by Dr.Harald Wiesendanger– Klartext
What the mainstream media is hiding
Do ut des, “I give so that you give”: Even doctors can hardly evade the basic social principle of reciprocity. Not only donations in the five to the six-digit range but even relatively small favors also make people inclined to show their gratitude. Pharma marketing takes advantage of this.
“One hand washes the other”: Charities of any kind tend to return the favor to the giver. Being vulnerable when pharmaceutical companies generously try to tempt them is something that most physicians reject—at least as far as they are concerned. Of course, they don’t want to put their hands on the fire for colleagues. Many succumb to the belief that they themselves are less easily manipulated than the rest of their profession, according to a survey of 208 resident specialists in neurology/psychiatry, general medicine, and cardiology on the influence of pharmaceutical representatives. Only six percent said they could be influenced “often” or even “always.” At the same time, however, more than one in five suspected this was very much the case for their peers. (1)
The misconception of being immune to marketing influences is even “dose-dependent”: the more grants doctors receive from companies, the more often they state that such gifts do not affect their prescription behavior. (2)
It is in such contexts that the door-to-door salespeople of the drug industry are made very familiar with them during their training. Pharmaceutical reps adopt advertising-psychologically sophisticated strategies that will sooner or later persuade the doctors they visit to contribute to higher sales figures for the advertised products. Hardly any other scientist enjoys a higher reputation among marketing professionals than the American psychologist Robert Cialdini. While he was a professor of psychology and marketing at Arizona State University, he also ran a consulting firm called Influence at Work. (3) His best-known work, The Psychology of Persuasion (1997), has sold over three million copies and has been translated into thirty languages. His book Pre-suasion: How to win before the negotiation was published in German in 2017. Cialdini is celebrated for aligning marketing concepts with a fundamental social science insight: the reciprocity rule.
Mutuality: a fundamental social norm
In its simplest form, reciprocity denotes a social interaction that occurs in three steps: someone gives; the other must accept the gift – and show his gratitude with a gift in return. The rule that we must reciprocate favors, gifts, invitations, and the like because all dealings must be mutual is deeply rooted in all human societies. By basing relationships on give and take, she creates trust in fellow human beings. This is what makes group formation, division of labor, and systems of mutual help possible in the first place.
All cultures sanction violations of this basic norm: those who only take and never give, or those who take more than they give, are ostracized. The urge to give back to others what we have previously received seems so ingrained in the human psyche that it takes conscious effort not to obey the rule of reciprocity.
As Cialdini recognized, this rule applies largely regardless of the size of the gift. Without exception, every present, no matter how small, prompts return gifts; these sometimes even have a disproportionately higher value. Accordingly, there is no threshold below which an influence is excluded. All the more questionable are regulations on conflicts of interest that allow “appropriate” benefits to be accepted, as provided in the professional code of conduct for Germany’s doctors. (4)
Social psychological experiments have shown that people who are aware of the rule of reciprocity but who consider themselves resistant to being manipulated in this way have proven to be particularly susceptible to being influenced. They succumb to an “illusion of invulnerability”. (5)
Accordingly, sales psychological calculations prevail when the rep showers the doc with benefits. And the bill tends to add up. The US research center ProPublica, which has been publishing payments to US doctors since 2010, found a clear connection between the amounts a doctor collects from pharmaceutical companies and the number of expensive original preparations he prescribes. Among ophthalmologists who had no cash flow, only 46 percent prescribed originals instead of cheaper generics; among colleagues who received more than $5,000, the proportion rose to 65 percent. (6)
“I’ll pay for my food myself.”
Even simple invitations to dinner succeed in having a marketing impact. This is what physicians at the University of California in San Francisco found when they evaluated data from 280,000 doctors: sponsored meals increased the likelihood that the host would prescribe a drug from the sponsor. For example, psychiatrists who did not accept such an invitation prescribed the antidepressant desvenlafaxine with a frequency of 0.5 percent among drugs in this class. That figure tripled to 1.5 percent for peers who ordered a meal for less than $20. For nebivolol, a beta-blocker used to lower blood pressure, the prescription rate increased from three to eight percent after one meal and to 14 percent after three meals. (7)
To immunize their colleagues against such temptations, incorruptible doctors founded MEZIS in 2007. “MEZIS” stands for “I pay for my food myself.” The non-profit initiative now has around 1,000 members. There should be many more.
(Harald Wiesendanger)
Remarks
More in Harald Wiesendanger: The health care system – how we see through it, survive and transform it
1 Klaus Lieb/Simone Brandtönies: „Eine Befragung niedergelassener Fachärzte zum Umgang mit Pharmavertretern“, Deutsches Ärzteblatt 107/2010, S. 392-398; www.aerzteblatt.de/archiv/76324/Eine-Befragung-niedergelassener-Fachaerzte-zum-Umgang-mit- Pharmavertretern.
2 A. Wazana: “Physicians and the pharmaceutical industry: is a gift ever just a gift? “, Journal of the American Medical Association 283 (3) 2000, S. 373-380.
3 Siehe www.influenceatwork.com
4 Bundesärztekammer (Hrsg.): (Muster-)Berufsordnung für die in Deutschland tätigen Ärztinnen und Ärzte, § 32, Stand 2018, www.bundesaerztekammer.de/fileadmin/user_upload/downloads/pdf-Ordner/MBO/MBO-AE.pdf, abgerufen am 30.5.2019.
5 B. J. Sagarin/R. B. Cialdini u.a.: “Dispelling the illusion of invulnerability: Themotivations and mechanisms of resistance to persuasion “, Journal of Personality and Social Psychology 83/2002, S. 526-54114; Dana J, Loewenstein: “A Social Science Perspective on Gifts to Physicians From Industry “, JAMA 290/2003, S. 252-255.
6 Nach Spiegel online, 26.7.2015: „Zahlungen an Ärzte – Keiner ist so nett wie der Pharmareferent“, www.spiegel.de/gesundheit/diagnose/zahlungen-an-aerzte-der-nette-pharmareferent-a-1104739.html
7 Colette de Jong u.a.: „Pharmaceutical Industry-Sponsored Meals and Physician Prescribing Patterns for Medicare Beneficiaries“, JAMA Internal Medicine 2016 Aug 1;176 (8) 2016, S. 1114-1122, doi: 10.1001/jamainternmed.2016.2765.
This text is part of a series of articles with the following additional contributions:
1) Trained demigods – How doctors become drug dealers
2) Visit from the Rep – Mendacious Friendship based on the script
4) Off-label – crossing borders as routine
5) Purchased Observer – When the doctor becomes the “researcher.”
6) How easy – When doctors play “Kick-back.”
7) “As you do to me, so do you” – reciprocity as the secret of success
8) Softened – education and training as brainwashing
9) Insatiable Renters – The uncanny power of paid opinion leaders
10) Among Gorillas – Silverbacks call the shots
11) As KOL to the Golden Nose – Why “Key Opinion Leaders” have taken care of it
Editors Note watch: BREAKING: US To Sign Over Sovereignty To W.H.O.