TANSTAAFL

Its all about data.

There is data that free lunch influences doctor’s behavior. If our primary goal is to help patients in a tranpsarent fashion, we shouldn’t be accepting food if the patients are paying (indirectly) for that food. Imagine you are a patient and your doctor writes a script for lipitor when mevacor will do and you find out that the difference is $100 per month. Then you find out that everyday someone from the lipitor company is paying for lunch for the doctor and the entire staff. “Doctor, can I have mevacor instead?”

This is not make believe. It is reality. We should all stop doing this immediately as it is a shameful embarassment not just to the patients, but to ourselves. It is one thing to trade our services for money in a pre-arranged fashion through an insurance plan. It is another to gimmick our way into a few more dollars in a way that is not transparent and underhanded.
b

oskie,

I think you miss the point. b has hit the nail on the head. Physicians have a fiduciary duty to their patients to deliver unbiassed information, not only about their health, but also cost effective treatments.

My wife is a government employee and is not allowed to receive anything of value. She is only allowed to participate in group activities where all those present receive the same item. i.e. breakfast. SOX brought about disclosure in the financial world, as conflicts were found in brokers recommendations to clients. Limitations are placed all the time on a persons business activities.

Free food has taken the place of event tickets or outings where the drug reps has access to the doctor in an out of office setting. This is not some nice once a week get together but a daily routine in many offices. One sales technique is to try and monopolize a doctor’s schedule so that competing reps do not get a chance to get their foot in the door.

In my wife’s ob/gyn office each rep has a day and a time to supply a specific preordred meal. The office claims they need this contact to get samples. This office is in the highest income section of a major city. They are not serving the poor.

Big pharma is always looking for a loop hole. Nobody is stopping the doctor from kicking back after hours and buying the drug rep a beer.

Steve Lucas

Steve,

Similarly, no one should be trying to stop the drug rep from buying the doctor a beer.

You and b are fundamentally misunderstanding what a “feduciary” is. A fiduciary duty is the highest standard of care imposed at either equity or law. Because of this high standard, these roles are explicitly defined in contractual relationships between beneficiaries and trustees. You would not want to wake up one day and discover that you were involved in a feduciary relationship that you didn’t know about. Similarly, it is difficult to conceive of a scenario where you would be forced into a feduciary relatiionship in the role as the trustee without your explicity knowledge and consent. Seldom do trustees violate feduciary relationships unknowingly. That is what makes these violations all the more grevious; the roles are so explicitly defined between between the principal and the trustee that any defense of “non-knowledge” is laughable. If your real estate agent convinces you to sell your home your home to him (or his associate) below market value and then turns around and sells it at fair market value the next day and pockets the differences (on top of charging you a comission) that is a violation of a feduciary relationship. If your stock broker persuades you to buy junk bonds with knowledge that they are are going to be worthless next month, that’s a violation of a feduciary relationship. In feduciary relationships, the trustee has a defined measure of influence over the beneficiary’s finances, assets, or properties.

This is not what happens when an unethical physician prescribes an overpriced medication of dubious or unclear efficacy after a drug rep bought him or her lunch the day before. The physician, albeit in a position of influence over a patient’s finances, assets, or property. That’s why you should never give your patients investment advice or stock tips.

Because physicians commonly consult with Pharma or attend events sponsored by Pharma situations arise where physicians may have a legitimate conflict of interest. This conflict is far subordinate to the feduciary relationship defined above. Many conflicts of interest are unavoidable on a pragmatic basis. That is where codes of ethics come in. Codes of ethics help to minimize problems with conflicts of interest because they can spell out the extent to which such conflicts should be avoided, and what the parties should do where such conflicts are permitted by a code of ethics (disclosure, recusal, etc.).

Many physician groups (including the AMA) have developed codes of ethics and physicians should follow them. You are welcome to hold yourself to a higher standard, but you are not legally nor professionally entitled too. Still, if your colleagues are within the parameters of code of ethics developed by which ever professional group they feel most allegiance to (AMA or specialty society), then you should really keep your nose out of their business.

If you’ve never taken the time to read the AMA guidelines for managing these relationships, you make take a moment to do so. They”re on the AMA website.

E-8.061 Gifts to Physicians from Industry

Oskie,

I am not a doc, I am a business person. From that perspective any time I pay, or someone pays on my behalf, a fee we have created a contractual relationship. Inherent in this relationship is the creation of a fiduciary relationship given the doctors superior knowledge and their holding themselves out as an expert. My expectation is for them to act in my best interest.

As far as the AMA goes less than 1/3 of doctors belong. The AMA tracks a doctor’s career from the time they enter med school and then sells this information to the drug companies to the tune of millions of dollars per year. Many people would consider the AMA nothing more than political action committee or lobbying group.

You are right, a lot of this is silly. Many of us consider lunch incidental to doing business. The problem is pharma has levered this into a scheme to exert as much influence as possible on their client base, doctors. They then use DTC ads to drive demand from the patient.

As a patient, I saw my now former doctor become a captive of this system, with her office procedures reflecting this sales mentality and her prescribing only branded drugs, no generics.b’s point is still well taken, if a doctor does not want to appear to be influenced by pharma then simply skip the food and keep the meetings on a professional basis.

Drug samples are the number one influencer of your prescribing habits:

Published on: http://www.pharmagossip.blogspot.com
You Have Now Been Sampled
While the pharmaceutical industry’s image and reputation has and appears to continue to suffer, added damage has expressed itself with costly patent expirations with certain corporations within this industry. As the president of the lobbing group for the industry which is called PhRMA would likely concur to a degree if asked, the image of this industry has experienced noticeable trauma over the past two decades in particular, and for solid reasons. We will start with the issue of samples.
Quite remarkable, and apparently legal, is the ability of prescribers to request branded pharmaceuticals from the makers of certain medications if a prescriber obtains a request form on the internet, for example. This, of course, bypasses representatives from the various pharmaceutical companies. For possibly a number of reasons, this avenue is rare for obtaining samples, as it is not offered by most pharmaceutical companies.
So even though the value of requesting samples of medications by prescribers is, apparently, an authentic method of obtaining samples, it appears that most pharmaceutical companies prefer to have their own representatives dispense samples of their promoted medications. This also allows for the release of inducements to certain prescribers that are of a much greater value than drug samples, which they believe affects the image of their products and its preference for them related to the inducement they may have accepted from you, which does not seem to be the situation always when it occurs.
These sales forces of pharmaceutical companies have been examined more now than in the past due to their size, for one reason. The size of the sales forces of large pharmaceutical corporations tripled at one point, starting in the mid 1990s. Also, estimated total income for an individual pharmaceutical representative may exceed 200,000 a year. Overall, the amount spent on these reps exceeds 20 billion dollars annually.
Sadly, and with a high degree of confidence, most big pharma representatives are viewed and evaluated by their employers as it relates to their offering of prescriber inducements they may provide to targeted prescribers, as their ability as a sales representative is difficult to determine, since most with big pharma have several representatives visiting the same doctors with identical blockbuster promoted products. In fact, one could conclude that an individual representative in such a work environment is ultimately exonerated from any individual responsibility in regards to their vocation, which is one etiology of the premise that they are judged by their employers according to how much of their employer’s monetary surplus they dispensed in a certain period of time. This will be further addressed later. Yet the inducements are never described by what they actually are, which are bribes. Who receives these bribes is largely determined by the volume of scripts they write, as well as their loyalty to a particular pharmaceutical company’s products. This data of the prescribing habits analyzed by certain pharmaceutical companies is certainly available, and this will be further addressed below.
However, and empirically, the drug sampling of doctors may be considered an ultimate if not primary type of an inducement of certain representatives. Some pharmaceutical representatives are falsely led to believe that their territory’s performance is due in large part to their powerful ability to influence others. Although such pharmaceutical representatives want to believe such a false premise, it is samples of medications that determine the prescribing habits of health care providers. This is obvious now more than ever.
Many years ago, drug reps used their persuasive, yet ethical, abilities to influence the prescribing habits of doctors in an honest and credible manner, as they focused on the benefits for the doctor’s patients with particular drugs that the detailer may promote to such a doctor. However presently, most health care providers now simply preventing drug reps to speak with them. This is especially true when they are in clinic treating and assessing patients. More and more medical establishments are completely banning drug reps from their locations, and I speculate that this is occurring for many reasons, which may include the following:
The doctors lose money. Doctors are normally busy, so their time is valuable. As a drug rep, you are an incredible waste of their time. Yet they will accept your samples still. The credibility you possibly have thought you had and were perceived as such by doctors as a drug rep is no longer viewed to exist to any noticeable degree by the prescriber.
Based on information and belief, the prescriber’s perception of you as a drug rep is you only provide information that is presumed by them to be overall inaccurate and void of authentic objectivity related to your promoted products as a pharmaceutical representative. This view is due to the frequent statistical gymnastics the employers of drug reps engage in way too often in relation to the clinical benefits of their medication illustrated by what is likely biased data.
Doctors by their very nature seek answers objectively. And doctors do in fact find out about drugs through other methods besides the representative of the drug’s maker, such as the internet and experience with certain medications, because of their awareness of the lack of authenticity of certain medications combined by the absence of credibility of the representatives of such medications. This is further illustrated by reps being selected by pharmaceutical companies due to their perceived appearance and personalities judged by certain employers. Further trait desired is their candidate’s potential and complete obedience in relation to their directives to them, which is expressed by the displayed affinity for money from a potential candidate. Qualities related to anything of a scientific, medical, or clinical nature is of no concern to most pharmaceutical companies, quite apparently.
This is why pharmaceutical representatives have no interest or concern regarding public health, perhaps. This premise is further validated by their employers’ minimal concern regarding the medical knowledge of their sales representatives, as this is replaced with teaching their representatives on how to issue various inducements to select prescribers., yet are just shy of calling these inducements what they actually are, which are bribes. Examples may be creating a check from your company to a certain supporting doctor and handing this check to thank a doctor for supporting your company’s products for doing little, if anything, for your employer to justify this check. Knowing this, it seems to validate their apathy regarding the medical knowledge of their sales representatives, while emphasizing obedience of them instead, which does not allow them to examine what they are told to do by some pharmaceutical companies, which may be viewed as inappropriate inducements to select prescribers.
In relation to non-monetary inducements given to certain prescribers, they may be of a certain value and are possibly without any clear medical benefit, such as TVs or DVDs, perhaps. And the autonomy that exists with some pharmaceutical companies allows such activities of legal or ethical consequences to be applauded by them to certain representatives of theirs as examples of innovation or creation by representatives who implement these activities. This appears to eliminate the need to examine the consequences potentially of some activities and tactics encouraged by certain pharmaceutical companies.
Another issue is what is referred to as data mining, which is a determining variable as it relates to who a pharmaceutical maker may choose to support financially, as determined by this data available to them, which authenticates the prescribing habits of others. When a pharmaceutical company issues such a reward, that takes many forms, the pharmaceutical maker, which is often very large and lucrative, alters their relationship with certain prescribers into a pathological symbiotic relationship of one that is focused on the continued monetary gain presumed to be of one that is great benefit to the maker of such medications. By doing this, the maker has not even allowed in a conceptual sense to be of an entity of any medical benefit of others ho to reward via numerous financial incentives for supporting the medical products produced and marketed by the gift giver, as this product maker often manifests itself into a creator of a quid pro quo relationship through what could be considered a pathological form of symbiosis that becomes a destructive host upon its creation by such companies. The receivers of such corruption are determined by those pharmaceutical companies that analyze this prescribing data, which is available to them starting with the selling of various identifying numbers of certain prescribers that are made available through the selling of these identifiers for the monetary gain of the providers of this data, which starts with the American Medical Association. Further disturbing is the fact that this behavior is not prevented by our lawmakers. In addition to pharmaceutical companies determining the supporters of their medications, the data also allows these companies to select certain prescribers that are of high volume, both of particular disease states and overall frequency. Because this variable allows a pharmaceutical company to conclude who could potentially affect their business and therefore dispense their financial stimulus methods accordingly. This allows certain pharmaceutical companies to create reciprocal relationships in addition to the anticipated continued prescribing habits of known supporters of certain drugs provided by and promoted by their makers.
Conversely, if a prescriber is determined by a pharmaceutical company to be harmful or of minimal financial benefit to a pharmaceutical company in relation to its promoted products, such a prescriber is often determined by such a company to be ignored by such a company, which includes any items of benefit to the health of others become forbidden and without access to such prescribers, which could include samples to such a prescriber as well.
While such unethical activities may appear to be ridiculous and without reason to some, this does not mean they do not occur, as the apparently unethical behaviors of certain pharmaceutical companies seem to be unbelievable by others on occasion. Furthermore, such tactics may cause an outbreak of corruption by other similar organizations, perhaps.
For example, possibly as a response to some tactics of branded pharmaceutical companies, some managed care providers are giving financial incentive to prescribers if they choose a generic medication that is typically less expensive than the branded variety. While legal, this activity is overall unknown to most citizens. However, such activity makes them no different in their approach to health care than certain pharmaceutical companies, as both affect the sterility of the judgment of some doctors who accept these inducements.
It seems that external regulation is necessary to prevent the drug companies from allowing the autonomy of drug reps and their own often secretive tactics that are utilized by some of the companies in the pharmaceutical industry. To many, it is rather obvious that internal controls of companies that perform such wrongdoing, are void of self-regulation, and choose to be this way with deliberate intent. If regulation happens, then it may be possible to resurrect the ethical element necessary as a participant in the health care system. The importance of public health should be the apex of their existence as a company that participates in this system..
Overall, pharmaceutical representatives are good, intelligent people who perhaps do not realize the results of actions that many consider to be unethical. Yet they do as they are told in order to maintain their employment, yet may compromise their integrity at the same time- as at times these methods implemented by members of the pharmaceutical industry with progressive frequency may result in a toxic culture and environment of certain companies that create with force certain representatives who perform activities that may be against their desire as a person.
I believe most reps really WANT to do well for their employers, yet are prohibited from doing so now because of how their employers are now viewed in their medical community, in relation to any contributions they may appear to make, which is not in the best interests of the patients, overall. Ethics once associated with this industry have atrophied over the past decades, and the result is the pharmaceutical industry is no longer viewed as a segmented type of a corporation, yet is unfortunately viewed as one with the objectives of greed and profit, and there are no exceptions of this perception that has been known to members of the pharmaceutical industry, yet have refused to shift their own point of view regarding this accurate premise the public has of them

Fear ensures loyalty.” — Author unknown
Dan Abshear (what has been written is based upon information and belief).