Physicians are trained to “do no harm” and exercise independent judgment in their role as the patient’s advocate. They guard their reputations and take pride in the public’s trust, allowing physicians’ recommendations about treatment options to be a primary influence with patients choosing a course of treatment.

Given physicians’ prominent position in medical decision-making, an entire industry has developed effort focused on influencing the clinical judgment of physicians, which extends well beyond their drug and device preferences. More than 90,000 drug and device manufacturer representatives call on physicians to discuss new products and answer questions. The reps typically may have  four to seven of these interactions daily, while it would be usual for the reps to get less than five minutes of actual face time with the clinicians themselves. The interactions can include meals and other goodies, and according to a ProPublica analysis, they work. The analysis concluded that as doctors received more goodies from a company, they prescribed more of their drugs.

At the same time, manufacturers spend $5 billion annually advertising brand name drugs and devices to consumers, ending their ads with “contact your physician … .” Investors in promising early-stage biotech companies hire “experts” in medicine to make the rounds in professional society meetings to tout their wares. Funding for continuing medical education programs is sourced heavily from drug and device manufacturers who see value in face-to-face time with clinicians.

Drug and device makers play the physician-influence game well and they are not alone. Among hospitals, physicians who are important to the organization’s strategy are recipients of special attention. Sometimes they’re put into prominent positions as directors of clinical programs or in medical affairs leadership roles. Sometimes, they’re asked to join the hospital board. Stark laws and other related regs limit hospitals’ ability to influence physicians, but the necessity to align with the right clinicians is more important than ever. As part of the transformation of health care into a more integrated approach, health systems have an incentive to keep patients within its family of aligned clinicians. Many physicians already are employed by hospitals, which laready muddies any physician-alignment strategies and exposes the organization to added risk. Laws addressing self-referrals, private inurement and others slowed and constrained physician influencing by hospitals, but it’s a gray area. And, as prosecution via expansion of the False Claims Act increase and shared-risk arrangements with payers proliferates, influencing physician behavior will become even more complicated.

And every health insurer seeks to curry favor with physicians who can be compensated as “advisers” or promoted in narrow networks for the plan’s business purposes. Insurers value relationships with physicians who practice safe and efficient medicine, and engage those in their ranks to influence their peers and assist in their medical management operations through recognition and fees. It’s just part of the business of running a plan.

Little evidence care is compromised

The physician-influence industry is big. Has patient care been compromised as a result of its clout? There’s scant evidence showing any correlation. Growing bodies of evidence suggest that overtreatment might be problematic, but these data point more to physician aversion to evidence-based practice rather than responsiveness to influence peddlers as root cause. And, to the extent that patients might pay more for care that’s unnecessary, or for a branded drug about which the clinician was explicit in the recommendation, then higher costs result.

The bigger issue is this: For manufacturers of drugs and devices, there’s a fine line between influencing physician clinical judgment and educating physicians about new treatments and cures. The data show that physicians are hard-pressed to stay abreast of the latest science in their disciplines and only one in five uses an information system equipped with clinical knowledge-management capabilities to assist in their patient care activity. The profession needs to address better ways to educate its own, as well as enhance lifelong learning and demonstrated competence as requisites to practice.

For hospitals and insurers, influencing physician behavior is impossible without peer influence, so both walk a tightrope in how they shape their physician-influence programs. Physicians singled out to play leadership roles in either setting may be tainted among their peers. So understandably, they expect to be compensated well for discarding their white coats for the land of the suits. Providers and payers must take a fresh look at the scope and impact of their physician-influence activities, and determine changes necessary to avoid risks and reward desired behaviors.

Medicine is a noble profession, just below nursing as the most trusted occupation in our society. We don’t like to believe physician influence can be bought. We dismiss stories about the bad deeds of a few, rationalizing that there are bad apples in every bunch. And we acknowledge that the physician-influence industry is there, but are inclined to think it does no harm.

The physician-influence industry is under the microscope today because it is more widely exposed to public scrutiny, and because there’s growing evidence that a physician’s clinical judgment can be swayed. And, any drug and device manufacturer, hospital or insurer might find itself on the witness stand to defend its role.

Paul H. Keckley, Ph.D.,, does independent health research and policy analysis and is managing editor of The Keckley Report. He is a member of Health Forum’s Speakers Express; for speaking opportunities, please contact Laura Woodburn.