In this study, we used in-depth patient interviews to explore patients’ beliefs and preferences regarding how doctors prescribe a new medication. Our results suggest there may be modifiable entities influencing medication adherence that have not been previous described in detail. These entities include participant’s concerns about doctors’ relationships with pharmaceutical representatives and beliefs about “best” medications, which are discussed in detail.
Some participants expressed concerns that medication recommendations are influenced by doctors’ relationships with the pharmaceutical industry, specifically by the presence of pharmaceutical representatives in the doctor’s office. Prior studies suggest patients may not be fully aware that pharmaceutical companies give gifts to doctors.13,14
When patients were given examples of different types of gifts, patients felt small gifts or gifts that benefit patients were generally acceptable but gifts directly benefiting doctors were less acceptable.15
Doctors’ relationships with pharmaceutical representatives appear to influence prescribing practices16,17
, and concerns exist related to gift-giving ethics.18,19
Recent lay publications have also raised ethical questions about some doctors’ relationships with the pharmaceutical industry.20–22
Participants in our study described trust as important in accepting a doctor’s recommendation for a medication. Participants’ concerns that doctors’ medication recommendations are being influenced by pharmaceutical representatives rather than being based solely on patient needs may indicate a threat to patients’ trust in doctors. This finding implies a need to empirically evaluate the impact doctors’ relationships with pharmaceutical companies have on trust and medication adherence. To maintain patient trust, it may be advisable for doctors to disclose their practice’s policies regarding interactions with pharmaceutical representatives. This information could be provided in written details about the practice, e.g., “The doctors in this practice do not accept gifts from pharmaceutical representatives.” Providing this disclosure would be consistent with disclosures of financial relationships between doctors and pharmaceutical companies required in peer-reviewed publications and for many speaking engagements.
Participants believed that doctors have the information needed to determine which medication is safest and most effective for a patient in a specific clinical situation, revealing that participants were not aware of the lack of medication equivalency studies. Addressing equipoise (no clear scientific evidence for 1 treatment choice over another) is an important aspect of shared decision making.23,24
A familiar example of such a discussion might be about generic medication use. Patients may be more likely to accept a new medication recommendation if they actively participate in the decision process. However, conversations about differences between similar medications, such as “out of pocket” costs, rarely happen, although they are desired by patients.25
Further evaluation of how and when such discussions take place in practice, the adequacy of medical school curricula to develop the skills for such discussions, and the actual effect such practices have on adherence are necessary.
This study was conducted in the context of 2 managed care health plans, and thus findings may not be generalizable to patients who belong to other types of plans or who are uninsured. Further, most participants were Caucasian, so we do not know whether members of racial or ethnic minorities would have responded similarly. Prior work in medication adherence shows that adherence rates may be lower for certain ethnic minorities.26–29
Differences in health beliefs and use of alternative therapies may explain some differences found in adherence rates for special populations.30–32
Replicating this study in special populations could yield novel and clinically useful results. The vignette also may have primed participants to respond to questions differently than they would have without the vignette. Although unlikely to invalidate results, it may be useful for future studies to explore responses with and without vignettes.
Accepting a doctor’s recommendation is a necessary first step in the complex process of taking a medication as prescribed. This study’s findings suggest a need to rigorously evaluate how doctors’ relationships with pharmaceutical representatives impact patient trust and medication adherence in a diverse population. Studies evaluating correlations between a patient’s beliefs and attitudes about pharmaceutical representatives and the patient’s actual medication adherence could provide additional data in this area. In addition, it is important to evaluate how patients’ understanding of equipoise impacts medication adherence. Assessing whether medication equipoise discussions impact adherence and, if so, whether medical school curricula prepare students to discuss medication equipoise with patients would inform future recommendations for medical education curricula and for practitioners.