As far as $4B of marketing money being spent in a year, I’m not sure where you’re getting those figures from. Most pharma companies spend about 33% of their gross on marketing costs and about 15% on R&D. (Note that either one of these figures would be above $4B for just one big pharma company like Pfizer)

And to the person who says that a doctor’s business is not only about the almighty dollar, that might be true for some of them. It is not true for all of them. For every rep who’s out there after a script at the expense of the patient’s health, there is a doctor doing worthless aesthetic procedures, selling magnets or running some other tangential business to add $$ to the bottom line.

Drug reps make me feel dirty.

http://www.nofreelunch.org

If we have lost our ability (or more likely, simply fail to exercise it) to critically evaluate what we’re told by drug reps, that is a moral failure on our part. And we need to change our ways.

We all have conflicts of interest affecting our professional life all the time. Different ways of paying physicians simply alter them without removing them. A sandwich or a pen do not strike me as creating unacceptable conflicts. To suggest that they inevitably must is to infantilize us. I wouldn’t cry if all gifts were forbidden, no matter how small, but that would make the drug rep’s job almost impossible. I think we should focus on discouraging and avoiding wrongdoing rather than the avoidance of “even the appearance of conflict of interest”. That standard has not noticeably improved actual ethics in business, government, or any other realm so far as I can see.

You are correct, life is full of contradictions and hypocrisy. I will leave the curriculum discussions to the academics.

Tom and you both make the valid point that pharma serves a purpose, in our current environment, where we expect medicine to include a business component. The problem arises, as you both point out, is when the doctor looses that critical component of what the drug rep is selling. All to often in their busy schedules, doctors do not read the literature, tear apart an abstract, or even solicit feedback from their patients.

This is the issue I think many of us contend with, how to bring doctors back to the critical thinking stage were they question the information they are being given. My business experience tells me this interaction is tainted when the sales rep has a position of prominence in the doctors information stream. The easiest way to do this is to remove the drug rep from the office environment.

This will not solve the problem, as you pointed out and any number of current cases exist, where the academic and professional journals have questionable ties to pharma which the are not disclosing. The leadership in medicine, in many of our most prominent institutions, do not feel a need to disclose their financial ties as they now feel this is business as usual.

Medicine is a zero sum game that consumes well over one trillion dollars of our GDP. We cannot devote more of our national resources to this portion of our economy without causing problems in other areas. b and I see such number as the $4B spent on direct to doctor advertising and see where these funds could be shifted to research or helping the poor. What would be the impact of $1B injected into the medical system be from just a 25% decline in this marketing area? PBM’s are restating earnings due to Zocor going generic. $39B of drugs are going generic in the next couple of years, how much money will that free up in the system?

b’s point is a good drug will sell itself. Tom’s point is the “me too’ create pricing pressure. Both points have merit and as long as doctors view all of the information with a critical eye this is a good system. My experience, and the experience of others is, doctors have lost the ability, due to time and other pressures, to be critical of the information they are receiving from the drug reps.

The key is for you, and other doctors, to remain critical of the information you are being given and do not allow even the appearance of conflict to enter your office. As you pointed out, your time belongs to your family and your patients, not the drug reps.

Steve Lucas

I am sorry if my use of the word “fascism” offends you. I, too, am of Jewish descent (Sephardic) and our family, too, knows the meaning of the wordin a very intensely first-person way.

Nevertheless, when I see medical school Deans, Dept Chairs, and other academic medical “literati” demonizing Pharma, all the while polluting medical school curricula with all sorts of nonsense aimed not at furthering the education of physicians, but instead, winning NIH/HRSA/AHRQ grants I cry “hipocracy!”

There is a lot of “influence mongering” in health care and medicine; there will never be any escaping it in an industry demanding as large a chunk of our GDP as it does… If medicine is to indeed be an autonomous profession than we to be self-aware, self-responsible, and self-critical and not look to Big Mommies and Big Daddies to help us sort wheat from chaff.

It is not a fall from grace for physicians to “bite from the Forbidden Burrito of Knowledge,” every so often at a noon conference, just because it happened to be purchased for our consumption by a Drug Salesman.

Drug reps are indeed not high priests/priestesses of science; but the good ones make the best case they can within the constraints of the truth. Their companies want to make money, in exchange for a good product. So do we.

There is no doubt that drug reps influence us (I wish db and others would stop announcing this as if it were a momentous discovery). And in medicine such advertising can lead to bad outcomes—if physicians are uncritical or venal; or if such advertising is positively mendacious. Yet if drug reps play by the rules, physicians likely learn about new drugs that they would not otherwise learn about; outside, that is, of academic medical centers and other settings where they have the time and incentive to keep up with the literature. In the world of practice it is doubtful that many succed in keeping up. So that practicing docs learning about unfamiliar drugs and using them appropriately is the good outcome of pharmaceutical advertising. The question is whether advertising influence balances out in favor of good or bad overall in this particular venue; as its influence is undoubtedly good (meaning that prices are lower and consumers get more of what they want) in others.

Those such as db and commenter b who don’t like drug reps appear to wish that pharmaceuticals weren’t part of the market economy or the business world; and that we physicians weren’t either. Yet medicine has always been business as well as profession, especially in America. And its business-like aspects are not necessarily a bar to integrity and professionalism. Physicians interacting appropriately with drug reps is not only possible but is something that medical educators ought to teach. And those who wish to declare drug reps persona non grata owe the rest of us an explanation as to how new drugs are to be developed, manufactured and promulgated to doctors (not marketed, heaven forbid!) outside of the market economy.

I must take exception to the use of the word fascism. This was used in a previous post as a cheap sales trick to manipulate the discussion. The use of this word is designed to elicit first anger and then a defensive position. Anger is designed to get the discussion off point. Secondly you then have one of the parties trying to defend an ever changing position. This then allows one party to control the tone of the conversation since one person is trying to “prove” they are not fascist which ranks some where near “Do you still beat your wife.”

A generation ago a Jewish friend told me every Jew in America had lost someone in the Holocaust. I have met people who escaped Italy in the 1930s. My father-in-law is a WWII veteran. A Ph.D. from Yale divinity often reminded me of the equal number of priest, ministers, educators, politicians, an others who could speak out, who were killed in the camps.

This is not a word to be used lightly, and is a word that should only be used in a historical context.

Since you are sure of your position, I might suggest you print out the original rant with all of the comments, and show them to someone at your medical school. I am sure they will see the value in your position and you will prompt some very interesting discussions. After all, I am just an aging business guy who never had a critical thinking class, so I am sure they will see the merit in your position. As you stated, you don’t need someone like me setting your business standards.

Steve Lucas

BC information intermediaries are called CMEs. And Journals. And colleagues. The cost you are paying your doctor should include time spent learning new information and refreshing old information. However, because most primary care doctors are so busy, they can’t keep abreast of everything. So you the public might need to revise their expectations about what primary care doctors can know (third line treatment for metastatic sarcoma is not one of them) and about what they should be paid.
b