Sunday, September 25, 2005

Should we throw the bums (drug reps) out?

The medical blogging about the dispute between No Free Lunch and the American Academy of Family Physicians has been mostly favorable to No Free Lunch. I am glad to see that AAFP has finally decided to allow No Free Lunch (NFL) to exhibit and I hope ACP follows suit next year. I believe in a free market place of ideas, and theirs deserve to see the light of day.

I said before that while I agree with the basic premise of NFL (“that pharmaceutical promotion should not guide clinical practice”) I am concerned that some of their positions are extreme, or are taken to extremes by their supporters. My intention here is to state my specific areas of concern and issue a call for moderation. (Disclaimer: try as I will to avoid the straw man argument, I could be perceived as misstating the NFL position. NFL has eloquently stated its principles, but with the possible exception of the pledge these principles have not been codified in any formal way. As I express my concerns I realize that the opinions of NFL supporters occupy a spectrum. If this shoe doesn’t fit don’t wear it).

One of my differences with NFL lies in the distinction between skepticism and cynicism. At a recent CME conference at McGill Dr. Jerome Hoffman, professor of emergency medicine at UCLA and a supporter of NFL, pointed out the difference between these two approaches to evaluating claims and evidence. The cynic, he said, seeks to knock everything down; the skeptic, by contrast, thinks critically and questions claims, but all the while with an open mind. Webster defines the cynic as “contemptuously distrustful of human nature and motives” (italics mine). My perspective about the pharmaceutical industry is skeptical, while I view the attitude of many NFL supporters as cynical.

The cynic’s position might be that the drug companies care only about their stock holders, never have the public good in mind and that their interests are always in conflict with those of patients. The cynic might feel that the medical profession should have no interaction with the industry and never believe anything they say.

As a skeptic I believe that while there are conflicts of interest, in perception and in fact, the interests of the drug companies are sometimes but not always in conflict with good patient care. (Good patient outcomes can help increase profits). Unlike the cynic I believe win-win situations are possible. My skepticism says not to believe everything they claim and to always check primary sources. However, out of hand rejection of every claim based solely on source (the ad hominem fallacy) is unreasonable.

What about the practical consequences of the NFL objections? Are we ready to give up industry supported CME? I enjoy attending CME meetings. Although I can do without the pharmaceutical company exhibits, were it not for partial industry support the registration fees would be prohibitively expensive for many meetings. Not all physicians are wealthy. Those who attend AAFP and ACP meetings are among the least likely to be wealthy. I dare say many would not be able to attend at all without industry support.

There are other examples. Many of us enjoy (and often link to) emedicine and Medscape. I don’t want those free resources to go away. What about all the open access medical journals which would not survive without pharmaceutical advertising?

So to those who want to “throw the bums out” I urge caution. This highly nuanced issue does not lend itself to simplistic ideas.


Anonymous said...

I appreciate your reluctance to condemn the drug companies outright.

That's why I think it's important to be very precise about what (many) supporters of NFL object to: the provision of gifts to individual physicians by pharmaceutical companies.

The pharm industry could, for example, sponsor CME conferences without engaging in gift-giving by simply charging a low fee across the board to any physicians that wanted to attend. The industry could pay to put the content of the presentations on the internet.

The problem with gifts or "sponsorship" of individual physicians is the unavoidable expectation of a quid-pro-quo. Generic sponsorship of educational activities doesn't present this problem.

From what I know about NFL, I don't think they'd object to general sponsorship. (As you say though, some of their more zealous followers probably do...)


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 doctors’ prescribing habits by the drug rep. And no embellishments stated by reps actually sounds pretty good for any medical community.

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 Santa in a nice suit, when they want to be much more, but are not allowed.

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

Author’s note: What has been written has been based upon information and belief.