Don’t Trust Your Gut: Part 3: The Influence of the Pharmaceutical Industry on Clinical Decision-Making

 Save as PDF

doi:10.62055/76803666Sb

“I’m not biased. But they are.” Or stated another way, “Gifts from the pharmaceutical industry don’t affect my decision-making, but it affects theirs.”¹

We’ve arrived at the finale of our three-part series discussing the pitfalls of relying on instinct over structured evidence in clinical decision-making.

In part 1, we reviewed the statistical phenomenon of regression to the mean, which explains how many conditions improve naturally over time, potentially obscuring whether a treatment is effective or simply coincident with natural recovery. In Part 2, we tackled the cognitive biases that complicate objective decision-making. These biases, like availability bias, confirmation bias, and anchoring, all too easily mislead clinicians by emphasizing recent or familiar experiences over a balanced assessment.

Now, in Part 3, we turn our focus to another, often overlooked, factor that influences clinical decision-making: the thorny topic of the pharmaceutical industry’s (or industry, in general) impact on prescribing tendencies. While it’s impossible to deny the benefits of pharmaceutical advancements, we must also scrutinize how industry influence can subtly—and sometimes overtly—shape our clinical choices.

Industry Influence: Subtle Nudges Accumulating into a Big Shove

As a residency-trained, ocular disease-experienced student of evidence-based medicine, I take a lot of pride in my objective, science-based approach to decision-making. It would be easy to believe I’m immune to pharmaceutical or industry influences. But other optometrists without my training, experience, and commitment to EBM? Certainly, they could be influenced. Me? Never. However, somewhat ironically, that same research I’m committed to also informs me that I’m easily influenced and biased like everyone else. We are all wired this way and are all influenced whether we acknowledge it or not.

What makes industry influence on our decisions so easy to overlook and underestimate is that the influence comes to us more in subtle nudges rather than obvious shoves.  Each nudge, individually, doesn’t seem like it would move us, so we tend to dismiss it easily. However, each industry nudge does affect us, and even more so when each nudge accumulates to a big shove in one direction without much awareness of what is happening.

What, specifically, are the nudges I’m talking about? The four common nudges of industry influence are direct incentives to clinicians, speaker payments and educational bias, industry-funded research and publication bias, and direct-to-consumer advertising. Again, we tend not to believe that each of these factors independently influence our decisions for patients (they do, keep reading) but their accumulation creates an undeniable influence on our decision making.

Nudge #1: Direct Incentives to Clinicians: Meals, Gifts, and Samples

Pharmaceutical companies often use gifts like free lunches, samples, and even small financial incentives as part of their strategy to build rapport with clinicians. Research has consistently shown that these seemingly minor benefits can have a significant impact on prescribing behaviors. For example, one study found that each free meal accepted was linked to a statistically significant increase in prescribing the promoted drug over its alternatives.² Even meals as low as $20 correlate with higher prescribing rates for promoted medications. The effects are particularly concerning because many clinicians believe they are immune to such influences, while studies reveal that these gifts create an unspoken expectation of loyalty to the drug brand.³

Free samples, another common tactic, often lead to long-term prescribing of branded drugs that may not be the most cost-effective choice for patients. In fact, samples can raise prescription costs by steering physicians and patients toward newer, expensive drugs, sometimes bypassing generics entirely.⁴ For example, drug samples increase prescriptions for brand-name drugs by 60% over generic options, a trend associated with higher costs to both patients and insurers.⁵ Additionally, while samples are often framed as a benefit for financially struggling patients, they are rarely provided for first-line treatments or the most affordable options, ultimately increasing healthcare costs over time.⁶

In response to these findings, transparency initiatives, such as the Physician Payment Sunshine Act, now require companies to disclose payments to doctors, intending to encourage self-awareness and public accountability. However, the influence of even minor perks continues to highlight the need for careful consideration of how these interactions impact clinical decision-making.⁷

Nudge #2: Speaker Payments and Educational Bias

Another substantial area of influence is through paid speaking engagements and advisory roles, where pharmaceutical companies compensate clinicians to present information about new drugs or therapies. While these events are often framed as educational, speakers may present biased or incomplete information, consciously or unconsciously, to favor the sponsoring company’s product.⁸ One review found that financial ties to the pharmaceutical industry were associated with increased prescription rates for promoted drugs among clinicians who attended these presentations.⁹

This approach creates a direct conflict of interest, as paid speakers might downplay a drug’s risks or overstate its benefits. Notably, 75% of authors of clinical guidelines—many of whom participate in speaking engagements—had financial ties to the pharmaceutical industry, raising questions about potential biases in the guidelines they promote.¹⁰ For healthcare providers seeking impartial advice, relying on speakers with financial connections to industry may obscure important evidence and distort clinical judgment.

Nudge #3. Industry-Funded Research and Publication Bias

Pharmaceutical companies often fund the very research that informs clinical decision-making. While such funding is essential for bringing new treatments to market, studies funded by drug manufacturers are more likely to report positive results than independently funded research.¹¹ This publication bias can lead clinicians to perceive a drug as more effective than it truly is because negative findings are less likely to be published.

Moreover, industry-funded studies frequently report results that are statistically but not necessarily clinically significant, which can mislead clinicians about the actual impact of a drug. For example, one analysis of statin drugs revealed that industry-sponsored trials were more likely to show favorable outcomes than independently funded ones, often through selective reporting of results.¹² This selective reporting creates a skewed evidence base, where clinicians may unknowingly make treatment decisions based on incomplete or overly favorable data.

Nudge #4. Direct-to-Consumer Advertising (DTCA) and Patient Influence

Direct-to-Consumer Advertising (DTCA) allows pharmaceutical companies to market medications directly to patients, which is legal only in the United States and New Zealand. DTCA has proven highly effective, leading patients to request specific drugs by name and often increasing prescription rates regardless of clinical need. Studies show that patient requests for DTCA-promoted drugs are twice as likely in countries where this type of advertising is legal, with patients 16 times more likely to receive a specific drug when they request it.¹³​ Furthermore, DTCA spending increased from $1.3 billion in 1997 to over $6 billion in 2016, with every $1,000 in advertising generating an estimated 41 additional prescriptions.¹⁴ This powerful influence reinforces clinicians’ inclinations to prescribe advertised medications, impacting clinical objectivity. As a result, DTCA not only influences patient expectations but also impacts the treatment decisions of healthcare providers who feel pressured to meet patient demands.

So…Can We Trust Our Gut?

Predictably, if you’ve read this and my other columns thus far, my answer may frustrate you: don’t be certain about your certainty. The cumulative effect of industry nudges, cognitive biases, and the difficulty of differentiating treatment effects from a condition’s natural history should humble our reliance on our intuition. Ironically, the faster we understand and accept the limitations of our experience and opinions, the more we can make better decisions. Decisions should be research-informed, nuanced, transparent about risks and benefits, and governed by understanding the relative uncertainty of all we do in medicine. Interestingly, this type of decision-making is the opposite of the ego that says, “You are biased but not I.” Good decision-making starts from a position of humility, acknowledging our limitations, knowing what the best of the best research says and doesn’t say, and judiciously combining that with our experience-based intuition and our patients’ preferences. Yes, we are back to our ever-helpful definition of evidence-based medicine.¹⁵

References

1. McKinney WP, Schiedermayer DL, Lurie N, Simpson DE, Goodman JL, Rich EC. Attitudes of Internal Medicine Faculty and Residents Toward Professional Interaction With Pharmaceutical Sales Representatives. JAMA. 1990;264(13):1693–1697
2. DeJong C, Aguilar T, Tseng CW, Lin GA, Boscardin WJ, Dudley RA. Pharmaceutical Industry-Sponsored Meals and Physician Prescribing Patterns for Medicare Beneficiaries. JAMA Intern Med. 2016 Aug 1;176(8):1114-1122.
3. Dana J, Loewenstein G. A Social Science Perspective on Gifts to Physicians From Industry. JAMA. 2003;290(2):252–255.
4. Hurley MP, Stafford RS, Lane AT. Characterizing the relationship between free drug samples and prescription patterns for acne vulgaris and rosacea. JAMA Dermatol. 2014 May;150(5):487-93.
5. Brax H, Fadlallah R, Al-Khaled L, Kahale LA, Nas H, El-Jardali F, Akl EA. Association between physicians’ interaction with pharmaceutical companies and their clinical practices: A systematic review and meta-analysis. PLoS One. 2017 Apr 13;12(4):e0175493.
6. Adair RF, Holmgren LR. Do drug samples influence resident prescribing behavior? A randomized trial. Am J Med. 2005 Aug;118(8):881-4.
7. Rodwin, M. A. (2011). Conflicts of interest and the future of medicine: The United States, France, and Japan. Oxford University Press.
8. Angell, M. (2004). The truth about the drug companies: How they deceive us and what to do about it. Random House Incorporated.
9. Wazana, A. (2000). Physicians and the pharmaceutical industry: is a gift ever just a gift? JAMA, 283(3), 373-380.
10. Moynihan R, Henry D, Moons KG. Using evidence to combat overdiagnosis and overtreatment: evaluating treatments, tests, and disease definitions in the time of too much. PLoS Med. 2014 Jul 1;11(7):e1001655.
11. Bekelman, J. E., Li, Y., & Gross, C. P. (2003). Scope and impact of financial conflicts of interest in biomedical research: a systematic review. JAMA, 289(4), 454-465.
12. Ridker PM, Torres J. Reported Outcomes in Major Cardiovascular Clinical Trials Funded by For-Profit and Not-for-Profit Organizations: 2000-2005. JAMA. 2006;295(19):2270–2274.
13. DeFrank JT, Berkman ND, Kahwati L, Cullen K, Aikin KJ, Sullivan HW. Direct-to-Consumer Advertising of Prescription Drugs and the Patient-Prescriber Encounter: A Systematic Review. Health Commun. 2020 May;35(6):739-746.
14. Schwartz LM, Woloshin S. Medical Marketing in the United States, 1997-2016. JAMA. 2019 Jan 1;321(1):80-96.
15. Sackett, D. L., Rosenberg, W. M., Gray, J. A., Haynes, R. B., & Richardson, W. S. (1996). Evidence based medicine: what it is and what it isn’t. BMJ, 312(7023), 71-72.

Kyle D Klute, OD, FAAO

Good Life Eyecare | Omaha, NE

Dr. Klute owns and practices at Good Life Eyecare, a multi-location practice in Eastern Nebraska and Western Iowa. He is a fellow of the American Academy of Optometry and is certified by the American Board of Certification in Medical Optometry. He writes and lectures on primary eye care practice management, evidence-based medicine, glaucoma, and dry eye disease.