If a pharmaceutical company offers a doctor a free slice of pizza in exchange for listening to a presentation about their new drug, would it be a conflict of interest for the doctor to accept? What about accepting a free plane ticket to a conference, or getting payments to offer advice to a drug company?
Passionate about studying conflicts of interest in medicine, in 2011, a team of researchers surveyed medical students and residents across the country, asking them to describe their interactions with, and attitudes toward, the pharmaceutical industry. Then, 13 years later, they re-surveyed the same people to see how their feelings have changed, publishing their findings in the JAMA Health Forum.
Ultimately, the research team — which includes Eric Campbell, PhD, professor of general internal medicine and research director of the Center for Bioethics and Humanities at the University of Colorado Anschutz — found that respondents were more likely to strongly agree that trust in medicine was threatened by industry marketing interactions, but many respondents also believed they can receive useful information from marketing.
“Right now, in medicine, we are experiencing a trust crisis. The American public is showing reduced trust in doctors, reduced trust in researchers, and reduced trust in the government agencies that manage healthcare,” Campbell says. “Doctors recognize that these interactions can erode trust, but they see them as being a source of information. It’s a conflict.”
Campbell and his co-investigators write in their paper that pharmaceutical manufacturers spend over $35 billion per year to market drugs, often directly to health care professionals.
Interactions between physicians and pharmaceutical marketers can take a number of different forms, Campbell explains. For example, marketers may visit medical institutions to advertise their company’s drugs, often offering free items like samples and meals. Some physicians may get paid to serve as consultants for a company, providing advice to the company or marketing activities. There have also been cases where companies have paid for physicians to travel for free, such as to a conference.
“The research shows that if physicians get things, whether that's a meal, payment, or attention, they are significantly more likely to prescribe the company's products and services. It’s an implicit quid-pro-quo. But if you ask a doctor whether a gift would influence them, they usually say no,” Campbell says. “It’s an economic transaction that people fail to recognize as influencing their behavior, despite evidence to show that it does.”
An exception is when it comes to research. For example, there are times when drug companies provide funding for physicians and scientists at an academic medical institution to conduct peer-reviewed research, such as to test the efficacy or safety of a drug. There are many regulations in place that oversee this process to ensure the information is accurate, Campbell explains.
“These are highly regulated interactions that are disclosed,” he says. “That’s an acceptable way to translate information from basic science into the clinic.”
The initial survey in 2011 garnered responses from 1,610 medical students and 739 residents, finding that industry-sponsored gifts like meals and free drug samples were common. The research sparked from a collaboration between three physicians at Harvard Medical School — Kirsten Austad, MD, Jerry Avorn, MD, and Aaron S. Kesselheim, MD, JD, MPH — who recruited Campbell to join their efforts.
“Dr. Austad wanted to understand how often medical students and residents were interacting with drug company representatives, what they were getting, and what impact it had on their views,” Campbell says. “At the time, this was incredibly groundbreaking. I believe it was the first data of its kind that focused on medical students and residents.”
More than a decade later, Campbell received a call from Kesselheim asking if he’d be interested in helping track down the respondents to re-evaluate their thoughts. For the 2024 survey, the researchers got nearly 300 responses, mostly from people who reported working in hospitals or clinics as medical specialists. The majority of the 2024 respondents were medical students in 2011, when they originally filled out the survey.
“The purpose of this follow-up was to say: What has changed? Because what you do as a student and trainee is highly managed, but the minute you get out into clinical practice, you’re mostly on your own,” Campbell says.
Campbell and his co-investigators explain in their paper that researchers “have repeatedly found direct associations between pharmaceutical detailing, prescribing choices, and ultimately patient outcomes.”
Pharmaceutical detailing is when marketers directly meet with health care providers, often at their workplace, to advertise the company’s products, such as through a presentation. These marketers often bring free food and beverages with them to entice participation.
“People will say that this is an educational meeting, but research has shown that the information that drug companies provide is often biased in terms of the safety and efficacy of their products,” Campbell says. “People recognize the potential problems with this. In our study, we found that virtually all of the respondents felt that these transactions have a negative influence on trust.
“Yet, they also say that they rely on this as a source of information,” he adds. “I think the important thing to ask is: What is the quality of information I’m getting, and could that information be obtained from another source that doesn’t involve a conflict of interest?”
Research suggests small gifts, such as free coffee and slices of pizza, can actually be more influential than larger gifts, Campbell says, because people’s guards are lowered with smaller products; gifts that are worth more typically raise people’s concerns.
“The marketer can say to the doctor, ‘I know you would never be influenced by a $2 piece of pizza.’ But that is contrary to the scientific evidence that shows that if you give people things, even seemingly small things, it creates a certain level of dependency,” he says.
Given the trust crisis facing the medical system, Campbell underscores the value of being transparent and reducing the potential for conflicts of interest to occur.
For patients, there is a government database, called Open Payments, that aims to disclose the financial relationships that drug and medical device companies have with health care providers. Campbell also hopes patients feel empowered to ask their health care providers questions if they have any concerns about the providers having potential conflicts of interest.
“When their doctor prescribes something, it’s within a patient’s rights to ask the doctor if they ever received anything from the manufacturer,” he says. “But this is not the patient’s job — we shouldn’t put the burden of managing conflicts of interest on patients. It’s the responsibility of the medical profession to self regulate.”
The goal of studies like Campbell’s is to show the extent and consequences of these relationships, allowing health care leaders to make decisions about whether these interactions should continue or if new restrictions should be enacted, he explains.
“It’s always been my hope that providing data on what is a long-standing ethical debate in the field about these practices would motivate the field to better exercise its responsibility to appropriately limit and manage conflicts of interest,” he says. “I believe the field of medicine, as a profession, is the strongest mechanism to move change toward what should happen, instead of what does happen.”