“What’s the harm in taking something small? It’s just a pen. It’s only lunch. It was just one weekend at the bed & breakfast with my partner. And I learned about a topic that I wouldn’t have known about otherwise. Plus I got some samples in return! It won’t affect my prescribing habits…”
These are the common arguments one might hear from a family doctor, internist, psychiatrist or other specialist who is attempting to mitigate their personal misgivings of allowing drug reps into their place of practice. Almost every practicing physician will at some point face these similar ethical conundrums. The policy each individual takes towards pharmaceutical representatives is often a combination of their personal values, guiding principles, observed precedence set by mentors and previous experiences. There is no right or wrong, but each physician must find his or her comfort level with “Big Pharma.” It is therefore important to keep in mind that what follows is my opinion (at times supported by facts); however this does not make it the only opinion.
Much has changed since the boom years of the 1980s and 1990s when industry’s interaction with physicians had no boundaries. In those days, doctors who wrote a high volume of prescriptions for certain companies’ drugs were routinely whisked away to luxurious resorts in exotic locations, taken for dinner at the fanciest restaurants, and given “honorarium stipends” (ie. money) with no restrictions. Now moving into the 21st century, thanks to harsher limitations placed on pharmaceutical companies, the magnitude of compensation has changed, however the interaction has not.
The biggest misconception held by physicians is that nothing will affect their prescribing habits. This is simply untrue. In 2005 in the United States there was a drug rep for every 2.5 doctors and somewhere between 7.5 and15 billion dollars spent on marketing specific medications via drug reps. Drug companies are not stupid – this investment must be leading to substantial returns. Despite this, many physicians will contend that they can see how their colleagues may be affected by this marketing, but that they are stronger willed; nothing affects their own prescribing. The ethical dilemma occurs as those that benefit from the pharmaceutical company’s intervention (physicians), are different than those who are affected by the change in prescribing habits (patients). Putting myself in the shoes of the patient, I would hope and expect that a physician is making decisions based solely on what is best for my health as opposed to which drug rep has recently visited his office.
The drugs most heavily marketed or “pushed” by drug companies are not always their most effective or the ones with the best evidence. Marketable drugs are ones that have a long patent life with good financial returns. Drug companies have no prerogative to the patient themselves, they don’t recite the Hippocratic Oath (do no harm) and they don’t have to look the patient in the eyes if things go wrong. The quality of “Educational materials” used to entice physicians to prescribe their marketable drugs varies dramatically. Physicians must keep in mind the ultimate goal of the rep is not altruistic medical education – their goal is the same as for any other business: to make money. A new tactic employed is acknowledging the utility of competitor’s medications in a thinly veiled attempt to appear impartial; however the entirety of the session will almost inevitably end with the superiority of their product.
Many physicians validate their interaction with drug companies through the supply of free samples. Samples can be used for patients who cannot afford to purchase the drug and in many offices serve an important need. As above, sample meds are not an altruistic attempt by the drug companies to treat poor patients. They are intended to get patients or physicians hooked on using their most expensive or marketable drugs. Once the sample runs out, the patient or insurance company will have to pay to continue using the med. Also, the physician gets comfortable using the samples and then starts prescribing that drug more to patients who can afford it. Not to mention the huge amount of waste associated with drug sample packaging.
I think it’s important to reiterate I don’t believe drug reps are bad people or that pharmaceutical companies are malicious (though some have been found guilty of misleading the public). I do believe that drug company representatives, drug company handouts and drug company sponsored medical education can get in the way of the most important interaction in medicine: the trust patients and their families place in their doctors to act in their personal best interests. For me, this is too important to sacrifice for a free pen or pizza lunch.
For more on this topic, see Healthydeabte’s article Doctors & Drug Reps: Prescription for Trouble?