New drugs are developed every month, and doctors are continuously bombarded with information.
Much of this information is provided by pharmaceutical sales representatives who visit doctors’ offices, sponsor lectures and give out medication samples.
Are these encounters in the best interest of patients and the health care system?
We went out to the street and asked members of the public whether pharmaceutical companies should be involved in educating doctors about their products. Click on the video link to see what they have to say.
In the film Love and Other Drugs, Jake Gyllenhaal plays a “drug rep” named Jamie Randall. Working for Pfizer, his task is to charm his way into doctors’ offices, educate them about the latest Pfizer drugs and provide free samples – all so that he can influence them to prescribe more of his company’s medications. Luckily for Jamie, he is eventually assigned Viagra, and his sales go through the roof. Parts of the movie are clearly intended as satire, but the jokes wouldn’t be funny unless the audience perceived there to be some underlying truth to them. In fact, Pfizer’s antics weren’t just funny, they broke the law. In 2009, Pfizer paid a $2.3 billion dollar fine after pleading guilty to charges that they promoted a drug for several uses that the United States Food and Drug Administration specifically declined to approve because of safety concerns.
But are doctors actually influenced by drug reps? And is there a better alternative to having drug companies provide education to physicians?
The job of a pharmaceutical sales representative
New drugs are constantly being licensed, and information changes quickly. Most doctors find it difficult to keep up, and this is where pharmaceutical sales representatives step in. “Drug reps” as they are usually called, provide information about the newest medications – when they should be prescribed, what the side effects are and how a patient should be monitored. Drug reps provide education by visiting doctors’ offices, meeting with doctors and also by sponsoring meals at lectures for continuing medical education. In one study, most “high prescribing” doctors reported that drug reps were their main source of information. Drug reps also distribute free medication samples, which can be useful, particularly for patients without prescription drug insurance. At first glance, the arrangement seems like a win-win situation – doctors stay up to date, and patients who otherwise can’t afford new medications get access to them.
The hitch is that a drug rep’s job is not simply to provide doctors with unbiased information and medication samples. Like any sales representative, the primary goal is to increase the company’s bottom line.
Do drug reps really change how doctors prescribe?
Studies indicate that doctors who attend lectures sponsored by pharmaceutical companies are more likely to prescribe that company’s drugs, and that pharmaceutical company ‘gifts’ are associated with higher prescribing rates. In one study, 84% of doctors thought that their colleagues were influenced by gifts and other forms of industry promotion – even though only 39% of respondents admitted being influenced themselves.
However, the evidence from these studies does not convince everyone. Declan Hamill, Vice President of Legal Affairs for Rx&D, an association of Canadian research-based pharmaceutical companies, notes that the majority of these studies took place in the United States where the regulatory and health care system environment differs from the Canadian context. Hamill also notes that Rx&D has developed a Code of Ethical Practices which outlines that interactions between reps and doctors should “be conducted in a highly professional, business like and ethical manner” and that gifts are not acceptable. As a matter of policy, all employees of Rx&D member companies are provided with education about the code, however, Rx&D does not include all Canadian pharmaceutical companies, and Hamill does concede that “awareness of the Code has been an ongoing challenge.”
But perhaps the best evidence that marketing works is that pharmaceutical companies spent well over $500 million in 2007 in Canada to promote their products to physicians. Would drug companies spend so much mony on an activity that they didn’t feel works?
Times and relationships are changing, but fast enough?
The dynamics of the pharmaceutical industry are changing. In the 1990s and early 2000s, many new drugs were developed, and individual detailing — drug reps visiting doctors’ offices one by one – was perhaps the industry’s go-to marketing tactic. But an increasing number of doctors, about 1 in 4, now refuse to see drug reps. The landscape has changed so much that the number of drug reps in the United States has dropped by about 25% over the last 5 years. Some drug companeis have also been hit with lawsuits about fraudulent marketing practices.
Some argue that the changes are not happening quickly enough. Joel Lexchin, a Toronto emergency room doctor and professor at York University argues that “ideally doctors should stop seeing drug reps completely.” If that’s not possible, he says that at the very least, “regulation of drug reps needs to be taken out of the hands of the pharmaceutical industry and turned over to an independent authority established through legislation.”
However, in some places, the clock is actually being turned back. Although Massachusetts banned the practice of drug company gifts to doctors and sponsorship of continuing medical education in 2008, the law banning the practice was repealed in April. Critics of the law said that it would hurt the pharmaceutical industry.
Moving forward
Some argue that the best step forward would be to change the culture so that doctors no longer feel that it is acceptable to be educated by drug reps. Some Canadian training programs have placed restrictions on how pharmaceutical industry representatives can interact with medical students or residents. These changes are in large part the result of a study at McMaster University, which found that medical residents who were exposed to drug reps and promotional material were more likely to continue to work with drug reps in their medical practice. Danyaal Raza, a family medicine resident at Queen’s University, says that “residency programs have a responsibility to set a standard for how doctors practice.” His department has a policy prohibiting drug reps and industry material from student education, an approach that Raza agrees with. He says relying on pharmaceutical industry sponsored education “flies in the face of evidence-based medicine designed to eliminate bias from patient care.”
But if drug reps don’t provide education, who will? Lexchin looks to examples abroad, like Australia, where the government pays for doctors to receive education through the National Prescribing Service, a body funded by the national government. Here in Canada, the Nova Scotia government and Dalhousie University have set up a program to provide “academic” detailing. Doctors who wish to participate are visited once or twice each year by a health care professional who provides one-on-one education using material produced by the university. Almost two-thirds of Nova Scotia family doctors have participated in the program. However the program’s budget only allows it to address two topics per year. Pharmaceutical companies do not face the same financial constraints.
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1. There was a research report which found big pharma’s claim for 1.3billion in production cost to actually be closer to a $250 million average. The timeline of 8-11 years was reduced to nearly half also in that study.
2. After I finished undergrad i wasnt sure if i wanted to become a doctor so the only industry my degree seemed suitable for was Big Pharma. I didn’t just follow the typical application over the internet protocol. I met with an ex-CEO, a national sales manager, and multiple reps. They all had the exact same perspective when I asked what my attitude should be and how I could expect to succeed. I’ll summarize it with the words of a rep who was about 40 years old, did not want to be promoted beyond a pharma rep because he made a six figure salary and only worked 30 hours a week, “Listen. It’s dog eat dog. Make as much money as you can”. In fact right now he’s probably golfing instead of working as he proudly exclaimed to me. Another phama rep outright instructed me the best response for my interviewer is to say “I love money. It motivates me”. Can’t say he was wrong, being a pharmaceutical rep is a commissioned based job. This experience led me to turn my back on the offers when they came. I decided i really would like to become a doctor to help others. Wealth and prestige are psychopathic desires, be careful of the docs who value this.
3. Those other two posts are here to contribute to this back and forth chat. But here’s my real opinion. You don’t need most drugs prescribed. Humans have live far longer than pharmaceuticals have been synthesized. The majority of chronic health ailments stem from poor lifestyles an issue being addressed by an upcoming term called mind-body medicine because the disease is in healing the persons mind the place where one justifies their outlook on life and attitude. In fact, ask doctors if you don’t believe me, but if life coaching were a course we had to take from grade 6 to grade 12, people would be far more balanced and live more prosperous lives as a result. The reason for my saying, the majority of disease results from stress and indulgence.
For the far fewer pharmaceuticals left around, less money would be pocketed by Big Pharma. The number of pharma companies would shrink and less innovations would come out. But that’s fine. Because less, not 0 innovations would come out. If innovation is the only source of profit, then they will innovate that which people cannot naturally heal from or with the assistance of a doctor. Next, if profits shrunk, the best sales girls (yes, white women are the best pharma reps by numbers) would leave to more profitable types of industries, or at least be paid less for pushing products. As for the scare tactic of Big Pharma ceasing innovation, its bullshit. Because if they do, they will loose money and risk being noncompetitive. If they don’t then new drugs will be produced that should be more superior. This last sentence leads into my last point.
New drugs are not necessarily more superior than older drugs. Take aspirin and tylenol for example. They are still extremely beneficial. The only guarantee a new drug has is more revenue. This is because innovations can only be made by providing something unique.Thus pharma companies are often inventing diseases in order to patent. This is why a lot of the drug companies are leaving the general physicians and moving to the specialists, where the big money is. When you’re usually seeing a specialist its because your problem is probably pretty bad and possibly urgent, a point where you actually listen to your doctor for once (as you often ignore the advice on exercise and a healthy diet) and then obligingly splurge money without even consideration of cost because the well being of your body, or even worse – your parents, or the worst – your children is on the line.
To the benefit of justifying your choice of trying to live well, I will mention this last part. An overwhelming majority of the drugs created in the labs are extracted from the natural society. That means the therapeutic effects were created by mother nature. Thus if your well being pill can be found in the fruits of the earth, why not just save your time of suffering from illness altogether which will let you eliminate on the drug costs, function better (so you do away with that excuse for taking a pill when you get sick and have to work), minimize profits of Big Pharma, and be a role model for your parents, siblings, and/or kids. A perfect proponent of this philosophy is Deepak Chopra. Not only is he proving this to be the case, but he’s profiting off people healing themselves through his non-pharma techniques, and if he’s making money then that’s at least 1 less source for big pharma to dispel their new drugs through.
What I find problematic about all this is the ironic relationship between doctors and the drug industry. I mean, the two parties undoubtedly share very similar interests. They both want to promote effective drugs for the treatment of patients, both want to ensure the drugs are safe to use, and both are always seeking to create innovative drugs to replace current ones. But a problem arises due to the different areas that each party focuses on; both of the parties’ visions don’t align to a common goal. Drug industry is obviously concerned primarily with sales, while doctors are focused heavily on competent delivery of patient-care. So, this conflict of interest really doesn’t help much but exacerbate the ethical concerns that already surround this issue. What I think is the best way to resolve this is to not ban the interaction between doctors and drug industry completely but instead establish a friendly relationship between the two parties that can aided by implementing a fair criteria/guideline. One proposal can be that “gifts” are to be offered less by the drug industry to the physicians, and the further scientific research should be validated by ethics more so than commerical reasons.
Yes Rx&D does have a code of conduct and here is what it says: (CAPS are mine for emphasis.)
Members accept the obligation to ensure Canadian health care professionals and patients have access to education and information about appropriate uses of their products and services.
That obligation includes:
Providing BALANCED representation of the benefits and risks of their products;
Representatives must provide FULL and factual information on products, without misrepresentation or exaggeration.
Representatives’ statements must be accurate and COMPLETE;
They should not be misleading, either directly or by implication.
However they don’t appear to follow the code. I attended a presentation by Barbara Menzies from UBC at the recent Cochrane symposium.
She surveyed ~130 family docs about their experiences with drug reps and found that 86% did not spontaneously mention contraindications, 98% didn’t mention drug inetractions, and 75% didn’t menion adverse effects.
In fairness, docs’ have their own code of conduct (CMA 2007).
Physicians should resolve any conflict of interest between themselves and their patients resulting from interactions with industry in favour of their patients.
We should make sure we all follow it.
As for who should pay for CME. With the drug industry spending well over $500 million a year, there is no way docs can cough up enough money on their own to counter that. So government’s should help out. Even $100 million a year would help.
Has anyone seen a new drug cost less than the one it is designed to replace? Has anyone ever verified big pharma’s claim that it costs on average 1.3 B to bring a new drug to market? Does anyone believe that drug companies are acting in anything other than their bottom line interest and shareholders’ demands for ROI. No. I didn’t think so.
Big pharma is a racket just as the remainder of the medec industry is a racket that holds an uncontested monopoly on therapeutics. It makes my blood boil and there is nothing we can do about it.
However an appropriate check would be to ban the practice of drug reps sponsoring events and doing office visits. I personally refuse to see any of them and refuse to go to industry sponsored events. The learning should be part of mandated, paid for CME. In no way should doctors through their own dollar direct or via their medical associations be on the hook for this. We don’t expect it of any other profession (unless you happen to believe that the “cost” is not incorporated into their collective agreements). 4 engine pilots require recheck every 14 days and it is part of their work schedule and paid for within their collective agreement. So let’s not engage in too much hypocrisy by putting the burden of the education on doctors – and incidentally taking them out of the workplace with resultant loss of productivity within the health care system as a whole.
Grumpy notes after a 90 patient clinic
Short answer no. This practice has inadequate governance and is directed by pharmaceutical companies/drug reps who research prescribing patterns and develop “champions” to influence practices in their territories. Physicians are taking increasing initiative on being proactive in developing policies to improve transparency, but let’s be clear, drug reps feed and cater to doctors wants in order to gain access and promote their product and generate profit.
It has a huge potential of coming back to ruin the credibility of a physician attempting to undertake a leadership position. See for example: See, for example: http://shm.informz.net/shm/archives/archive_1175838.html.
As physicians, in an increasingly connected world we must be able to stand behind and justify our actions and stay clear of the slippery slope of what amounts to lobbying.
Not to say that physicians should not be allowed to receive education or participate in research that has contributions from the deep pockets of drug companies, but let us be transparent and clear on the motivation “funding” certain ideas to the top of the opinion ladder.
Physician self-education is an important priority and continuing effort for most practitioners. Education is multifaceted and various regulatory and government agencies are demanding some specific physician accountability. However that is mostly a façade and represents the physician desiring to meet arbitrary targets for hours of learning per year .
Pharmaceutical companies have filled the void through sponsored educational events such as meetings or dinners, conferences, advertising journals, and direct visits to physician offices.
Perhaps the government should take a definitive step by paying physicians per day or per week to attend the office of a designated teaching colleague for a one-on-one experience similar to apprenticeship or personal mentoring. The learning physician would be obliged to sign-in for the day or week with his teacher and not be allowed to bill Medicare during that time nor would he be tempted to return to his office and attend patients. The provincial government would be able to pay the physician for his learning time as he otherwise would have been working at his office, clinic, or operating room and bill Medicare for that day’s patient services. Government and many physicians would agree to such a plan as it is revenue-neutral for them other than a stipend for the teaching physician.
I’d like to put this question out to the Healthy Debate community:
We know that seeing drug reps tends to increase the rate at which a physician may prescribe drugs from that rep’s company. But do we know whether that increase is due to medically inappropriate prescribing, or might it be due, in part or in whole, to improved awareness of available products to treat legitimate medical conditions?
Presumably, the concern about drug reps is that they are influencing docs not just to prefer their medication over another equally good medication, but to prefer their medication even when another drug would be more appropriate for treating a particular condition. That would be categorically unacceptable, but my impression is that we don’t really have any concrete evidence about whether this is happening. Even the data on physician self-reports is not really clear on this matter. 39% report that they are influenced by drug reps, but the studies in question don’t clarify whether this influence results in compromising care.
Is anyone aware of any studies that clearly demonstrate that drug reps influence physicians to compromise patient care by favoring particular brands of drugs? If not, would such a study be feasible? How might it be undertaken here in Canada?
To be clear, I favor continuing education from neutral parties, using evidence synthesized by organizations like the BC Therapeutics initiative. However, changing the status quo is never easy, and if a major evidence gap exists, such change will be hard to justify.
These are good questions Jeremy.
Interactions with drug reps does increase awareness, and this is a good thing in areas where we have significant “underprescribing” problems. For example, there are still many patients at high risk for a heart attack who are not on a statin.
It is difficult to conduct epidemiologic studies to determine whether interactions with drug reps leads to compromised patient care. But some of the legal settlements that pharmaceutical companies have made in the United States are revealing. For example, when Purdue pleaded guilty to “misbranding” OxyContin (see http://www.vawd.uscourts.gov/PurdueFrederickCo/Exhibit-B.pdf) the company admitted that its sales representatives told doctors that the drug was less prone to abuse and not as addictive as other similar drugs. The evidence suggests that doctors did indeed believe these messages and prescribe OxyContin more frequently than they would have otherwise. And as OxyContin prescribing has increased, we have seen a very large increase in the number of opioid overdose deaths, both in the United States and Canada.
Agreed that the case of OxyContin is an important cautionary tale about the damage that can be done by unscrupulous corporations and their representatives. Given that so much of the marketing happens behind closed doors, it’s very hard to detect illegal behavior until significant damage has already been done.
To play devil’s advocate for a moment, however, the case of OxyContin represents illegal behavior that while not unique (Pfizer’s recidivism on marketing drugs for unapproved uses comes to mind), does not appear to be particularly common. Those who would prefer no major change to the current system can argue that these exceptional cases have been addressed through the courts, and future cases can be avoided simply by tightening some regulations. I think the battle to move to independent continuing education is going to be particularly hard unless there is some evidence that interacting even with law-abiding drug reps is capable of influencing physicians sufficiently to compromise patient care through misprescribing.
I definitely agree that the research involved in generating such evidence would be tricky, to say the least. Perhaps the starting place is to reframe the questions used in self-report studies. While 39% of physicians surveyed admitted to being influenced by drug reps, I wonder what number would report that this influence led to compromised care. What fraction think that their colleagues have been influenced to compromise care? Even small numbers might have a powerful impact.
How about rosiglitazone and rofecoxib? Presumably drug reps influenced docs to prescribe them which would lead to compromised care. Another example might be inappropriate use of fluoroquinolones leading to increased resistance. One could argue that paying unnecessarily high costs for drugs can compromise care since if drug A is too expensive, the patient may not be able to afford drug B which is necessary for good care.
Great topic and interesting to hear people’s perspectives in the video.
If we’re truly talking about education (not marketing), it’s helpful to have an intermediary to ensure a level of accuracy, neutrality and peer review.
The medical associations definitely have a role to play, and with social media and other tools, perhaps we could be leveraging the collective wisdom of the physician & academic/research community in a new way. I.e. What about a wiki that is initiated by the drug company but then open to editing by community members and registered experts?
Interesting comment/question about social media. My sense (using the so-called Zamboni procedure for people with MS as an example) is that the social media is not always a mechanism for respectful, evidence-informed debate about an issue, but can instead be quite one-sided. Part of the reason it can be so one-sided is that the physician and research community tend not use social media that much (yet).
Perhaps more of a closed community with an established editorial/review board comprised of recognized experts would help to foster physician confidence and participation – i.e. similar struture to a journal but delivered in an online format for easy access/searching and where members have the ability to comment. It’s true that social media can be one-sided; however, the same could be argued about the education materials developed by drug companies. A more participatory framework would allow for a level of diversity of opinion, independence and decentralization – all key to ensuring a “wise crowd”.
It’s great to see Healthy Debate highlighting the crucial issue here: what exactly is the alternative, and who is going to pay for it? Nova Scotia’s approach is particularly instructive, because they have grasped one of the key strengths of the pharmaceutical companies’ approach: they go to doctors’ offices. Yet the budgetary constraints under which this program operates are also important, because direct to physician marketing/education is not cheap.
While it makes some sense to have the colleges or the medical associations responsible for educating their membership, making these organizations responsible for financing such education represents a significant shifting of the financial burden away from consumers (who absorb corporations’ marketing costs) and over to physicians. Some public financing would probably be necessary in order to ensure that these organizations could afford to provide top quality education.