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.
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.