Background
In the 1990s, the relation between the pharmaceutical industry and medical personnel came under scrutiny in the United States and Western Europe. People started thinking about the ethics of marketing in this sensitive area, and the first ethical codes were created. At this point of time in Poland, however, the industry had only just started promoting itself directly to the medical establishment. During this period, national enterprises such as Polfarma, Jelfa, Polfa Kutno, or Polfa Rzeszów were being privatized, and, one by one, Western players gradually entered the market. The advertising of medicines in Poland had been forbidden by lawFootnote 1 until 1993, when the Polish legislature first began to allow advertising for over-the-counter medicines.Footnote 2
For several decades Poland has seen rising drug sales. In 1990, sales amounted to 6.2 billion zlotys; by 1999, after the law had changed, this figure had risen to 11.3 billion,Footnote 3 and by 2011 it had mushroomed to 28.1 billion.Footnote 4 Its current market size makes Poland the sixth-biggest pharmaceutical market in Europe. People mostly buy generic drugs, which constitute 66 percent of the market.Footnote 5 This growth in the sale of medicines has several possible explanations: for example, Poland’s systematic economic recovery, the increasing gross domestic product, increases in the size of the average salary, and low unemployment rates.Footnote 6 Living conditions are better than they have ever been, so people are more willing to start thinking about their health and doing something to improve it. The pharmaceutical industry’s aggressive marketing strategies have certainly also contributed to the increase in sales.
Foreign pharmaceutical concerns transferred Western models of marketing medicines to our postcommunist society, and neither Polish society nor its medical professionals were well prepared for this development. “Observation of pharmacists shows the unbelievably powerful influence of the media on customers’ behaviour: there is a hurricane of sales after a television advertisement about a medicine.”Footnote 7 The first teams of medical sales representatives (reps) in individual companies were small, at most several dozen personnel, but they expanded rapidly. By 2006, the biggest market players (GSK, Sanofi, Pfizer, and Polpharma) each employed 300 representatives.Footnote 8 Sales specialists direct their marketing campaigns at patients, pharmacists, and doctors; but physicians generate the biggest profits for pharmaceutical companies, because, according to Polish law, they are the only professionals allowed to order prescription drugs, the sales of which create 66 percent of the profits.Footnote 9 It is therefore no surprise that pharmaceutical companies make doctors the prime target of their campaigns.
“Personal selling” is the most effective promotional tool used by pharmaceutical companies, and it relies on visits of industry representatives to doctors’ offices. The question of whether physicians should meet with them is being discussed in many countries. The crucial question is whether doctors can sustain these relationships while remaining independent when making decisions concerning which medicines to prescribe.
For many years in Poland there was no legal regulation concerning relations between physicians and the pharmaceutical industry. Representatives could visit doctors whenever they wanted, and there was no restriction on the kind of gift that could be offered. This situation was rationalized by citing the low salaries earned by medical personnel and the fact that, although the government encourages doctors to improve their skills, it does not provide support for continuing education, whereas the pharmaceutical industry can sponsor conferences and training.
Once it became clear that marketing strategies by pharmaceutical companies were definitely influencing doctors’ behavior, this situation changed. New ethical codes started to be developed in 2006, followed by subsequent amendments to Polish pharmaceutical law in 2007 and 2008. Physicians often do not realize the power of the impulse of reciprocity and its effect on their practice if they accept gifts both big and small from corporations. Research in other countries shows that many physicians deny that a connection exists between taking gifts and their professional objectivity.Footnote 10,Footnote 11,Footnote 12,Footnote 13 However, research has been published that provides evidence that accepting gifts from pharmaceutical companies (in many different forms) causes doctors to more frequently prescribe the medicines of the sponsor.Footnote 14,Footnote 15
In Poland there has been a relative lack of interest in this subject and thus little in the way of scientific papers or research. Although journalists do write a lot about the relation between pharmaceutical sales representatives and doctors in Poland, if only for the sake of shocking stories and cheap sensationalism, such stories are rarely based on credible research. The industry also conducts its own research, of course, but this is for internal use, and any research findings go unpublished. Attempting to ascertain the true relationship between Polish doctors and pharmaceutical representatives was the main purpose of the present research, the key findings of which are introduced in this article.
Methods
The research was carried out with the help of an Internet questionnaire form completed online (computer assisted Web interview [CAWI]). Practical Medicine—one of the most popular Web sites for physicians in Poland—publicized my request for participants in the research. The questionnaire was accessible to physicians for more than a month. Respondent anonymity was the biggest advantage of the online questionnaire, because the subject could be a sensitive one for some. This anonymity enables us to conclude that the results are accurate and present a true picture of the relations between doctors and pharmaceutical representatives, even though, because of the sampling and number of respondents, we cannot conclude that they reflect the views of all Polish medics. A total of 372 doctors (58.3% female and 41.7% male) completed the questionnaire between November and December 2008, just before a ban on meeting pharmaceutical representatives during doctors’ working hours was introduced in Poland.
Results
Frequency of Contact between Doctors and Pharmaceutical Representatives
The vast majority of respondents (98.4%) acknowledged that during their medical career they had met with a pharmaceutical sales rep at least once, and 89.6% admitted that they met them regularly. This result is similar to research in other countries, which has shown that the majority of doctors have some relationship with the pharmaceutical industry.Footnote 16,Footnote 17,Footnote 18
Doctors were also asked to write down the average number of representatives they had met with during the previous week. Here, replies ranged from 0 to 30. The average was 3.32. Using that figure, we can conclude that during one month in Poland, a single doctor may be visited by approximately 13–14 reps. The results of research conducted in other countries show that, on average, doctors meet with 4 reps per month.Footnote 19 We can therefore conclude that the frequency of visits in Poland is much greater than elsewhere.
Doctors’ Trust in the Accuracy of the Information Provided by Pharmaceutical Representatives
The research indicates that the majority of doctors (71.3% of the 372 respondents) “tend to trust” the accuracy of the information provided by representatives, although virtually no participants (2.7%) stated that they “strongly trust” the information given. This suggests that most doctors approach information provided by representatives with some discernment. Almost a quarter of respondents (24.4%) declared that they “tend to distrust” representatives’ information, although again only a small number (1.5%) decided to choose the more extreme “strongly distrust” option. These results conform to the results of research conducted in other countries: that doctors tend to believe the information provided by pharmaceutical representatives in relation to the medicines being promoted.Footnote 20 This raises the question of why even some doctors who “tend to distrust” and “strongly distrust” the information given to them by sales reps are still among those who meet with them.
Doctors’ Reasons for Meeting with Pharmaceutical Representatives
Doctors who regularly meet with sales representatives were asked about why they do so and could choose up to 3 among 12 possible answers. More than half of doctors (56.5% of the distrustful, 55.1% of the trusting) stated that they do so because they understand the work and role of the sales rep. Another reason chosen by almost half of respondents (47.1% of the distrustful, 46.9% of the trusting) was the possibility of receiving financial support for training or conferences. Free samples of medicine were also an attraction, regardless of the degree of trust of the respondents (32% of the distrustful, 29.6% of the trusting).
For four of the possible reasons for meeting with sales representatives, the divergence between the trusting and the distrustful doctors was statistically significant. The most frequently chosen answer, chosen by 60 percent of total respondents, was that the information provided by reps about their medicine was valuable; but 70.8 percent of those who chose that response fell in the category of those most trusting, whereas only 29.2 percent of the less trusting doctors gave that as a reason. On other diverging responses, 7.8 percent of the more trusting doctors gave as a possible reason for meeting with reps the notion that it was “an obligation, part of the work of the doctor,” whereas only 1.2 percent of the less trusting chose that as a reason. Respondents who distrust sales reps more frequently chose the replies “If I don’t meet with them they will constantly wait near the office” (12.9% of the distrusting, versus 4.9% of the more trustful) and “I am not able to refuse them” (22.4% of the distrusting versus 7.4% of the trusting).
Gift Giving
Free samples are not the only gift available from pharmaceutical representatives. The large majority of doctors (97%) state that Polish doctors receive small gifts from representatives—pens, notebooks, flowers, tea, coffee, or chocolates. Furthermore, 88.7 percent of respondents claim that sales reps bring doctors medical books, and 57% of doctors note that they receive invitations to dinners, suppers, and other social events from pharmaceutical companies. These gifts are not against the law in Poland; under Polish pharmaceutical law (article 58, section 3, 2008)Footnote 21 and the Code of Pharmaceutical Marketing Ethics (article 9),Footnote 22 a doctor may accept a gift that might enhance his medical practice, up to the value of PLN 100 (equal to EUR 25 or USD 33).
However, 58.2 percent of respondents stated that doctors receive at least one gift that would be prohibited under Polish law, and 43.6 percent of respondents said that doctors received expensive gifts connected with their medical practice, such as a desk, a chair, or a branded stethoscope. Whereas it may be possible to buy a low-quality chair within the legally permitted allowance, that would be less likely for a desk or branded stethoscope. In addition, 29 percent of respondents admitted that doctors receive tickets for entertainment and sporting events; 19.5 percent responded that doctors also receive gifts that are in no way connected to their medical practice, such as a good-quality wine or an expensive watch; and 16.2 percent admitted that doctors take money from companies. Among those who selected “other” when asked what type of gifts they received—16.2 percent—the most popular answers were training and conferences (8%) and trips (3.9%). Trips are also a violation of Polish regulations.
Polish doctors are more prone to notice the influence on other doctors of gifts from pharmaceutical companies than such influence on themselves. If a doctor notices an influence on himself, as a rule he also notices an influence on others. However, 34.1 percent of respondents who did not acknowledge any influence on themselves nonetheless did claim to notice it on others. This also accords with the results of research in other countries.Footnote 23,Footnote 24
Discussion
The results of the research presented previously enable us to draw some significant conclusions about the relations between Polish doctors and pharmaceutical sales representatives. Doctors’ lack of experience in advertising and marketing during the communist era and the absence for many years of any ethical codes of practice or regulations have clearly affected relations between doctors and pharmaceutical sales representatives in Poland. On average, a single doctor is visited by 13–14 sales representatives per month, which is more frequent than in other countries. The majority of doctors in Poland usually agree to meet with representatives, primarily because they think that the information about medicines provided by sales reps is valuable. A number of doctors stated that they meet with representatives because they understand the purpose of the reps’ jobs, and another common reason for meeting with reps was the benefit of financial support to attend conferences or for further training.
In Poland, as in many other countries, most doctors are prone to place their trust in information about drugs given by sales representatives. This result is somewhat alarming, because increasing the sales of a certain drug is the main purpose of the representative. This situation points to failures in the Polish medical educational system. Doctors should know how to find other reliable and accurate sources of information about drugs. Even medical professionals who purport to distrust representatives meet with them, either because they accept their role or for the sake of various accompanying benefits.
In December 2008, shortly after the completion of the research here reported, regulations from the health minister came into effect forbidding visits of representatives during doctors’ working hours. Even to meet with a physician after work, the rep has to receive permission from the hospital administration for the visit. This regulation— particularly the suggestion that managers have control over whom physicians see after work—has generated considerable resistance. On our survey, before the legislation was introduced but when its provisions were already known, almost a quarter of our respondents indicated that they would not be observing the proposed regulations. Because they seemed at that time uncommitted to the spirit of the legislation, it is likely that doctors would reject these new procedures and continue to act as they did before. Unfortunately there has been no research that analyzes the situation in Poland since this regulation was introduced.
More than half of the doctors responding admitted that medical professionals in Poland receive gifts from pharmaceutical representatives that violate Polish law. They do so because for many years before the regulation came into effect, they could accept whatever was offered. As in other countries, doctors observe the influence of gifts on prescriptions written by their colleagues more frequently than they recognize such influence on their own behavior. In Poland, taking gifts from pharmaceutical companies by doctors is often excused by references to the relatively low salaries earned by medical personnel, or to the fact that, although the government does not provide financial support for the doctors to improve their skills, it demands that they constantly retrain. The lack of a fixed formulary exacerbates the problem. Undoubtedly, such relationships have negative consequences, and they should be rethought. The suspicion also exists that a doctor corrupted to the pharmaceutical company’s service might not make his or her patients’ health the priority and instead might prescribe expensive drugs and medicaments that the patient does not necessarily need.
This research points out that despite recently sharpened Polish law on relations between doctors and pharmaceutical representatives, there still remain many challenges for both the medical profession and the pharmaceutical companies. Perpetuation of the current situation may well lead to patients’ loss of trust in the medical profession. This could encourage Poles toward medical self-treatment, putting them at risk of fatal consequences, and has the potential to destroy the image of pharmaceutical companies among Poles more generally.
