Dr. Kurt Stange, the editor of the Annals of Family Medicine who called for an end to consumer advertising of drugs, said the effects of a detailing visit can be subtle. But, he added, these encounters are made all the more powerful when physicians either deny or ignore their influence.
"You're not overtly thinking, 'I'm going to prescribe this drug because I got a pen," Stange said. "You're just thinking, 'What will help this patient?' and you've been bombarded with advertisements, and the name is always before you. . . . You have to have a fair amount of self-awareness to notice that."
In the end, advocates of reform say, there is no stronger evidence that drug marketing influences behavior than the simple fact that drug companies do market their products -- and that they are spending more money doing it than ever before. The makers of the nation's bestselling drugs field on average 4,000 sales representatives to detail doctors, staff booths at medical meetings and organize trips and meals for doctors, and spend more than $1 billion per year to market drugs to physicians alone. They spend, all told, roughly $5 billion a year to advertise directly to consumers. Though they are not counted in marketing budgets, the funds they dispense to support research, medical professional organizations and patient-advocacy groups run into the billions.
In terms of cold, hard return-on-investment, that money was well spent, says a study unveiled in 2001. Tracking prescription sales for 391 drugs and company marketing budgets from 1995 through 1999, Dartmouth College marketing professor Scott Neslin has calculated, down to the penny, how well increases in marketing pay off.
Each additional dollar spent on advertising in medical journals brought $5 worth of sales of a drug, Neslin found, and an extra dollar devoted to sponsorship of continuing medical education and professional meetings yielded an average of $3.56 in sales. A dollar spent on physician-detailing generated sales, on average, was worth $1.72. But in the case of the most aggressively marketed drugs, that dollar generated sales of more than $10.
Appealing directly to consumers was lucrative, Neslin found, but a little less than wooing physicians. Each dollar spent on direct-to-consumer advertising generated, on average, increased sales of $1.37.
Such calculations flesh out a self-evident truth, said, UCLA's Dr. Martin Shapiro, a past president of the Society of General Internal Medicine and an advocate of reform in the relationship: "These are large and sophisticated organizations. . . . They would not be spending that money if it didn't work."