medical students who challenge these practices.

Despite their concerns about the marketing of drugs to consumers, physicians are not exempt from the ethical issues raised by pharmaceutical marketing. Issues of influence, patient-physician distrust, and a susceptibility to marketing ploys apply to caregivers as well as to patients. By highlighting these parallels, the debate over DTC advertising may be a useful way for the medical profession to reflect on its own relationship with the pharmaceutical industry.

AUTHOR INFORMATION

Funding/Support: This work was supported in part by the Veterans Affairs National Quality Scholars Fellowship Program.

2. Scott-Levin Consulting. The pharmaceutical industry: more reps and more promotion fuel new launches. Press Release; 1999 June 18. Available at: http://www.scottlevin.com/news/rel_archive.cfm?rel_id = 63&prsearch. Accessed on Sept. 15, 2000.

3. Perri M III, Shinde S, Banavali R. The past, present, and future of direct-to-consumer prescription drug advertising. Clin Ther. 1999;21:1798-1811. CrossRef | ISI | MEDLINE

4. Steinman MA, Shlipak MG, McPhee SJ. Of principles and pens: attitudes and practices of medicine housestaff toward pharmaceutical industry promotions. [abstract]. J Gen Intern Med. 2000;15(suppl):45.

5. Hopper JA, Speece MW, Musial JL. Effects of an educational intervention on residents' knowledge and attitudes toward interactions with pharmaceutical representatives. J Gen Intern Med. 1997;12:639-642.

6. Lurie N, Rich EC, Simpson DE, et al. Pharmaceutical representatives in academic medical centers: Interaction with faculty and housestaff. J Gen Intern Med. 1990;5:240-243. ISI | MEDLINE

7. Chren MM, Landefeld CS. Physicians' behavior and their interactions with drug companies: a controlled study of physicians who requested additions to a hospital drug formulary. JAMA. 1994;271,684-689.

8. Blake RL, Early EK. Patients' attitudes about gifts to physicians from pharmaceutical companies. J Am Board Fam Pract 1995;8:457-464. MEDLINE

9. Gibbons RV, Landry FJ, Blouch DL, et al. A comparison of physicians' and patients' attitudes toward pharmaceutical industry gifts. J Gen Intern Med. 1998;13:151-154. CrossRef | ISI | MEDLINE

10. Brotzman GL, Mark DH. The effect on resident attitudes of regulatory policies regarding pharmaceutical representative activities. J Gen Intern Med. 1993;8:130-134. ISI | MEDLINE

11. Ziegler MG, Lew P, Singer BC. The accuracy of drug information from pharmaceutical sales representatives. JAMA. 1995;273:1296-1298. ABSTRACT

12. Avorn J, Chen M, Hartley R. Scientific versus commercial sources of influence on the prescribing behavior of physicians. Am J Med. 1982;73:4-8. ISI | MEDLINE

13. Lichstein PR, Turner RC, O'Brien K. Impact of pharmaceutical company representatives on internal medicine residency programs: a survey of residency program directors. Arch Intern Med. 1992:152:1009-1013.

14. Sergeant MD, Hodgetts PG, Godwin M, Walker DMC, McHenry P. Interactions with the pharmaceutical industry: a survey of family medicine residents in Ontario. CMAJ. 1996;155:1243-1248. ABSTRACT

15. McKinney WP, Schiedermayer DL, Lurie N, Simpson DE, Goodman JL, Rich EC. Attitudes of internal medicine faculty and residents toward professional interaction with pharmaceutical sales representatives. JAMA. 1990;264:1693-1697. ABSTRACT