...attention factors may (adversely) affect physician drug decision making. Factors that draw particular attention are marketing actions of pharmaceutical firms targeted directly at physicians and patient requests for a specific drug. "There has been a public outcry, especially in America, over the cozy relationship between doctors and drug companies. Some practices are illegal, others are simply part of the customary trio of food, flattery, and friendship" (The Economist 2005, p. 9). The prosecution of Merck for its marketing actions for the drug Vioxx is a very recent, heavily publicized, case in point, that regulators take notice (The Wall Street Journal 2006).

Pharmaceutical firms spend a huge and ever-increasing budget on detailing visits (sales calls by pharmaceutical representatives) and meetings. The number of sales representatives in the pharmaceutical industry has undergone a six-fold increase in the last 20 years to approximately 100,000 today, and 77% of the companies are planning to further expand their sales force in 2005 (Hradecky 2004). Detailing (30.6%) and sampling (50.6%) to physicians amount to 81% of promotion spending by pharmaceutical firms in 2000 (Rosenthal et al. 2003). In addition, patients increasingly request a certain brand of drug from the physician. In the United States, one in three patients at some point has asked about a drug by name (Calabro 2003). It is a commonly held belief that such patient requests are often triggered by direct-to-consumer (DTC) advertising, presently at an all-time high of $4 billion in the United States (Edwards 2005).

The most important decision of a physician, especially if it concerns general practice physicians, is which drug to use in treatment of patients. The decisions physicians make on drug treatment can be witnessed through observing prescription behavior. They can also be observed in sampling behavior, as samples are provided together with a prescription (as a financial subsidy to the patient), or instead of a prescription (as a trial, e.g., when uncertainty about drug-patient interaction is high). Sample dispensing by physicians is rarely studied. Sampling is an important physician decision as well, because sampling may lead to prescribed long-term treatment (Morelli and Koenigsberg 1992), and thus have significant consequences for pharmaceutical firms and public health.

Academic scholars and regulators have turned to assessing how both marketing actions of pharmaceutical firms and patient requests influence physician decision making on drug treatment, both prescription and sampling behavior. At this point, most research has been conducted on how marketing efforts targeted to physicians affect physicians' prescription behavior. Patient requests as a factor influencing physician decision making and sampling as a physician decision have received less attention so far.

Even in the relatively developed research stream on marketing efforts and prescription behavior, controversy has been raised recently. While some studies (e.g., Gonul et al. 2001) find that detailing has a positive and significant effect on prescriptions written, other studies find either a very modest effect (Mizik and Jacobson 2004) or no effect at all (Rosenthal et al. 2003) of detailing on brand prescriptions or sales. Recently, Leeflang et al. (2004) posited that the reason for these incongruent results is that prior models may be misspecified, in that they pool the effect of marketing expenditures across brands, while brands may in fact differ in the extent to which physicians are responsive to the marketing expenditures a firm makes to promote them through detailing, meetings or other promotional instruments. This is also the stance we take in the present study.

This study posits that drug characteristics, such as side effects and effectiveness, are a potential source for brand-specific differences, if any, in the responsiveness of physicians' brand prescription behavior to marketing efforts by pharmaceutical firms. Our insight may contribute to resolving the controversy on how marketing efforts of pharmaceutical firms affect prescription behavior. We also examine the role of these drug characteristics in the effect of other "influencers," such as patient requests, and other physician decisions, such as sample dispensing. A coherent picture arises from our empirical analysis. We find that drug characteristics affect both the influence patients (in this study through patient requests) as well as the pharmaceutical firms (in this study through their marketing efforts targeted to physicians) exert on physician decision making, both in a physician's prescription and a physician's sample-dispensing decisions. Thus, we underscore the importance of including drug characteristics in any study of influence by firms and/or patients on any drug treatment decision a physician makes. By our knowledge, this study is the first attempt to test for interactions between influencers (e.g., detailing by the pharmaceutical firm) and drug characteristics (e.g., efficacy) on physician behavior.

For this study, we have composed a unique data set that matches three data sources. The first contains detailed information on manufacturers' detailing visits to physicians, physician attendance at manufacturers' meetings, and drug requests of patients for 2,774 physicians in the United States, as well as the number of prescriptions written and samples dispensed by each of these physicians on a monthly basis. The second and third data sets we composed ourselves. These contain data on (1) effectiveness, and (2) side effects of each drug in our database.

The next section discusses the theoretical background. Section 3 describes our data set and the analysis methodology we use. Section 4 presents our results. Section 5 discusses our findings, their implications for public policy and management practice, and the study's limitations.

2. Background

This section first discusses prior research on the effects of pharmaceutical firms' marketing efforts on physician prescribing and explores their effects on sampling behavior by the physician, which until today remained unstudied. Second, we discuss the limited prior research on the effects of patient requests on physicians' prescription and sample-dispensing behavior. Third, we explore the role that drug characteristics may play on physician decisions and their interactions with firms' marketing efforts and patient requests. Fourth, we discuss any other relevant variables that may affect physicians' prescription and sample-dispensing behavior.

2.1. Effects of Pharmaceutical Firms' Marketing Efforts on Physician Prescription and Sample-Dispensing Behavior

One can divide the prior literature regarding the effect of pharmaceutical firms' marketing efforts on individual physicians' prescription behavior into two streams, namely, one finding positive effects and one finding mixed effects, at best. We discuss each stream in turn.

Gonul et al. (2001) and Manchanda and Chintagunta (2004) find that marketing efforts by pharmaceutical companies to the physician positively affect prescriptions issued by a physician, but there are diminishing returns to detailing. Manchanda et al. (2004) find that detailing positively affects prescription behavior, but that high-volume physicians, while being detailed more, are less responsive to detailing, as compared to low-volume physicians. Narayanan and Manchanda (2004) find that while detailing influenced physicians positively in an overwhelming number of cases, there was significant cross-sectional and temporal heterogeneity in physician responsiveness to detailing. Janakiraman et al. (2005) find that nonpersistent physicians are responsive to both detailing and symposium meetings, while persistent physicians are only responsive to symposium meetings. Also, many studies that use aggregate (sales or prescription) data find a positive effect of detailing on drug sales (e.g., Chintagunta and Desiraju 2005; Narayanan et al. 2004, 2005; Neslin 2001; Rizzo 1999).

According to the prior literature, firms' marketing efforts may have a positive effect on prescription behavior because detailing visits or symposium meetings provide information to the physician on efficacy and side effects of the drug (Gonul et al. 2001). In line with a long tradition in economics (e.g., Becker and Murphy 1993, Grossman and Shapiro 1984, Leffler 1981), Narayanan et al. (2005) have argued that firms' marketing efforts may actually have both an informative role (e.g., reducing cognitive uncertainty) and a persuasive role (e.g., inducing positive affect).

Mizik and Jacobson (2004) find that marketing efforts by pharmaceutical companies to the physician positively affect new prescriptions issued by a physician, but the effect sizes are very modest. Their findings cast doubt about a strong and positive effect of marketing efforts on physician prescription behavior as evidenced in studies using aggregate and individual-level data. Parsons and Vanden Abeele (1981) find that physician prescription behavior is quite unresponsive to marketing efforts by pharmaceutical firms to the physician, and sales calls may even have a negative effect. Rosenthal et al. (2003) did not find robust and significant effects for detailing at the individual brand level.

To the best of our knowledge, there has been no prior research that examines the effect of marketing efforts on sample-dispensing behavior by the physician. The most useful research for our purposes is probably the sparse literature in medicine that examines the motives physicians have when dispensing free samples to their patients. Motives that have been cited are: (1) financial savings for patients; (2) convenience; (3) initiate therapy immediately; (4) demonstrate the appropriate use to patients; (5) adjust prescribed doses before the full prescription is purchased; and (6) evaluate early effectiveness or adverse effects (Chew et al. 2000, Duffy et al. 2003).

2.2. Effects of Patient Requests on Physician Prescription and Sample-Dispensing Behavior

Most of the research that studies the effects of patient requests on physician decision making is driven by the growing importance of DTC advertising in the United States, mostly after the FDA's 1997 Draft Guidance on DTC broadcast advertisements. DTC advertising is an important driver of patient requests (Mintzes et al. 2003), and scholars have only studied patient requests when triggered by DTC advertising, rather than...

NOTE: All illustrations and photos have been removed from this article.



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