Shaili Jain does not need much justification for writing this book: if the pharmaceutical industry is allocating nearly $100,000 and one representative for every eleven practicing physicians in the United States, these latter should ask themselves whether such investment has any effect on their prescriptions. At least, there is evidence that their patients (and often the taxpayer too) would want them to. There is indeed an extensive literature about consequences of pharmaceutical marketing on physicians, published not only in medical journals, but in many other social sciences outlets. It seems though that most doctors consider themselves impervious to the advertising strategies of the industry and Shaili Jain knows that they won't spend much time learning about them.
This book offers to health care professionals a fast and frugal understanding of these strategies, as they are implemented in the United States: each chapter is about four pages long, of which the analytical presentation of the author's case takes at most three. In addition there are quick fictional vignettes of each situation analysed, bullet point summaries and an updated reference list. Here goes a list of the topics addressed.
The first two chapters state the author's main thesis: there is serious evidence that industry gifts create biases that influence physicians' prescriptions and this has ethical consequences regarding their obligations to their patients. The following three chapters discuss the more prominent ways to create these biases. Namely, through medical detailing (pharmaceutical representatives visiting doctors to present their products), informal teaching to physicians in training, and also sponsoring clinical research to be later published in scientific journals. In chapters 6 and 7 Jain ponders the benefits and disadvantages of these sophisticated marketing mechanisms and provides a list of suggestions to constrain the promotional dimension of industry sponsored events. She offers a brief remainder of the existing professional guidelines about the topic, which are reproduced at length in a 60 pages closing appendix.
Chapters 8 to 11 deal with the public understanding of the interactions between physicians and the pharmaceutical industry. In chapter 8 Jain summarizes evidence showing that patients often don't know how many gifts their doctors receive from the industry and when they are informed, they do not approve of it. When patients receive medication samples as gifts themselves, they tend to overlook the inferior standards of care they are often associated with (physicians are often unaware too). Chapter 10 briefly explores the possibility of applying federal antikickback laws to punish pharmaceutical companies and physicians for exchanging gifts for prescriptions. Finally, in chapter 11, Jain considers the pros and cons of direct-to-consumer advertising of prescription drugs. The book closes with a glimpse of the situation in countries other than the USA and a brief list of internet resources on the topic.
Jain seems to be arguing namely to raise the awareness about the consequences of pharmaceutical marketing among health care professionals. Her review of the literature is often too quick, and sometimes may seem unconvincing or inconclusive. At least, if we compare it with the more "partisan" approaches which abound in this field (either for or against "Big Pharmas"). Yet the book is rich in checklists which allow the physician to ponder the dilemmas she is facing in her daily practice. This self-assessment may not automatically correct her biases (psychologists have experimentally documented our resilience to this kind of corrections), but may open a more informed discussion among health care professionals in which the possibility of biases is not discounted ex ante, as it usually happens now. Perhaps pharmaceutical companies should be compelled to include this book in their catalogue of promotional gifts for the coming years in order to see how it contributes to their sales.
© 2009 David Teira
David Teira, UNED (Madrid)