Yale Journal of Health Policy, Law, and Ethics
`Volume 5
`Issue 2 Yale Journal of Health Policy, Law, and Ethics
`
`Article 8
`
`3-2-2013
`
`The Effects and Role of Direct-to-Physician
`Marketing in the Pharmaceutical Industry: An
`Integrative Review
`Puneet Manchanda
`
`Elisabeth Honka
`
`Follow this and additional works at: http://digitalcommons.law.yale.edu/yjhple
`Part of the Ethics and Professional Responsibility Commons, and the Health Law Commons
`
`Recommended Citation
`Manchanda, Puneet and Honka, Elisabeth (2005) "The Effects and Role of Direct-to-Physician Marketing in the Pharmaceutical
`Industry: An Integrative Review," Yale Journal of Health Policy, Law, and Ethics: Vol. 5: Iss. 2, Article 8.
`Available at: http://digitalcommons.law.yale.edu/yjhple/vol5/iss2/8
`
`This Article is brought to you for free and open access by Yale Law School Legal Scholarship Repository. It has been accepted for inclusion in Yale
`Journal of Health Policy, Law, and Ethics by an authorized administrator of Yale Law School Legal Scholarship Repository. For more information,
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`Manchanda and Honka: The Effects and Role of Direct-to-Physician Marketing in the Pharmaceutical Industry
`
`The Effects and Role of Direct-to-Physician Marketing in
`the Pharmaceutical Industry: An Integrative Review
`
`Puneet Manchanda, M.Phil., Ph.D.* and Elisabeth Honkat
`
`INTRODUCTION
`
`The pharmaceutical industry plays a vital role in the world's economy, as
`well as in ensuring the welfare of its citizens. In the United States, this industry
`constitutes a large and important part of the economy. In 2002, health care
`expenditure in the United States reached $1.6
`trillion, accounting for fifteen
`percent of total GNP.' This percentage is also growing over time-it was seven
`percent in 1970.2 An important component of the health care industry is the
`pharmaceutical industry-in 2002, its size was estimated at $193 billion. 3 While
`the pharmaceutical industry is driven by innovation, it spends more money on
`marketing than on research and development.4 For example, this industry spends
`more than any other U.S. industry on its sales ,force ($7 billion annually) and on
`media advertising ($2.8 billion annually). 5
`Pharmaceutical companies typically direct their marketing efforts toward
`physicians and, as of late, directly to patients (consumers). The marketing efforts
`directed at physicians comprise personal selling through sales representatives
`
`* Associate Professor of Marketing, Graduate School of Business, University of Chicago. He
`would like to acknowledge research support from the Kilts Center for Marketing at the Graduate
`School of Business, University of Chicago.
`f Doctoral Student, Graduate School of Business, University of Chicago. She would like to
`acknowledge financial support from the German Academic Exchange Council (DAAD).
`1. What's Driving Health Care Costs and the Uninsured: Hearing Before the Senate Comm.
`on Health, Educ., Labor & Pensions, 108th Cong. 38 (2004) (statement of Douglas Holtz-Eakin,
`Director, Cong. Budget Office).
`2. Id.
`3. PHARM. RESEARCH & MFRS. OF AM. (PHRMA), PHARMACEUTICAL INDUSTRY PROFILE 2004
`44 (2004), http://www.phrma.org/publications/publications//2004-03-31.937.pdf.
`4. FAMILIES USA FOUND., OFF THE CHARTS: PAY, PROFITS AND SPENDING BY DRUG
`COMPANIES 3 (2001), http://www.familiesusa.org/site/DocServer/offfhecharts.pddoclD=823.
`5. DICK R. WITrINK, ANALYSIS OF ROI FOR PHARMACEUTICAL PROMOTION (ARPP) (2002),
`http://www.rxpromoroi.org/arpp/media/arpp-handout_0927.pdf.
`
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`Yale Journal of Health Policy, Law, and Ethics, Vol. 5 [2005], Iss. 2, Art. 8
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`(detailing); 6 sampling (provision of drugs at no cost); physician meetings and
`events; and advertisements in medical journals.7 Since 1997, a change in the legal
`environment that allowed direct-to-consumer advertising (DTCA) has resulted in
`a 350% increase in expenditures for such advertising between 1996 and 2001.8
`is directed toward
`the biggest chunk of marketing expenditure
`However,
`detailing. 9 Historically, detailing has been the pharmaceutical industry's primary
`promotional instrument. 10 Our aim in this Article is to provide an integrative
`review of the academic research on the effect and role of detailing. We highlight
`the main findings that arise from the medical, legal, economics, and marketing
`literature. Finally, we propose an explanation of the pervasiveness of detailing
`over a drug's life. We conclude by proposing how an increase in the efficiency
`and effectiveness of this expenditure can benefit firms, physicians, and patients.
`As noted above, we attempt to provide an integrative review of the literature
`on detailing. As a result, we need to provide organizational criteria in order to
`deal with the large number of studies on the subject. We use two such criteria to
`organize this review: the outcome variable and the nature of the data collected by
`the researcher. The outcome variable is the variable that is affected by detailing,
`which can range from "softer" variables, such as physician attitudes, to "harder"
`variables, such as drug sales. The nature of data collected can be survey data or
`actual behavioral (market) data. While we believe that these two criteria are
`important, we also describe the extant literature using all relevant criteria in the
`form of tables in the Appendix." We first examine physician attitudes toward
`
`6. For an excellent overview of the evolution of modem detailing in the United States, see
`Jeremy E. Greene, Attention To 'Details': Etiquette and the Pharmaceutical Salesman in Postwar
`America, 34 Soc. STUD. Sci. 271 (2004).
`7. STEPHEN P. BRADLEY & JAMES WEBER, THE PHARMACEUTICAL INDUSTRY: CHALLENGES IN
`THE NEW CENTURY 7 (Harvard Bus. Sch., Working Paper No. 9-703-489, 2004).
`8. Id.
`9. WrrriNK, supra note 5, at 6-7.
`10. BRADLEY & WEBER, supra note 7, at 8-9.
`11. There have been other such integrative articles. See, e.g., Dale B. Christensen & Patricia J.
`Bush, Drug Prescribing: Patterns, Problems and Proposals, 15a Soc. ScI. & MED. 343 (1981);
`Richard J. Plumridge, A Review of Factors Influenciig Drug Prescribing (pt. 1), 13 AUSTL. J.
`HosP. PHARMACY 16 (1983). But not all include detailing as an independent variable, see, e.g.,
`Dennis W. Raisch, A Model of Methods for Influencing Prescribing (pts. 1 & 2), 24 DICP, ANNALS
`PHARMACOTHERAPY 417, 537 (1990), even the ones that do not differentiate between detailing as a
`general source of information, detailing's function in new product introductions, and its influence
`on physician prescribing, see, e.g., James R. Williams & Paul J. Hensel, Changes in Physicians'
`Sources of Pharmaceutical Information: A Review and Analysis, 11 J. HEALTH CARE MARKETING
`46 (1991). Most other literature reviews cover a very broad set of variables that affect physician
`prescribing. See, e.g., T.S. Caudill & Nicole-Lurie, The Influence of Pharmaceutical Industry
`Advertising on Physician Prescribing, 22 J. DRUG ISSUES 331 (1992); Elina Hemminki, Review of
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`Manchanda and Honka: The Effects and Role of Direct-to-Physician Marketing in the Pharmaceutical Industry
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`THE EFFECTS AND ROLE OF DIRECT-TO-PHYSICIAN MARKETING
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`detailing using studies from the medical literature. As the purported reason for
`the existence of detailing is that it provides information to physicians, we then
`examine whether the medical community indeed perceives it as such and if these
`perceptions have changed over time. We then look at whether detailing affects
`stated and actual prescription behavior. Finally, we examine the role of detailing
`over the life cycle of a drug with a special emphasis on its effects in the early,
`awareness-building stage. We conclude by integrating the main findings into a
`coherent explanation of the role of detailing.
`Based on our analysis we draw the following major conclusions. First, it
`seems that physicians have negative (at one extreme) to neutral (at the other)
`attitudes toward pharmaceutical sales representatives. The variance in this
`attitude is explained by a variety of factors. Some of the important factors are the
`quality of informational and educational support provided via detailing, detailer
`style, and the physician's practicing environment. However, detailing exists and
`flourishes in spite of this attitude as it provides an inexpensive and convenient
`source of information. Interestingly, the importance of detailing as a source of
`information has declined over the past five decades, as it is no longer the most
`important source of information.
`Second, not only is detailing an important source of information, it affects
`physician prescription behavior in a positive and significant manner. More
`important, this seems to occur over the length of the drug's life cycle. This is
`puzzling considering that over a drug's life cycle, most information about the
`drug is likely to be disseminated early on-a fact confirmed by physician
`surveys. Thus, detailing's effect should diminish over the life cycle of a drug.
`There is no obvious explanation for the fact that detailing has a positive and
`significant effect late in the drug life cycle. Based on our analysis and industry
`observations, our explanation is that in addition to providing a "reminder effect,"
`constant interaction builds a stock of goodwill between a detailer (or the firm)
`and the physician, translating into positive physician prescription behavior. This
`goodwill is not based on purely objective and rational factors but on social and
`cultural norms. Its character changes from informative to more persuasive in the
`
`Literature on the Factors Affecting Drug Prescribing, 9 Soc. SCI. & MED. 111 (1975); Russell R.
`Miller, Prescribing Habits of Physicians: A Review of Studies on Prescribing of Drugs (pts. 1-8), 7
`DRUG INTELLIGENCE & CLINICAL PHARMACY 492, 557 (1973), 8 DRUG INTELLIGENCE & CLINICAL
`PHARMACY 81 (1974); J.P. Rovers, The Doctor's, the Druggist's, and the Detail Rep's Dance: Who
`Leads, Who Follows, 37 CAN. FAM. PHYSICIAN 100 (1991); Dennis B. Worthen, Prescribing
`Influences: An Overview, 7 BRIT. J. MED. EDUC. 109 (1973). In other words, reviews concentrating
`on detailing as a factor influencing physician attitudes and prescribing behavior are relatively rare.
`Also noteworthy is Joel Lexchin, Doctors and Detailers: Therapeutic Education or Pharmaceutical
`Promotion?, 19 INT'L J. HEALTH SERVS. 663 (1989), which critically discusses doctors, detailers,'
`and their relationships.
`
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`later stages of the drug life cycle. The evolution of goodwill in this manner
`reflects the deepening relationship between the physician and the pharmaceutical
`sales representative.
`Finally, detailing is clearly here to stay. Although physicians claim to
`tolerate it as a necessary evil, detailing evidently has an impact on prescription
`behavior via both a subjective and an objective path. From the industry
`perspective, pharmaceutical firms continue to invest heavily in this mode of
`promotion-they have more than doubled their 1997 sales force to about 90,000
`in 2002.12 Thus, one possible approach that could be beneficial to all concerned
`parties-patients, physicians, firms, and policy makers-would be to ensure that
`this large expenditure on detailing is carried out in the most efficient manner
`possible. We conclude the Article by providing suggestions on how this could be
`carried out.
`
`I. REVIEW OF PAST STUDIES
`
`A. Physician Attitudes Toward Detailing
`
`In this Section, we focus our attention on physician attitudes as documented
`(mostly) in the medical literature. We focus on general attitudes toward detailing
`and detailers and attitudes toward gifts. We then look at studies that provide an
`explanation for the formation of these attitudes. (Tables l a-lc provide a more
`detailed overview of the studies discussed.)
`
`1. Physician Attitudes Toward Detailers
`
`A series of studies document that physician attitudes toward detailing and
`pharmaceutical sales representatives are mostly negative. First, Poirier et al.
`toward pharmaceutical marketing
`their attitudes
`surveyed physicians on
`practices. 13 They found that only 24% of the physicians were satisfied with
`detailing and 48% were dissatisfied.' 4 These skeptical attitudes were confirmed
`by the finding that only 20% of the physicians believed in the accuracy and
`objectivity of presented information, while 44% did not. 15 Nevertheless, 56%
`admitted that representatives could influence formulary decisions if efficacy,
`
`12. Pushing Pills, THE ECONOMIST, Feb. 15, 2003, at 61.
`13. Therese I. Poirier et al., Pharmacists' and Physicians' Attitudes Toward Pharmaceutical
`Marketing Practices, 51 AM. J. HOSP. PHARMACY 378 (1994).
`14. Id. at 379.
`15. Id.
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`Manchanda and Honka: The Effects and Role of Direct-to-Physician Marketing in the Pharmaceutical Industry
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`THE EFFECTS AND ROLE OF DIRECT-TO-PHYSICIAN MARKETING
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`toxicity, and cost were the same, while 28% disagreed with this statement. 6
`Strang et al. surveyed Canadian general practitioners and specialists on their
`attitudes toward sales representatives. 17 Ninety-two percent of the physicians
`thought that drug promotion was a major goal of sales representatives, while only
`37% saw physician education as a major goal of sales efforts. 18 Forty-seven
`percent of the physicians
`thought
`that sales
`representatives provide all
`information to describe a drug, while 80% thought that detailers overemphasized
`the effectiveness of a drug.' 9
`In 1996 Caudill et al. surveyed physicians about their attitudes toward the
`educational
`value
`and behavioral
`influence of pharmaceutical
`sales
`20
`representatives. Physicians agreed that sales representatives provided useful and
`accurate information about newly and already established drugs, but only slightly
`agreed that they performed an important teaching function.2' Physicians strongly
`agreed that sales representatives should be banned from making presentations
`where the physicians practice.22 McKinney et al. examined physicians' attitudes
`toward detailing and its potential for ethical compromise.23 They found that
`physicians had somewhat negative attitudes
`toward
`the educational and
`informational value of detailing activities, but also acknowledged sales
`representatives' support for conferences and speakers.24
`Hopper et al. collected
`information on the effects of an educational
`intervention
`aimed
`at
`training physicians
`in
`interactions with
`sales
`25
`representatives.
`They surveyed residents and faculty before and after the
`intervention. Before the intervention, physicians slightly agreed that contact with
`detailers was not beneficial, but strongly disagreed that it might influence their
`
`16. Id.
`17. David Strang et al., National Survey on the Attitudes of Canadian Physicians Toward
`Drug-Detailing by Pharmaceutical Representatives, 29 ANNALS ROYAL C. PHYSICIANS &
`SURGEONS CAN. 474 (1996).
`18. Id. at 476.
`19. Id.
`20. T.S. Caudill et al., Physicians, Pharmaceutical Sales Representatives, and the Cost of
`Prescribing, 5 ARCHIVES FAM. MED. 201 (1996).
`21. Id. at 204.
`22. Id.
`23. W. Paul McKinney et al., Attitudes of Internal Medicine Faculty and Residents Toward
`Professional Interaction with Pharmaceutical Sales Representatives, 264 JAMA 1693 (1990).
`24. Id. at 1695.
`25. John A. Hopper et al., Effects of an Educational Intervention on Residents'Knowledge and
`Attitudes Toward Interactions with Pharmaceutical Representatives, 12 J. GEN. INTERNAL MED.
`639 (1997).
`
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`prescribing in negative ways.26 However, physicians were rather neutral about
`whether interactions were likely to influence the prescribing behavior of other
`physicians in negatives ways. 27 Residents believed significantly more than
`faculty that sales representatives sometimes use unethical marketing practices
`and that the residents have too much contact with the detailers.28 Two items of
`to have statistically significant
`the post-intervention survey were found
`intervention and nonintervention resident groups:
`the
`differences between
`Participating residents more strongly believed than nonintervention residents that
`sales representatives may use unethical marketing practices and that interaction
`with detailers is likely to influence the prescribing of other physicians in negative
`ways.29
`Other studies have documented more neutral physician attitudes to detailing
`and pharmaceutical sales representatives. Andaleeb and Tallman's examination
`of physicians' relationships with sales representatives showed that although
`physicians viewed sales representatives as an important source of information,
`they thought they could also get the needed information from another source.3 °
`relationships with sales
`that physicians had friendly
`found
`The study
`representatives and did not distrust them, but did not consider them a vital part of
`their practice. Selling methods were not viewed as manipulative, nor were sales
`representatives perceived negatively. 31 The median overall attitude toward sales
`representatives was also reported as neutral in a study by Thomson et al. based
`on a survey of general practitioners in New Zealand.32 One specific attribute of
`this study was that only 77% of the physicians reported having access to
`colleagues.33 Physicians also tended
`if
`to see more sales representatives
`colleagues' advice was less readily available. Eighty-seven percent of the
`respondents reported having seen detailers; one physician would have liked to
`see sales representatives, but was never visited because of the isolated location of
`his practice. 34 The reasons given most often for seeing sales representatives were
`
`26. Id. at 640.
`27. Id.
`28. Id.
`29. Id. at 641.
`30. Syed S. Andaleeb & Robert F. Tallman, Relationships of Physicians with Pharmaceutical
`Sales Representatives and Pharmaceutical Companies: An Exploratory Study, 13 HEALTH
`MARKETING Q. 79, 84-85 (1996).
`31. Id.
`32. A.N. Thomson et al., Attitudes of General Practitioners in New Zealand to Pharmaceutical
`Representatives, 44 BRIT. J. GEN. PRAc. 220 (1994).
`33. Id. at 221.
`34. Id. at 221.
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`Manchanda and Honka: The Effects and Role of Direct-to-Physician Marketing in the Pharmaceutical Industry
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`THE EFFECTS AND ROLE OF DIRECT-TO-PHYSICIAN MARKETING
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`practical prescribing information, samples, a feeling of politeness, or pressure. 35
`Relative to all respondents, practitioners favorably disposed to detailers saw
`more sales representatives. Also relative to physicians in smaller practices,
`physicians in larger practices saw fewer detailers.
`
`2. Physician Attitudes Toward Gifts
`
`Another dimension on which physicians have very strong attitudes is the
`practice of gift-giving from pharmaceutical sales representatives to physicians.
`As part of the detailing process, sales representatives often not only give samples,
`but also give trinkets, books, or meals. Sixty-seven percent of the faculty and
`77% of the residents in the McKinney et al. study indicated that they believed
`that physicians could be compromised by accepting gifts
`from sales
`36
`representatives. Specifically, the authors found that 50% of the faculty and 42%
`of the residents perceived gifts of $100 or more to be likely to compromise a
`physician's judgment.37 Keim et al. questioned residents and directors in
`emergency medicine about their interactions with the biomedical industry3 8 and
`found that 74% of the residents who responded to the survey believed that
`representatives
`"sometimes cross ethical boundaries by giving gifts
`to
`physicians. 39 While 75% of the program directors believed that marketing
`techniques of sales representatives affected residents' prescribing, only 49% of
`the residents believed the same to be true. 40 However, in a 1997 study Madhavan
`et al. found that doctors slightly agreed that pharmaceutical companies gave gifts
`to physicians to influence their prescribing, but disagreed that, in general, gift-
`giving influenced most physicians' prescribing behavior.41 The physicians
`surveyed strongly disagreed that they themselves could be influenced in their
`42
`prescribing behavior by the gifts they receive.
`Aldir et al. also reported that
`physicians disagreed that their prescribing was influenced by gifts such as
`lunches or dinners, but the physicians surveyed admitted that their prescribing
`
`35. Id.
`36. McKinney et al., supra note 23.
`37. Id. at 1695.
`38. Samuel M. Keim et al., Beliefs and Practices of Emergency Medicine Faculty and
`Residents Regarding Professional Interactions with
`the Biomedical Industry, 22 ANNALS
`EMERGENCY MED. 1576 (1993).
`39. Id. at 1578.
`40. Id.
`41. S. Madhavan et al., The Gift Relationship Between Pharmaceutical Companies and
`Physicians: An Exploratory Survey of Physicians, 22 J. CLINICAL PHARMACY & THERAPEUTICS 207,
`212 (1997).
`42. Id.
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`might be affected by sample giving.43 Reeder et al. surveyed chief residents in
`emergency medicine programs about their attitudes surrounding their "gift
`relationship" with pharmaceutical companies. 44 One-fifth of the chief residents
`believed that accepting gifts could affect their own prescription habits.45
`While the studies above suggest that gifts are not generally acceptable, the
`ones that asked about the value of the gift found that gifts below a certain
`threshold-typically $100-are acceptable.46 Aldir et al. also found that the
`majority of physicians agreed that gifts above $100 were inappropriate, but found
`no relationship between physicians' values regarding gifts and their attitudes
`regarding scientific information provided by the pharmaceutical industry.47
`
`3. Antecedents of Physician Attitudes
`
`is
`the studies described above have expressed attitudes, there
`While
`relatively little research on the antecedents (or causes) of this attitude formation.
`A 1991 study by Lagace et al. showed that the salesperson's ethical behavior and
`trust and
`(especially
`attitudes
`affected physician
`expertise positively
`satisfaction).4
`It also found that the frequency of visits did not significantly
`affect satisfaction. 49 Brotzman and Mark provided an alternative set of
`antecedents; 0 they argued that regulatory policies affect physicians' attitudes
`toward sales representatives. 1 By comparing residents from free and restricted
`programs, 52 Brotzman and Mark found those from free programs to be twice as
`likely to view overall interactions, educational information, and extracurricular
`
`43. Rodolfo E. Aldir et al., Practicing and Resident Physicians' Views on Pharmaceutical
`Companies, 16 J. CONTINUING EDUC. HEALTH PROFS. 25, 31 (1996).
`44. Mike Reeder et al., Pharmaceutical Representatives and Emergency Medicine Residents: A
`National Survey, 22 ANNALS EMERGENCY MED. 1593 (1993).
`45. Id. at 1595.
`46. See Aldir et al., supra note 43; McKinney et al., supra note 23; Reeder et al., supra note 44.
`47. Aldir et al., supra note 43, at 29.
`48. Rosemary Lagace et al., The Relevance of Ethical Salesperson Behavior on Relationship
`Quality: The Pharmaceutical Industry, 11 J. PERS. SELLING & SALES MGMT. 39, 44 (1991).
`49. Id.
`50. Gregory L. Brotzman & David H. Mark, The Effect on Resident Attitudes of Regulatory
`Policies Regarding Pharmaceutical Representative Activities, 8 J. GEN. INTERNAL MED. 130
`(1993).
`51. Id. at 132.
`52. In a free program, residents' access to sales representatives is not overseen by the facility.
`However, in a restricted program, the quality and quantity of contact between residents and sales
`representatives is determined by the policies of the facility. This restriction usually results in much
`less access relative to that in a free program.
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`Manchanda and Honka: The Effects and Role of Direct-to-Physician Marketing in the Pharmaceutical Industry
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`THE EFFECTS AND ROLE OF DIRECT-TO-PHYSICIAN MARKETING
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`activities as beneficial, and four times more likely to view detailing as helpful. 53
`Physicians from free programs had more contacts with sales representatives and,
`as measured by eight categories, they were more likely to feel that gift
`acceptance was appropriate. 4 However, in contrast, Ferguson et al. found no
`differences in the likelihood of meeting with sales representatives or accepting
`samples between internists from hospitals with and without regulatory policies. 5
`Andaleeb and Tallman also identified factors that influenced physicians' attitudes
`toward sales representatives. 6 They found that physicians' attitudes were
`influenced by the information and educational support they receive, selling
`their volume of patients. 7 The more
`techniques, and
`informational and
`educational support from sales representatives and the higher the number of
`patients,
`the more
`favorable were physicians'
`attitudes
`toward
`sales
`representatives. 8 In contrast, a manipulative and aggressive selling style was
`associated with an unfavorable attitude. 59
`
`B. Detailing as a Source of Information
`
`The classic role of detailing is to provide (medical)
`information to a
`physician. This information ranges from awareness-building to detailed technical
`information. The importance of detailing as one of physicians' sources of
`information about drugs has often been investigated, as is outlined in Table 2.
`These studies were perceptual by nature and asked physicians how much
`importance they attributed to either detailing in general or its certain aspects.
`In general, physicians perceive detailers to be useful sources of information.
`Fassold and Gowdey surveyed Canadian physicians, about one-half general
`practitioners and one-half specialists, on their reactions to drug promotions.6 °
`Forty-six percent of the respondents considered detailing the most informative
`and/or acceptable form of drug promotion. 6' Among the general practitioners,
`
`53. Brotzman & Mark, supra note 50, at 132.
`54. Id. at 132.
`55. Robert P. Ferguson et al., Encounters with Pharmaceutical Sales Representatives Among
`Practicing Internists, 107 AM. J. MED. 149 (1999).
`56. Syed S. Andaleeb & Robert F. Tallman, Physician Attitudes Toward Pharmaceutical Sales
`Representatives, 20 HEALTH CARE MGMT. REv. 68 (1995).
`57. Id. at 73.
`58. Id.
`59. Id.
`60. R.W. Fassold & C.W. Gowdey, A Survey of Physicians' Reactions to Drug Promotion, 98
`CAN. MED. ASS'N J. 701 (1968).
`61. Id. at 702.
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`56% ranked it first while only 37% of the specialists did SO. 6 2 Only 13%
`considered detailing as the least informative and/or acceptable form of drug
`specialists, 31%
`promotion. 63 Twenty-four percent of the physicians (18%
`forms of
`that detailing and other spoken
`stated
`general practitioners)
`manufacturers' advertisements were their preferred choice of information on new
`drugs. 64 Another study by Henley et al. surveyed Iowa physicians on the
`information.65
`sources of drug
`they use certain
`frequency with which
`Pharmaceutical textbooks were ranked first, followed by drug salesmen.66 Fifty-
`five percent of the physicians indicated that they relied on pharmaceutical
`representatives very often or often.67 Twenty-seven percent indicated occasional
`use of this information source, and 17% seldom or never rely on detailers.68 A
`1976 study by Eaton and Parish surveyed general practitioners in Great Britain
`concerning how they gathered information and what sources they found useful. 69
`Ninety-three percent of the respondents indicated seeing sales representatives at
`least once a week, and 67% thought they would lose an important source of
`information if they did not see any detailers.7 ° While 90% of the physicians
`indicated that sales representatives were a helpful source to find out about the
`existence of a drug, only 51% said they were a helpful source in finding out
`about the usefulness of a drug. 71 Reeder et al. found that 80% of the respondents
`thought their residency program benefited from interaction with pharmaceutical
`representatives, usually through the presentation of new clinical data.72 Finally,
`Connelly et al. studied knowledge resources of family physicians and found that
`they regarded detailers to provide information that was less extensive and
`credible than secondary (e.g., Physicians' Desk Reference, medical texts, Index
`(colleagues).73
`terms of information
`In
`Medicus) and primary sources
`availability, searchability, understandability, and applicability, information from
`detailers was regarded as higher than information from secondary sources such as
`
`62. Id.
`63. Id.
`64. Id. at 703.
`65. Scott Henley et al., Dissemination of Drug Information, 42 HOSPITALS 99 (1968).
`66. Id. at 100.
`67. Id.
`68. Id.
`69. Gail Eaton & Peter Parish, Sources of Drug Information Used by General Practitioners:
`Prescribing in General Practice, 26 J. ROYAL C. GEN. PRAc. 58 (Supp. 1976).
`70. Id. at 61.
`71. Id. at 62-63.
`72. Reeder et al., supra note 44, at 1595.
`73. Donald P. Connelly et al., Knowledge Resource Preferences of Family Physicians, 30 J.
`FAM. PRAc. 353 (1990).
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`10
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`Manchanda and Honka: The Effects and Role of Direct-to-Physician Marketing in the Pharmaceutical Industry
`
`THE EFFECTS AND ROLE OF DIRECT-TO-PHYSICIAN MARKETING
`
`research articles, Index Medicus, and a computerized bibliography.74
`The underlying assumption in the above studies is that physicians are good
`at extracting relevant information from detailers. However, as this is usually not
`part of medical school training, Shaughnessy et al.
`investigated whether
`physicians would benefit from such training. 75 They developed a curriculum to
`teach hospital faculty and residents
`to evaluate
`information provided by
`pharmaceutical representatives.76 After receiving this training, physicians had
`generally positive attitudes toward the detailers' services and did not feel overly
`influenced by them relative to pre-training. This effect, while statistically
`significant, was small in magnitude.77 Samourai and Avom summarize a series of
`studies that also show that education of physicians about detailing leads to more
`accurate and cost-effective prescription outcomes.78
`In contrast, some studies have found detailers lacking in this regard.
`Williams et al. found that a minority (19%) of Canadian physicians viewed
`detailers to be an important source of information (though a quarter of high
`prescribing physicians found them to be an important source).79 Caudill et al. also
`asked physicians to rate sales representatives as a source of information on the
`three dimensions of credibility, availability, and applicability. 80 The mean
`responses were all nearly neutral, and there was a significant positive correlation
`the three measures. 8 Fassold and Gowdey's 1968 study asked
`between
`physicians to grade sales representatives on several characteristics.82 While
`detailers were rated good or excellent with respect to personality, reliability, and
`honesty by 86%, 65%, and 69% of the physicians respectively,
`sales
`representatives' general knowledge, knowledge of drugs, and usefulness was
`rated fair or poor by 67%, 63%, and 59% of the practitioners, respectively.83
`A more interesting question is the importance of detailing as an information
`source relative to other information sources. A study by Kalb tried to assess the
`
`74. Id. at 356 fig. 1.
`75. Allen F. Shaughnessy et al., Teaching Information Mastery: Evaluating Information
`Provided by Pharmaceutical Representatives, 27 FAM. MED. 581 (1995).
`76. Id.
`77. Id. at 584.
`78. Stephen B. Soumerai & Jerry Avorn, Principles of Educational Outreach ('Academic
`Detailing') To Improve Clinical Decision Making, 263 JAMA 549 (1990).
`79. A. Paul Williams et al., The Physician as Prescriber: Rela