Thursday, January 25, 2007

Conflict of Interest

Ok, ok. I guess I started this hot button topic. So, I should at least follow through on it. I should preface this post by saying that I am in no way, shape, or form - in a position of power in any health care policy organization. So, don't expect a polished statement. I'm just a peon in this mammoth health care system.

In discussions like this these, three questions always come up: How much does pharmaceutical marketing tactics make you prescribe their drug? Is this fair or unfair for your patient? Is this a conflict of interest?

Of course marketing tactics influence my prescribing habits! There have been many studies done to confirm this fact. This data is used by this medical school to forbid its docs from accepting any freebies from drug reps. This data is also used by this organization to advance its agenda of a zero tolerance policy of any acceptance of drug company free stuff.

Don't get me wrong, these are not the only groups who have this point of view. In every major medical organization in the US, there is a group of docs who want to absolve themselves and all medical organizations (like the American Medical Association) from all pharmaceutical funding - meaning that organizations like the AMA should accept NO FUNDING whatsoever from drug companies - because of conflict of interest.

While I understand these arguments, I disagree with them. (And, no, I'm not on the payroll of any drug company.) I think taking such an extreme point of view is not going to help them achieve their goal. I'll be curious to see follow-up studies at "that medical school" to see if removing drug rep freebies changed prescribing habits.

Drug reps and drug company marketing are always going to be there. There is no avoiding it. A few years ago, drug companies wised up and marketed directly to consumers - taking the doc right out of the loop. So, even if you ban drug reps from your office, patients always come in saying, "I heard on television to ask you about drug X." That's marketing getting at you a different way.

Even though I had my pissy rant yesterday, drug reps definitely do serve a purpose (and not just to give samples of meds). If for anything else, they serve as an information resource for me. Now, this is a biased resource. But, I know that going in. I work 12-14 hour days sometimes. I don't have the time to keep up on the latest medical research. I'm a clinician, not a researcher.

Through my medical school training, I've been taught to question all information that is given to me - whether it's a patient's vital signs, or physical exam, or lab work, or whatever. These skills I use when talking with reps about data they give to me. The pearls of info I receive during these interactions help me to make a more informed decision on prescription drug selection.

Finally, is this fair for patients? Fairness is always in the eye of the beholder. In my opinion, when you boil down the issue to its essence, it just comes down to the strength or weakness of the patient-physician relationship. Not only should the patient feel comfortable enough to express their feelings on this topic, the physician should be ready to listen and explain her/his point of view in a non-judgemental way. I didn't say it was easy, but it is necessary.


Anonymous said...

Absolutely. Dr.s know which drugs are best, and working with drug and other medical supply companies helps to provide a better service to the customer. Hospitols need to have policies in place to keep this under control, but the relationship should not be cut off.

And don't forget that these drug companies are a big part of the reason why patients are living as long and happily as they are. Their ability to sell drugs funds research into the next generation of health innovations.

Anonymous said...

Problem is, if you fail to change your prescribing practices as a result of the detailing, they stop sending the hot women to your office.



#1 Dinosaur said...

I started to comment, but really got going, so I just posted it instead.

Anonymous said...

The thing about marketing directly to the consumer is that usually those ads are really selling the disease first and the cure second. For instance, did anyone before last year ever have "restless leg syndrome?" It seems like a disease no doctor would diagnose unless a patient came in complaining of it.

Thankfully I have a great doctor who told me that my previous doctor had only prescribed a drug to me because there was no generic version available. She since put me on the generic, and it works just as well, and saves me oodles of money. In addition, I trust her now.

Anonymous said...

Thumbs up doc! Glad to read one doctor's views on the subject -- controversial no doubt. Bravo!

Lynn Price said...

Noelle wrote:
"For instance, did anyone before last year ever have "restless leg syndrome?" It seems like a disease no doctor would diagnose unless a patient came in complaining of it."

I couldn't agree with your more. How many times I've had visions of a drug rep coming into a doc's office saying, "You'll be so relieved that We Make 'Em and You Push 'Em Drug Company have come up with a revolutionary drug that will cure the heartbreak of spontaneous nose hair ignition."

Doc's eyebrows rise toward the ceiling, "Spontaneous what?"

"Oh come on," says We Make 'Em and You Push 'Em Drug Co. "Don't tell me you don't have these poor patients lining your waiting room."

"Uh, no."

We Make 'Em drug rep gets huffy. "Fine, I'll take this to the public. They'll demand this drug in droves. We'll get rich, rich, rich by creating a demand. And the best part is that patients won't care one whit that side effects include shrinking a man's penis to the size of a Gherkin and makes their ears turn purple."

Anonymous said...

Noelle, why do you think there's no such thing as restless legs syndrome? Have you ever seen sleep lab videos of people who have this condition? Ever talked to anyone who has RLS?

It's a legitimate problem that for many years was more or less untreatable. I'm sure there are people now being prescribed medication who don't really need it, but that doesn't therefore mean RLS is bogus and the drug is a waste of money.

Let's not throw the baby out with the bathwater here. Drug intervention can be very appropriate *for the people who need it and will derive benefit from it.*

The trouble is, the system doesn't always do very well at identifying who these patients might be. So some individuals get treated who are borderline at best, and others who might really be helped are left to fall through the cracks.

Whatever happened to all the preaching about how the health care consumer should be informed and empowered and ask questions? I mean, we keep being told that we should become more responsible consumers, more proactive and less sheep-like. I have a hard time reconciling this with the fact that so many people want to start restricting the public's access to drug marketing, because, you know, we're just too unfathomably stupid to be trusted with the slightest scrap of knowledge.


Anonymous said...

Hey Doc! Well, all I can say is that since zoloft has gone generic we haven't seen or heard from that rep. And believe me, one less drug rep is okay with me. Kudos on your blog site. I just found you and now you are bookmarked. I'm going to visit you again. So keep on telling it like it is. We need more folks like you...

Anonymous said...

I have no dog in this hunt -- but I'm following the discussion with interest.

Anonymous said...

As the mother of a child with Epilepsy, what really irks me is when a doctor tries to put your child onto a drug that may or may not be right for them simply because they are doing a "drug trial" for that specific drug. I don't think this involves the drug reps per se, but the push comes from the drug industry as a whole.

My daughter's epilepsy is followed by doctor at a teaching hospital, so he is usually up front when suggesting a drug trial. However, once when she went into status as was admitted to the PICU at a different hospital, the first thing the doctor wanted to do was change her seizure meds because they weren't working and that I should put her on X drug because he has all his other patients on it.

Wisely, I called our regular neuro on my cell phone and found out that drug X they wanted to put my daughter on would have made her seizures worse (and here she was already in status!) Later I found out the hospital that wasn't our normal hospital was doing a trial on drug X.

There needs to be reform, I'm just not sure where it begins.

Anonymous said...

And have you seen the direct advertising for the AICD, implanted defibrillator!!?? Hey, Doc, I need one of them thangs, I don't want my heart to stop while I'm playing with my grandkids! It's awesome!

Anonymous said...

Everything I know about drug-reps I learned from Heather Locklear's appearance on Scrubs.

Anonymous said...

Everything I know about drug-reps I learned from Heather Locklear's appearance on Scrubs.

Anonymous said...

Everything I know about drug reps I learned from Heather Locklear's appearance on SCRUBS. Are they as hot and slutty in real life as they are on television?

Anonymous said...

Gaw-dammit. These weren't all appearing earlier. BAH!

Anonymous said...

As a patient though it is such a turnoff to go into a doctor's clinic and see that everything they use has a drug label on it (from the tissue paper to tongue depressors to those tissue sheets on top of the examining table). it makes one feel that the doctor is "owned" by the drug company (ies)

Anonymous said...

Are Drug Reps Really Necessary?

One of the main functions of pharmaceutical representatives is to provide free samples to doctor’s offices presently instead of authentic persuasion, and these samples in themselves cost billions to the pharmaceutical industry. Yet arguably, samples are the most influential tool in influencing the prescribing habit of a health care provider. Let me be clear on that point: Its samples, not a representative, who may be the top influencer of prescribing habits.

Yet considering that drug promotion cost overall is approaching 20 billion a year, combined with about 5 billion spent on drug reps themselves, what if there is another way for doctors to get free drug samples, which is what they desire for their patients to initiate various treatment regimens? What if prescribers could with great elation avoid drug reps entirely?
There is, actually, a way to do this, but it is limited. With some select, smaller pharma companies, doctors have the ability to order samples by printing order forms on line for certain medications through certain web sites associated with the manufacturers of these samples. Some examples are such medications that can be ordered in this way are keflex, extendryl, and allerx. Possibly several more can or are available to prescribers in this way. Others, however, cannot be acquired by this method.

So in some situations, a doctor can go on line, print off a sample order form, fax it into a designated fax number after completion of the form, and the samples are shipped directly to the doctor’s office with some products thanks to their manufacturers who provide this avenue. There is no review of the doctor’s prescribing habits. No embellishments from reps actually sounds pretty good.

Usually, this system is available for those smaller companies with very small sales forces to compensate for what may be vacant territories, but can be applied to any pharmaceutical company who, upon discretion, could implement such a system.

Now, why is this not done more often? Apparently, it is legal to obtain samples in this manner. If samples are the number one influencer of prescribing habits, why spend all the money on reps to deliver samples personally? It’s worth exploring, possibly, since the drug rep profession has evolved into those who become UPS in a nice suit.

Think of the money that could be saved if more pharma companies offered samples to doctors in this manner. Furthermore, additional benefits with this ideal system are that there is no interruption of the doctor’s practice. And again, there is no risk of bias presented to the doctor by a rep, as they would avoid contact with reps if they order samples through this way- to have the samples directly to be shipped to their office.

When samples are shipped to doctors’ offices in this manner, prescribing information of the particular med is included with the samples shipped. Doctors can order and utilize samples according to their discretion, and would be free of interference from the marketing elements of pharmaceutical corporations. Patients benefit when this occurs.
Considering the high costs associated with the pharmaceutical industry, having samples shipped directly to doctor’s offices should be utilized more than it is presently- regardless of the size of the pharmaceutical company.
Something to think about as one ponders cost savings regarding this issue.

“The new source of power is not money in the hands of a few but information in the hands of many.”
---- John Naisbitt

Dan Abshear