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10 Oct 2017

BY PHOEBE MACINTOSH-EVANS, POLICY OFFICER, AUSTRALIAN MEDICAL STUDENTS’ ASSOCIATION

Over the course of this year, I have been the lucky recipient of (conservatively) a dozen free lunches. They’re always the same: I walk in, eyes instantly drawn to the platters of food trying to suss out the delights provided for me today. But alas, I’m initially blocked by an agile pharmaceutical representative leaping in front of me. “Let me give you one of my pens,” they tell me, prompting me to then sign my name on a list to demonstrate that people are engaging with the prospect of free food. To my young medical student mind, unburdened by the tonnes of pharmacology knowledge my seniors possess, it’s just a free lunch and a free pen and a free notebook, and some free knowledge.

And yet for years many organisations – AMSA and the AMA included – have been waging a war against what is said to be the coercive nature of pharmaceutical knowledge. But does it – could it – genuinely influence the way a doctor or a medical student were to prescribe? In the grand scheme of things, is my management of future patients going to be affected by the circumstances surrounding how I came about the sandwich I ate for lunch on Wednesday?

Fundamentally, we know advertising and sponsorship works. Personally, I know this because some of the decisions I have made are profoundly and identifiably swayed by the sponsors that I’ve had significant exposure to. More concretely though, a 2014 survey of students and trainees in the US identified a relationship between higher exposure to pharmaceutical marketing and reduced knowledge of evidence based prescribing, with greater likelihood to select brand name pharmaceuticals. This is repeatedly exemplified amongst doctors as well as students, with another study finding that practitioners who saw pharmaceutical reps frequently had significantly higher total prescriptions than those visited less.           

And yet despite this evidence my free lunches and the pharmaceutical sponsorship game remain unimpeached.

The medical profession is arrogant, many of us have the belief that we are immune to the bias of sponsorship, considering this attack on lunch an insult to their integrity. It seems though that the issue with pharmaceutical sponsorship is much greater than just the way it may subtly influence a doctor’s clinical decision making. Research funded by pharmaceutical companies and used to support the uptake of their products are both less likely to be published and more likely to report favourably on their sponsored products than research funded by other sources.

This sort of systematic bias can exaggerate the benefits of treatments – one study looking at low quality industry funded trials found this to be an average of 34 per cent. Furthermore, trials comparing drugs always seem to favour that which is industry sponsored; with higher doses that make a drug appear more efficacious against its comparator given at doses outside of the usual range, with a rapid spikes in dosage or routes of administration that are perhaps not the most appropriate.

At a glance, these results appear compelling and irrefutable. In a climate where evidence based medicine is hailed as the key to optimal patient care amongst time-poor professionals and statistically challenged students, it is genuinely unsurprising to think that the practiced pitch of a pharmaceutical rep would leave a mark. The pharmaceutical sponsorship industry exists and thrives because this works, and it does influence our patterns of thought and the way be treat.

We need to be cautious of the way we accept offers of sponsorship; it is difficult for us to personally rationalise the genuine impact of this exposure, and it is nearly impossible for an individual to identify the changes in their prescribing. It might seem like a small, almost inconsequential impact, but over the course of our careers we see hundreds of thousands of patients. But an adverse event to any one of these patients is not worth it.  The only solution? Buy your own lunch. 


Published: 10 Oct 2017