a “top-down” problem…

Posted on Monday 9 September 2013

by Sunita Sah and Adriane Fugh-Berman
Journal of Law, Medicine and Ethics. 2013 14[3]:–

Pharmaceutical and medical device companies apply social psychology to influence physicians’ prescribing behavior and decision-making. Physicians fail to recognize their vulnerability to commercial influences; due to self-serving bias, rationalization, and cognitive dissonance. Professionalism offers little protection; even the most conscious and genuine commitment to ethical behavior cannot eliminate unintentional, subconscious bias. Six principles of influence — reciprocation, commitment, social proof, liking, authority, and scarcity — are key to the industry’s routine marketing strategies, which rely on the illusion that the industry is a generous avuncular partner to physicians. In order to resist industry influence, physicians must accept that they are vulnerable to subconscious bias, and have both the motivation and means to resist industry influence. A culture in which accepting industry gifts engenders shame, rather than gratitude, will reduce conflicts of interest. If greater academic prestige accrues to distant, rather than close relationships with industry, a new social norm may emerge that promotes patient care and scientific integrity. In addition to educating faculty and students about the social psychology underlying sophisticated, but potentially manipulative marketing and about how to resist it, academic medical institutions should develop strong organizational policies to counteract the medical profession’s improper dependence on industry.
This is from the Safra Center Symposium, Institutional Corruption and Pharmaceutical Policy, that I mentioned several weeks ago [a little light reading…]. It’s really good, covering a wide range of topics. I’ve been reading it along, but haven’t mentioned it because all I could think of to say was to re-recommend reading it. There was an exception [Key Opinion Leaders and the Corruption of Medical Knowledge: What the Sunshine Act Will and Won’t Cast Light On], but Dr. Howard Brody’s commentary on his Hooked blog was really first rate [An Update on KOLs], so I just kept on reading in the spaces. But when I got to the above article, I had something to say.

Dr. Adriane Fugh-Berman of Georgetown University  is one of the good guys. Her web-site and project, PharmedOut, is a strong force working towards reform of the Pharma influence in Medicine, a particular resource for industry-free CME programs. This article makes some strong points about the susceptibility of physicians to PHARMA marketing techniques. And suggests some well informed policies about how academic medical institutions might approach making the needed changes. So if I’m so taken with what they have to say, what can I add to that? Admittedly, I’m a psychiatrist looking primarily at my own specialty, so my perspective might be skewed. I think the people they are advising on how to solve the problem are, in fact, the source of the problem. I would see this as a top-down problem, not a bottom-up problem. The academic medical institutions, the medical school administration, and the chairmen of the departments are the center of this mess, not its solution – those in need of reform, not the reformers. At least that’s true in psychiatry and to a lesser extent, it’s a factor in the rest of medicine I’d wager.

Back in the lead-into the 1980 revolution in psychiatry, there was a firestorm swirling around every corner. I won’t even list them because just the ones you know about are enough to paint the picture. But there was one that you may not have on your list. Academic psychiatry was broke. Medical departments mostly support themselves, and all of psychiatry’s resources dried up. Hospitals were closing almost daily. Third Party payers were cutting psychiatric reimbursement, in part because they could. Public funding was quickly evaporating from both State and Federal resources. The rest of medicine had ways to support itself, but we didn’t. So when I say broke, I mean flat broke. In fact, one of the forces driving the medicalization of psychiatry appears to have been a need to insure that third party reimbursement didn’t disappear altogether.

The solution to the funding of academic departments in psychiatry was funding from Pharma. The departments desperately needed support. Pharma needed academicians to author articles, be PIs for Clinical Trials, act as KOLs, etc. The trajectory of things moved in an unspoken straight line as the years passed, and the academic-industrial complex emerged in its current form by the late 1980s – a prelude to the Decade of the Brain. Medical Institution Administrators may speak in lofty terms, but when there’s a Chairman search, they go for the candidate that can bring in the dough. So in psychiatry, the pharmaceutical academic relationship felt at times more like a merger than anything else. In that climate, this article is more dream than plan because the higher up you go in psychiatry, the worse it gets eg the President of the APA writes articles like "Time to re-engage with Pharma?" [as if we ever disengaged].

This post is unfair to this article. Because the situation in psychiatry may well be unique. It will require a fundamental structural change and the direction that might take is neither guaranteed nor clear, at least not clear to me. I think the plan they outline here may be much more doable in other specialties – but there is no signal that the leadership in psychiatry has "changed gears."
    Steve Lucas
    September 9, 2013 | 2:48 PM

    When I saw this article I could not help but think of my undergraduate program in business so many decades ago. My management classes, which were many, dealt with motivation and psychology. There was a marketing and marketing management class, a sales and sales management class along with a lone psychology class.

    Everything that was taught was based on motivation. The sales management class was taught by a sales manager for a drug wholesaler. The class should have been title “Life.”
    We dealt with the persona of a true salesman, they do not lie but believe what they are saying at the time they are saying it. All that matters is the sale. You chose to buy and if I can just speak to someone I can convince them I am right.

    A concept of my psychology class was ritualistic feeding where being offered and accepting food from another person’s plate creates a primal bond. Pharma has used this to good use when that attractive drug rep offers a piece of cake from their plate.

    This changed so that by the time I finished my graduate degree there was a hard edged, win at any cost mentality in business. Goals are to be set and if people do not meet them we find new people. Pharma has embraced this win at any cost concept.

    I have felt for many years psychiatry with its softer science and smaller size was the business model pharma wanted to impose on all of medicine.

    Pharma has learned those lessons of old well and changing psychiatry will not be simple or easy, but will require a remaking of the science and leadership.

    Steve Lucas

    September 9, 2013 | 3:07 PM

    Perhaps these findings will make a great and lasting contribution, but this article looks a bit too bubbly to me.

    Their drive to find an answer has taken neuroscientists to uncharted waters – researching everything from psychedelic magic mushrooms, to the veterinary tranquilizer ketamine, to magnetic stimulation through the skull, to using electrical implants – a bit like a pacemaker for the brain – to try and reset this complex organ’s wiring and engender a more positive outlook…

    … “We have a new model for thinking about psychiatric diseases not just as chemical imbalance – that your brain is a just big vat of soup where you can just add a chemical and stir – but where we ask different questions – what’s wrong with brain chemistry and what’s wrong with brain circuits.”


    George Dawson, MD, DFAPA
    September 9, 2013 | 4:28 PM

    Social psychology is overblown. Not everybody eats at MacDonalds despite them using the same marketing principles. The idea that we are all robotically following subconscious bias on a massive scale seems a bit too Freudian to me. But maybe that’s because I never “liked” a drug rep.

    Is the hallucinogen revival a subconscious effort to create epiphanies or recreate the 1970s?

    donald klein
    September 9, 2013 | 5:09 PM

    The issue of whether we need top down or bottom up reform is remarkably vapid and askew to the public health issue which is not financial Conflict of Interest–although that makes for the easy–at times correct– attribution of shameful motivation– Rather it is the lack of access to the actual preclinical and clinical trials protocol and data-which are hidden by “trade secret” legislation and precedent.–To change that requires a shift of focus ,from an easy target to a detailed exposition– in these attempts to inform the public . That salesmanship is THE important issue ( although ancient as in Galbraith’s “managed demand” ) obscures the real central issue .It appalls me that this “critical” blog pays no attention to the current European Medical Agency stand re raw data access or the EU Ombudsman decree that matters of public health trump “intellectual property == trade secrets”.
    Now,that’s worth discussing and popularizing.
    Don Klein

    September 9, 2013 | 5:24 PM

    Very famous, classic book, Influence: The Psychology of Persuasion:


    Recommended for both sales people and those being “sold.”

    September 9, 2013 | 5:54 PM

    Bad Research Rising: The 7th Olympiad of Research On Biomedical Publication


    The congress hurtled off to an energetic start with John Ioannidis, epidemiologist and agent provocateur author of “Why most published research findings are false.” He pointed to the very low rate of successful replication of genome-wide association studies (not much over 1%) as an example of very deep-seated problems in discovery science.

    Half or more of replication studies are done by the authors of the original research: “It’s just the same authors trying to promote their own work.” Industry, he says, is becoming more concerned with replicability of research than most scientists are. Ioannidis cited a venture capital firm that now hires contract research organizations to validate scientific research before committing serious funds to a project.

    September 9, 2013 | 6:00 PM
    September 9, 2013 | 9:03 PM

    The NIMH director Thomas Insel actually just made a post on the 5th relevent to the last few posts.


    I’m not sure if I missed it earlier on here, but I’m going to take a look through whatever DORA is.

    September 10, 2013 | 2:47 AM

    EMA and Ombudsman:
    From http://www.bmj.com/content/347/bmj.f1880 :
    “But in 2010 the European ombudsman made a ruling of maladministration against the EMA, for claiming exactly that. The ombudsman examined the clinical study reports requested from the agency in detail, and concluded that the administrative burden of removing patient information, where necessary, was small. The European ombudsman has also stated clearly that there is no important commercially confidential information in these reports—the fact that a drug is not as good as claimed is not, in itself, something any company can hope to ethically withhold from doctors and patients.13 Since then, the EMA has released 1.6 million pages of clinical study reports14 under its new policy.13 Because these documents are so informative—and because the EMA holds only a small proportion of all the clinical study reports in existence—alltrials.net is asking for all existing clinical study reports to be made available, on all medicines currently in use.”

    From http://www.alltrials.net/2013/2338/:
    “AbbVie, has just argued that information about adverse effects of drugs “is confidential commercial information because if released other companies could use it to help them get products approved.””
    “Hans Georg Eichler, the EMA’s senior medical officer, said “I have been a regulator for many years and I am totally flabbergasted.””


    September 10, 2013 | 10:15 AM
    September 11, 2013 | 4:30 AM
    September 11, 2013 | 2:05 PM

    Physicians claiming they are impervious to marketing propaganda, as though they were better than mere mortals, has always been ludicrous.

    September 13, 2013 | 12:37 AM

    Updated edition of famous classic, Influence: Science and Practice by Dr. Robert B. Cialdini


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