Again, I think we're arguing different things. Personally, I don't care if we ban consumer advertising of drugs, but it's a small percentage of spending -- 1% of revenues. (Though to be fair, as a friend in pharma points out, physicians also prescribe cpntraindicated things that aren't advertised because they won't tell the patients no, like antibiotics for colds, and "I want what my friend's taking"; it's not really fair to blame the pharmaceutical companies for all those arguments, but physicians often do.) And an advertising ban would seem to be a more effective way of doing this than cutting revenues by 40% and seeing what happens.

I mean irrational in the sense that we tend to overweight what is very vivid to us. Physicians experience the marketing and assume that a) it is cost ineffective and b) it is very, very expensive and a lot of money could be saved by cutting it. These assumptions are questionable. But of course they're perfectly natural if you're attending expensive dinners, and have no idea how a pharma balance sheet works, which most physicians don't.

As for the track record, I'm taking material out of school, where we read med school and public health studies showing that fewer than 25% of physicians will independantly track recent studies on drug effectiveness (positive or negative), medical devices, or updates in the state of the medical art. It gets worse as they get older. Now, you're in a teaching hospital. But most physicians aren't; they're in small private practices. They're tired. They have kids and dogs and billing and dammit, haven't they earned the right to relax? What goes is the time spent reading literature. . . and of course, once you've skipped one generation of literature on a subject, it's very hard to follow the succeeding generations. That's why sales reps are effective and mass mailings aren't. Now, you think that you'd keep up with all the new drugs if no one was shoving them in your face -- but if each rep was replaced by a stack of literature on each of the drugs they sell, c'mon -- how much of it would you really read? How much of what you get sent and handed do you read now?

As for the rest, you're still arguing about what the pharmas should do. I'm arguing what they will. And I don't think you can successfully regulate marketing, other than on a very broad-brush ("No consumer ads") basis. Anything else will have costs, in terms of resources spent on court and compliance, that would far outweigh any benefits.

But on the legal issue we can both agree; the patent games are ridiculous. (Though I would point out that "me-too" drugs actually push down drug prices, so they're good for consumers, not bad. Except in the case of drugs like Clarinex, which are the same company trying to protect its patent.)

Jane Galt makes some interesting points. We do seem to talk about different problems. Could be a Mars - Venus thing.

My objection to direct to consumer advertising has to do with the effect on the doctor-patient relationship. I understand that it does not cost the company a high percentage of costs. However, it causes me much aggravation, and possibly undermines my relationship with patients.

I do understand that the companies would not spend money on dinners and such if they did not get a reasonable return on that investment. I think that is my point, the do influence physicians, and not always positively.

On the issue of continuing education for physicians, I agree that we need to address this better as a profession. I disagree that pharmaceutical reps are an answer. They are salespeople, not educators. They spin faster than James Carville. We (the profession) need to address continuing education in positive ways. At our institution, we are doing research, trying to learn how to help physicians stay up to date. But time is the problem (as I have stated many times). We need enlightened evaluations of the economics of outpatient practice. We spend so much time seeing patients, we have little time for education.

db,

What would you think of changing the FDA's mandate to determine safety only and let doctors determine efficacy? I favor it. Big time. Doctors can become complacent and rely on the FDA results rather than using their own observations on the ground to determine whether a drug works.

Robert

Great comment. Here is my problem. I am not sure how we can determine efficacy. Efficacy studies are expensive. The NIH rarely funds such studies. Many drugs have significant side effects, but the benefits greatly outweigh the risks.

I would like some evidence of efficacy, but do not want the pharmaceutical industry doing the studies. Could we charge a fee for new drug application (after safety is shown) to fund independently designed and performed studies? This would disentangle the marketing from the study design (and those 2 are entangled), give physicians data, and allow the right studies.

I also believe we should do this for medical devices.

So you want to charge pharmaceutical companies money to do studies that will cost them business? How about charging doctors a fee to find out where nurse practicioners are more cost-effective? After all, don't doctors have a moral obligation to make sure that Americans get the most cost-effective treatment they can, regardless of what that might do to their own personal incomes?

Think the AMA would let that pass?

I presume that we're talking mostly about new uses for off-label drugs, since the pharmas already have to prove efficacy of patent candidates to both the patent office and the FDA. In which case, why is that some special responsibility of the pharmaceutical companies? Because those bastards, having dared to produce new drugs, ought to pay for the privilege? It strikes me rather like Superfund -- why should GE pay to clean up sites it didn't produce merely because it is a "big business"?

Great - now we are getting to the issues! Please check my long post ( Doing the right efficacy studies) today for a more complete presentation of this idea.

I'm concerned about the entire FDA process. Drug companies have minimum requirements to meet. They meet them, but we do not gain as much medical knowledge as we (physicians and patients) need.

While I do care about the economics of the industry, I wonder how we should respond to an industry with remarkable patent protections. As a physician I worry about patient care, their ability to pay for medications, and what is the best medication to prescribe in a circumstance.

If we truly had a free market I would be happier. We have a regulated market, therefore I want to change the regulations.