A Move Towards Totalitarian Medicine?

People often ask me, if statins are so bad why do so many doctors prescribe them? This is a good question - it is perfectly understandable that people feel conflicted by the differing points of view.

Doctors worldwide prescribe statins to tens of millions of people who do not need them. These people will not receive any benefit from the medication and have a significant possibility of life altering adverse effects. Part of the reason for this catastrophic situation is related to the medical system in general. In particular: the commercial interests, the hierarchical nature of medicine, the Flexner report (discussed in Body Electric), medical education that is not only influenced by commercial interests but also professors representing the old guard unwilling to accept new evidence, unprofessional and lazy journalism, commercially driven media organizations, few unbiased alternative information sources, and the implementation of commercially driven clinical guidelines. Now, a new factor could be emerging - a new way to exert peer pressure on doctors.

Researchers at the University of Pennsylvania have found a way of nudging doctors to prescribe more statin medications to people who don’t need them. Well, actually two new ways, but both using a similar method. They used an online patient dashboard with 'nudges' to doctors. One nudge provided physicians with information on their performance relative to other physicians in terms of prescribing, and the other a simple prompt to physicians to make a decision on prescribing a statin.

During the study, the dashboard nudge that showed the physician information on their performance relative to other physicians, led to more than 3 times as many statin prescriptions. When compared to normal care.

The medical profession sometimes believes it is immune to the effects of persuasion and suggestion. For example, a survey conducted on medical students found that 86% thought it was improper for a politician to receive a gift, but only 46% thought it was improper for themselves to receive a gift of a similar value from a pharmaceutical company. Indicating that the medical students believed they would be less influenced by a gift than politicians are.

But the fact that simple onscreen nudges can lead to 3 times as many prescriptions, indicates that doctors are in fact only human. And these aspects do influence prescribing outside of the evidence base.

This should be a concern for all kinds of reasons. Not least because according to a survey completed in America, 94% of doctors have some kind of link with the pharmaceutical industry.

The idea of nudging the prescription habits of doctors is in my view a deterioration towards achieving control by the drugs companies over what doctors do. Commercially influenced clinical guidelines already do a good job of that, and now nudging doctors using peer pressure can help to exert control over those doctors brave enough to do what they think is best for the individual patient despite the guidelines.

Below is a video excerpt from the Statin Nation extras. Professor Peter C. Gøtzsche talks about clinical guidelines and the fact that these can sometimes inappropriately restrict doctors.


The study discussed above is published in JAMA

Effect of an Automated Patient Dashboard Using Active Choice and Peer Comparison Performance Feedback to Physicians on Statin PrescribingThe PRESCRIBE Cluster Randomized Clinical Trial

Other studies referred to:

Campbell, EG et al. “A National Survey of Physician-Industry Relationships” New England Journal of Medicine 2007; 356:1742-1750

Wazana, A “Physicians and the Pharmaceutical Industry: Is a Gift Ever Just a Gift?” Journal of the American Medical Association 2000; 283:373-380

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