Medicalization to Pharmaceuticalization:
The Shift in Medical Authority from Doctors to Pharmaceutical Companies
Abstract
To test whether there has been a paradigm shift in power from doctors to pharmaceutical companies, research must be conducted regarding quality of medical care. This research will set out to see what effect pharmaceutical companies have on patient care in terms of prescribing habits, doctor-patient interactions, and patient attitudes. In order to measure this, a mixed-methods explanatory sequential strategy will be employed. Surveying 200 adults in Chicago and 200 adults in Boston, we can compare two areas that have differing regulations on pharmaceutical companies. Follow-up interviews will be conducted to better understand the results of the surveys. Analyzing at the individual level, cross-tabulation and coding will be used to determine the validity of the proposed hypothesis. I hypothesize that patients in Chicago experience a greater influence of pharmaceutical companies in their medical care, while patients in Boston see less influence from the pharmaceutical companies. Furthermore, I believe we will see a feeling of lower quality of medical care in Chicago than in Boston.
Introduction
In an article published by Stefan Timmermans and Hyeyoung Oh, the role of medical authorities is explored. The authors cite the post-World War II period as the “golden age of doctoring,” which is mostly attributed to pharmaceutical innovations and surgical advancements. Because of these discoveries, money began flowing into the health care sector in amounts never seen before, “in 1970, U.S. health care spending was about $75 billion, or $356 per resident, and health care accounted for 7.2 percent of gross domestic product (GDP). In 2007, the United States spent $2.2 trillion on health care, just under $7,500 per resident, and 16.2 percent of GDP (Organisation for Economic Co-Operation and Development 2009)” (Timmermans, 2010:96). With healthcare spending only rising since then, there has been a distinct shift in power. Now, interest groups have more pull when it comes to their own agenda, with the largest and most powerful of these groups being the pharmaceutical industry. Due to the rise of the consumerism, industrialism, and bureaucratization of medical care, “we now have a multibillion dollar pharmaceutical industry targeting health professionals” (97). Currently, the United States and New Zealand are the only two developed countries in the world to allow Direct-to-Consumer-Advertising (DTCA) by pharmaceutical companies. There has been a large body of literature to suggest that these advertisements affect prescribing habits of doctors. In a 2004 survey conducted by the Food and Drug Administration, “most physicians view direct-to-consumer ads as one of the many factors that affect their medical practices and their interactions with patients” (FDA, 2015:1). This is what led me to ask: What effect do pharmaceutical companies have on quality of patient care in terms of prescribing habits, doctor-patient interactions, and patient attitudes?
Background & Literature Review
In Western society, biomedicine is an institution with an abundant amount of control. This is due to the discourse that encourages biomedicine; a discourse that links science and medicine as one. This has led to a perception that “medicine, aligning itself with sciences, assumes a powerful role as arbiter of truth in society, determining what is seen and observed, and therefore, what is knowledge” (Bell, 2011:103). This powerful role has allowed those who practice medicine in Western society to hold a higher level of authority. This coincided with the “Age of Reason,” or the Scientific Revolution in the 16th century, which shifted the belief that illness was caused by sin to the belief that illness was simply caused by sickness. This led to the rise of biopower, a term introduced and defined by Michel Foucault, marking the beginning of a new era in which medical knowledge made the population before it subject to its discourse. This entered surveillance and objectification into the arena of biomedicine, and “by combining the elements of observation, individualization, and classification, one can begin to alter behavior” (Bell, 2011:105). Essentially, by labeling individuals (in terms of diagnoses), biomedicine was able to produce a disciplined society.
The physician’s role as a person with medical authority has not only been established, but has increased significantly over the last several decades. This is partly due to the biomedical culture of medicine that exists in Westernized society. Since the rise of medicalization, “biomedical knowledge of what is normal constantly circulates throughout society” (Bell, 2011:105). During the nineteenth century, “medical education formally aligned itself with the sciences and promised increased diagnostic and therapeutic efficacy” (Knopes, 2015:193). It is this merging of science and medicine that the pharmaceutical industry took advantage of.
The pharmaceutical revolution started with the invention of antibiotics. This intrinsically linked the pharmaceutical industry to the medical profession. At a time when patients were losing their faith in the medical profession (around the 1950s), the ability of the physician to prescribe antibiotics “thus helped [them] maintain authority with individual patients” (Timmermans, 2010:100). The public felt it was easier to maintain health, and this lead to a boom in both the medical profession as well as the pharmaceutical industry. Trust was regained (or maybe never lost) because “medical knowledge still translates into a particular discourse that gives institutions and individuals power over people’s bodies” (Bell, 2011:104).
The aim of pharmaceutical companies has gone far off course of antibiotics, however. Now it is any pill imaginable, “as medicine’s pharmacological ability to create specific pills for specific conditions improves, a market solution for life’s troubles, in the form of drug consumption, is greatly advanced” (Esposito, 2014:425). They have even stretched beyond just creating pills, as well. They have taken on several new roles, “pharmaceutical companies are active in developing disease models, ghost-writing scientific articles, providing expertise for guideline committees, manipulating clinical trials, retaining prominent clinical researchers to promote medications, and seducing health professionals” (Timmermans, 2010:100).
Direct-to-consumer-advertising (DTCA) has been the pharmaceutical company’s greatest achievement in gaining power over the medical profession. Due to the powerful force of advertisements on consumers, many patients come in asking for specific medication, which leads to sales rising exponentially. It even leads to overuse of some types of medications (Mechanic & McAlpine, 2010:149). The most popular pharmaceutical products by far are mental health medications, since they are “currently among the best-selling and most heavily marketed classes of drugs in the United States. One in five adults in the United States received a mental health medication in 2010” (King, 2017:154). It should be noted that this report does not say that one in five adults had a mental health issue, however. We can no longer see a clear picture of this, because “the pharmaceutical and psychiatric establishments have been able to increase their roles and influences in studies that have redefined ordinary human behaviors or otherwise attributed problematic conditions such as depression and anxiety that might stem primarily from wider societal conditions, as the avoidable effects of profitable ‘diseases’” (Esposito, 2014:428). They have redefined issues that we deal with in everyday life and treat them any pill, because “the question became not so much what kind of drug could be developed in the laboratory, but which compound already sitting on the shelf could be retested for symptoms, syndromes or disorders so as to fit a profitable niche in the psychopharmaceutical market” (Applbaum, 2009:191).
It has been established thus far that we have entered into a new era in the medical profession – Pharmaceuticalization. This term, whether it be a verb or a noun, is simply “the predominant role of pharmaceuticals in combination with the privatization of health-care policy” (Applbaum, 2009:189). Not only have doctors seemed to have lost their medical authority, but any autonomy patients had left is completely wiped out by the conglomerate force of the pharmaceutical industry. There is no longer room for other types of health care – complementary, alternative, or integrative (Briggs, 2015:1). Pharmaceutical companies have their stronghold on both the medical profession (Larkin, 2014:1021), as well as the political and scientific arenas (Wadman, 2014:533). It seems to be clear how this industry’s actions affect healthcare professionals, but current research doesn’t elaborate on patient care (King, 2017:161), which is a necessary topic to explore.
Discussion of Preliminary Data
In an attempt to further understand the effects of pharmaceutical companies on patient care, I decided to interview a patient who was on several medications. Gabriela, who is currently on twelve different medications prescribed by six different doctors, was able to shed some light on the affect of Pharmaceuticalization in her relationships with her doctors. The most striking information she provided was from her interactions with her psychiatrist. Given that Gabriela was diagnosed with a rare form of Spinabifida, she incredibly depressed and anxious while trying to deal with what this meant for her. She knew that her life was going to be different now, but she felt that she was constantly on the verge of a nervous breakdown. In bringing up these symptoms to her psychiatrist, she was put on high doses of Xanax (for anxiety) and several different anti-depressants. In her words, “every time I walked into the psychiatrist’s office and said something, she gave me more pills.” While there is something to be said about the need to treat critical medical conditions, it is also important to note that she was seeing her psychiatrist every three months for several years. This would mean that there were dozens of increases in medications for Gabriela. The psychiatrist was also aware of her other medical conditions, but it seems that these were not taken into consideration as factors for Gabriela’s stress, anxiety, and depression. Instead, her continued mental health issues were seen as a fault of not enough medication, and the solution was to prescribe more.
In addition to daily doses of Xanax and antidepressants, Gabriela had other doctors that she saw for her various medical conditions. This meant that on top of pills which already had a strong effect on her body, she was also prescribed Fentanyl and OxyContin for her pain. After a year or two taking a combination of these medications, she began to stop breathing in her sleep at night due to the amount of respiratory depressants she was taking. She blames this on her doctors, considering that she carried a list of her prescriptions to every appointment to make sure they were all aware of the different types of medications she was on, including each individual dose (this was before doctors would ask in the beginning of appointments about medications a patient is taking). In Gabriela’s eyes, she should have been a statistic for Fentanyl overdose, and believes that she should not have been taking all of these medications at once. However, she trusted in the authority of her doctors and found herself believing at the time that they were taking the best care of her possible. She struggles with who to fully blame, because “as someone who struggles with depression and has been helped by medication, I thank the Lord that there are medications available and that they work.” On the other hand, it oftentimes felt like “as soon as I said a symptom, there was another medication.”
This symptom-to-medication connection is not a new one by any means. It seems that many doctors (psychiatrists, in particular) are trained to listen for specific symptoms and match them up with corresponding medications. In Gabriela’s experience, this certainly was the case. Pharmaceutical companies are the ones in charge of labeling their medications for certain symptoms/conditions, which would imply that their input has an affect on doctor training, ultimately having an effect on patient care.
In a survey distributed online with a total of 76 respondents, data from one question stood out to me the most. When asked if an advertisement for a medication ever prompted the respondent to ask their doctor about it, 13 out of the 76 (17.11%) of respondents answered yes. While this may seem like a small number, I was expecting the number to be even smaller. I decided to analyze the data of who answered yes to see if there were any patterns. The ages of these 13 respondents ranged from 18 to 35, 4 were male while 9 were female, and the ethnic makeup varied between Latinx origin, White/Caucasian, and Black.
In terms of age, most of the respondents were between 18 and 22. The three outliers were aged 26, 32, and 35, and were all Black women. These three women reported that their household income was between $41,000 and $80,000, leading me to believe that they all had private health insurance. These three outliers were the only Black respondents to answer yes, so further analysis there would be needed. The rest of the respondents who answered yes were Latinx origin and White/Caucasian, and much younger. This was mostly due to the audience that we distributed the survey to (college-aged young adults). All of the females who responded yes had incomes of $41,000/year and higher, while the males reported having lower average household incomes. Latinx origin comprised the highest group of respondents who said yes. While this data might have been skewed due to it representing our peer groups, it led me to want to analyze young adults and their interactions with doctors based on prior exposure to DTCA.
These respondents were not asked what commercial in particular led them to talk to their doctor, or if they were successful in being prescribed the medication that they brought up in their appointments. These questions, along with more, are needed in order to grasp a better understanding of the effect of DTCA on doctor-patient relationships, prescribing habits, and overall patient care.
Proposal
In my research, I will seek to answer the question of how pharmaceutical companies influence patient care through doctor-patient relationships, patient attitudes, and prescribing habits. In order to better understand this affect, it would be best to analyze two different cities, each one located in a state with differing policies in place regarding regulation of pharmaceutical companies. The two cities I have chosen are Boston and Chicago, because Massachusetts has some loose regulations in place concerning the pharmaceutical industry, while Illinois has none. I hypothesize that patients in Chicago see a greater influence of pharmaceutical companies in their medical care, while patients in Massachusetts see less influence from the pharmaceutical companies. This influence will be measured in terms of prescribing habits, doctor-patient interactions, and patient attitudes concerning quality of care. I further hypothesize that in Chicago, there will be a higher rate of prescriptions written, pharmaceuticals discussed more often in doctor-patient interactions, but an overall lower perception of quality of medical care than in Boston, due to the lack of regulations on pharmaceutical companies in Illinois.
For this research, I will be employing a cross-sectional research design. This research design will be most effective because it will help to establish the actions and attitudes of patients in terms of pharmaceuticals. My research with involve a mixed-methods approach, using an explanatory sequential design. I will first distribute a survey randomly to the population, and in-depth interviews will be employed upon follow-up with a subset of the survey respondents. The survey will be useful in gathering prescription data and habits of respondents, as well as broad and over-arching themes concerning attitudes towards patient care and influences in doctor-patient relationships (i.e. DTCA). The subsequent in-depth interviews will help to solidify attitudes towards quality of medical care.
The unit of analysis in my research will be at the individual level, in order to speak to individual attitudes and how the pharmaceutical industry affects individual-level quality of medical care. The population I will be focusing on is adults seeing psychiatrists to explore the explanations behind the literature that mental health medications are the largest market for pharmaceutical industries and that “one in five adults in the United States received a mental health medication in 2010” (King, 2017:154). The sample will include 200 respondents from each city (Chicago and Boston), and some from each city will be selected for the follow-up interviews.
For the nature of this research, a purposive sampling strategy would work best. This would ensure that each of the respondents have visited a psychiatrist, as the surveys would be distributed by either the doctors themselves or someone working in the office. This would also help to speak to the attitudes of the psychiatric patient community, which purposive sampling strategies are particularly helpful with. At the end of their appointments, respondents will be handed a card that will direct them to the survey electronically. Based on their answers, respondents will be produced with a phone number at the end of their survey to call for their follow-up interview. These answers will be selected during the writing of the survey, and will help in reaching a better understanding about DTCA, doctor’s suggestions, etc. They will be generated based on patterns found in responses.
The survey will generally employ close-ended questions, and utilized the Likert scale when determining patient’s attitudes on overall quality of medical care. The in-depth follow up interviews will help to try to understand these attitudes and any spurious variables that might encroach on the research. The follow up interviews will help to close the gaps in the quantitative data that may occur, and to provide a more comprehensive picture.
The majority of this work will be quantitative, but the qualitative aspects will play a major role. Prescription habits and attitudes can be measured quantitatively, but reasons and causal effects will need to use qualitative aspects. Since this research will be exploratory, it will be inductive. Starting with a theory, I will seek data to prove its validity.
There should not be many ethical issues in conducting this data. There will be limitations in the access gained, as this is a more sensitive topic and so the response rate may be lower. Confidentiality and privacy will be taken into the highest consideration, and anonymity will be maintained throughout the entire research process. At any point, the respondents may refuse to participate and discontinue with the research.
There will be a special issue with this research in the fact that, like mentioned before, this is a sensitive issue. While privacy will be taken into high consideration, there might be difficulty faced on the research end of this when facing trust of the respondents. Social desirability could also become an issue, as people do not typically like to be seen as “mentally ill”. These will all be addressed in the process.
Conclusion
In order to see if the pharmaceutical companies have taken authority in medical care, researching adults in cities with differing regulations would be most useful. Using a mixed-methods approach, we can gain helpful insight into the degree of influence of Pharmaceuticalization in quality of medical care through doctor-patient interactions, prescribing habits, and patient attitudes. These three qualities will be measured from the patient’s point of view, and I hypothesize that where there is no regulation, there is more influence of pharmaceutical companies in patient care.
References
Applbaum, Kalman. 2009. "Getting to Yes: Corporate Power and the Creation of a Psychopharmaceutical Blockbuster." Culture, Medicine & Psychiatry 33(2):185-215 (http://proxy.cc.uic.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=38219951). doi: 10.1007/s11013-009-9129-3.
Bell, Sheri. 2011. "Through a Foucauldian Lens: A Genealogy of Child Abuse." Journal of Family Violence26(2):101-108 (http://proxy.cc.uic.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=hch&AN=57390158). doi: 10.1007/s10896-010-9347-z.
Briggs, Josephine. 2015. "Americans' Active Quest for Health through Complementary and Integrative Medicine." Generations 39(1):56-64 (http://proxy.cc.uic.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=103796356).
Esposito, Luigi, and Fernando M. Perez. 2014. "Neoliberalism and the Commodification of Mental Health." Humanity & Society 38(4):414-442 (https://doi-org.proxy.cc.uic.edu/10.1177/0160597614544958). doi: 10.1177/0160597614544958.
King, Marissa, and Peter S. Bearman. 2017. "Gifts and Influence: Conflict of Interest Policies and Prescribing of Psychotropic Medications in the United States." Social Science & Medicine 172(Supplement C):153-162 (http://www.sciencedirect.com/science/article/pii/S0277953616306190). doi: //doi.org/10.1016/j.socscimed.2016.11.010.
Knopes, Julia. 2015. "Navigating the Cultural and Professional Legacies of Alternative and Mainstream Medicine in Nineteenth-Century America: A Review Essay." Culture, Medicine & Psychiatry 39(1):187-195 (http://proxy.cc.uic.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=101515652). doi: 10.1007/s11013-015-9428-9.
Larkin, Ian, Desmond Ang, Jerry Avorn and Aaron S. Kesselheim. 2014. "Restrictions on Pharmaceutical Detailing Reduced Off-Label Prescribing of Antidepressants and Antipsychotics in Children." Health Affairs 33(6):1014-23 (http://proxy.cc.uic.edu/login?url=https://search.proquest.com/docview/1534525411?accountid=14552).
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Timmermans, Stefan, and Hyeyoung Oh. 2010. "The Continued Social Transformation of the Medical Profession." Journal of Health and Social Behavior 51:S106 (http://www.jstor.org/stable/20798319).
Wadmann, Sarah. 2014. "Physician–industry Collaboration: Conflicts of Interest and the Imputation of Motive." Soc Stud Sci 44(4):531-554 (https://doi.org/10.1177/0306312714525678). doi: 10.1177/0306312714525678.