“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?
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Great piece! McMaster was the first medical training program to be so brave as to ban drug reps from sponsoring medical education events in recognition of the pharma concerns you cite above. BC was the first province to restrict medical device reps from entering operating rooms (why should the Stryker rep be in the OR observing a procedure without patient consent anyways?). More institution and government led restrictions are needed to enact change.
Ritika – some good ideas. Would love to hear more about this therapeutics initiative. Do you have a link or further info for those of us interested?
Danyaal – Agreed. Great (and cheap) solution for one of the most commonly cited drug rep benefits.
Mark – further example of how entrenched industry is in our day to day practice of medicine. Often to such a degree we can’t even comprehend. Sometimes its not as easy I guess as denying drug reps access to your office. We do the same thing in hamilton specifically with proton pump inhibitors (PPIs). Everyone’s PPI gets changed in hospital to one specific brand (that the hospital has negotiated with a specific company). THen the idea is we’re supposed to change back when they’re discharged but it hardly ever happens. They end up going home on the one they were changed to in hospital.
Great point Donna.
Thanks everyone for the insightful comments. Much appreciated.
Gail. Thank you for your comment.
I think the easiest answer for physician education and continuing medical education is to put it into the hands of the academic centers or universities as they are often looked upon as the last bastion of unbiased information (although this is at times the furthest from the truth).
It gets harder for small town or community physicians.
Ultimately there are many unbiased sources of information/education that physicians can turn to but it often requires more active investigation, literature review, etc (overall more difficult than someone who is coming to your office with info in hand). Government/charity groups such as the diabetes foundation, kidney foundation, alzheimers society are good resources as well although each of these organizations usually lists large pharm companies as a big contributor.
There is no easy answer unfortunately. Love to hear what others thing as far as solutions.
Remember that these companies do not market only medications to doctors and other prescribers, but also sell infant formula, medical equipment and supplies. All those free note pads have large pharmaceutical company logos on them and often a particular medication; this uses prescribers as vectors for advertizing their other products.
If it didn’t work well the pharmaceutical companies wouldn’t spend all of this money on targeting prescribers. It is folly to think anyone is immune to the influence of a lunch, free pens and items, free samples to hand out to patients, and little “new baby” packets to hand out.
Great commentary. The idea of “free” should extend to institutions too. I’ve heard reports of hospitals being given drugs at a reduced rate for use in the hospital – and many patients obviously are leaving hospital started on a new “free” medication – until they need a refill, then their family doctor given that the patient has already started one medication is likely to continue it.
I don’t know if this is true, or if it is a current practice, but it should be outlawed. it preys on the financial challenges of hospitals and limits choice and options outside of the hospital.
Thanks for writing this Bram. The free sample argument is the one I come across most in discussions with colleagues. A few years ago at Family Medicine Forum, a family doctor from Saskatchewan gave an excellent talk on the dangers of pharma supplied free samples. He outlined many of the same issues you have. As an alternative, he and his colleagues set aside a few hundred dollars each month and purchase common generic meds for their patients without adequate drug coverage. It’s a minimal cost and diffuses the ‘altruistic’ justification for interactions with pharma reps.
Thanks so much for addressing this extremely problematic and sometimes taboo issue. I think Step One is getting physicians to really open their eyes and stop hiding behind claims that they are impartial and unaffected by drug company samples, promotional materials and educational sessions. The studies very clearly point to us being influenced by all of these (just seeing the name of a drug on a pen, giving it as a free sample to your patient so you learn the dosing) and you very importantly stated that the drug companies are not stupid – they wouldn’t put money into these things if they didn’t get more than enough money back in profits. So what do we need to do? We need to kick pharma influence OUT of our offices. This means NO pens, NO mugs and yes, NO free samples. If we still feel these things are harmless, the other factor to consider is – all these expenses come out of the drug costs in the end – so who’s paying for your pen? It’s not pharma. It’s your patients!
The second step is having evidence-based methods of choosing medications – BC has done a great job with the Therapeutics Initiative and managed to keep drug costs lower than other provinces. We should be making prescription decisions based on what is best for our patients AND most cost-effective – physicians don’t know drug prices at all – this needs to change. For family docs, Rx Files is very useful for this as it includes cost information.
Finally, we need to consider how we can increase our purchasing power to drive down drug costs and pharmaceutical company power. This means considering support for a national pharmacare program – most OECD countries pay for drugs for their people, Canada is the expection, not the rule. Marc Andre Gagnon’s report found that we could save 10.7 billion dollars if we had a national pharmacare program simply because we can fight for lower cost drugs (one of the fastest growing costs in our healthcare system).
There is much that can be done. But it involves us coming together and actually doing it.
Nicely and succinctly put, Dr Rochwerg. I agree with all your points, and am left wondering, what’s the solution? Do disease area focus groups exist who could impartially compare competing meds?