The problem of drug reps

My thoughts exactly. One argument I’ve heard about maintaining drug rep visits is that doctors are not swayed by pens and such. But that underestimates the power of the subconscious. Clearly, drug companies aren’t giving away pens because they altruistically want to improve physician penmanship. Rather, they likely see a spike in sales after detailing a group of doctors. If it didn’t provide the necessary revenue benefit to them, drug companies would never give away pens, books, etc.

Let’s look at it this way: what industry other than the pharmaceutical industry regularly gives things away to people without any stated benefit to the industry itself? None. And as they say in economics, there’s no such thing as a free lunch. Drug lunches, while much appreciated when I was a resident, are not being provided without some gain to the drug industry. To do so otherwise would be bad business practice.

Dr. Toub’s question is naive. EVERY industry gives stuff away to people in the name of marketing/sales. Everything from the ‘Pennzoil’ caps worn by a mechanic, to ‘Budweiser’ clock on the wall of the bar, to tickets to the Masters in Augusta for the big hitters, are giveaways from business to the gatekeepers for their customers (I use the term gatekeepers, because it is usually the guy with purchasing power, not the end user in the company, that gets the bennie). Doctors are gatekeepers for patient’s pharmaceutical dollar, and until doctors give up the right/duty to prescribe, there will always be people trying to buy time/access/influence with stuff.

Pharmaceuticals are one of the most highly regulated industries, and the jihad against pharma giving out trinkets is, if anything, having negative effects on patient care. The cost-benefit ratio of having samples in the office seems to me to be heavily weighted on the benefit side: poor patients get free drugs (immediately, without having to jump through hoops, and directly supervised by their doctor), and doctors get to try new drugs on patients who are not responding to their usual regimen (which has the potential to improve quality of care). If you try a new drug a few times and there is no higher benefit, it inoculates most doctors against the drug company spiel–put up or shut up!

The fact is that doctors’ subconsciouses are being pummeled constantly by everything from the billing staff gossip to email stock reports. I don’t see why it is a problem when a doctor who is ‘on the fence’ over a treatment subconsciously factors in some big pharma factoids. Now if the doctor decides to use a drug against his CONSCIOUS better judgment, THAT is a problem! But the source of that problem is within the doctor and his/her ethics, not what marketing ploy is subconsciously pushing one way or another.

Whatever happened to reading sources like The Medical Letter? Are P & T committes at hospitals already an anachronism? Are doctors SO busy that they can’t take time out to read some objective info?? Would that take any longer than spending lunch hour or dinner time with a drug rep?

Should I have lunch or dinner with the GE or Siemens rep who ‘s provided that invaluable scanner which I use so often? Or maybe the J & J rep who provides us with the drapes and gloves we use in surgery? They’re a damned sight more important to me than any drug rep. and yet I can’t recall ever having dined with those folks or gotten pens, cups, caps, or stuffed animals from any of them. “Partners in care” indeed.

I don’t know what planet Dr. Toub practises on, but it must be one that still practices trephining and blood-letting for bad humors Since when is prescribing a drug, new to you, but having full FDA approval for the condition the patient has, make that patient a guinea pig? Especially given the situation I laid out, where the patient has failed your usual therapy? What has more health risk, trying a drug that has had at least two full clinical trials in 1,000s of patients, or just throwing the same old ineffective pills at the patient because you are comfortable with using them? If this makes a patient a guinea pig, how can you ever justify trying ANY new treatment.

Regarding informed consent, EVERY patient deserves informed consent for EVERY treatment prescribed, even if it is an old ‘tried-and-true’ remedy. Not necessarily the bureaucratic paper filling, but true information on expectations, risks, and alternatives. And part of that informed consent should be to explain that there are other drugs out there that claim to be more effective, and why you don’t use them.

And before other docs start up the chorus that “We don’t have time; we don’t get paid to talk with the patient; etc., etc.” explain to me why having some buffed drug rep dropping off pens and donuts is more of a risk to patient health than not spending the time to fully understand (and make sure that patients understand to the best of their ability) the treatments being prescribed.

Dr. Toub starts with some incontrovertible truths, throws in a straw man argument, and finishes with a non sequitur. In the interest of clear communications, let me respond line by line:

“all drugs, even H2O, are associated with potential side effects. There is a decision process involved in choosing between one drug vs. another. Vioxx vs. Naproxen is a good case in point.” Agree with no reservations.

“Let drug selections be based on science and evidence. Not upon which drug rep visited me last, who gave me the better lunch, etc. We’re physicians, and should be held to a higher standard than that.” Agree totally. But this is a straw man. Who do you know that chooses a drug JUST because a drug rep visited? I agree that any physician who prescribes a drug on criteria other than clinical judgment should be out on his/her can, but this is NOT equivalent to trying a new drug when there are clinical indications and the patient has failed your first-line drug. If a doctor is changing the drug the patient is on, and one drug is clearly better than another, how many doctors that you know will choose the inferior drug? And if the doctor is facing three options which all seem clinically equivalent in potential effect, why is it a big deal if he/she first tries the one that the nice drug rep promoted?

“Conflicts of interest, even those you would deem trivial, are unacceptable by our lawyer colleagues, so are you suggesting that physicians aren’t as ethical as attorneys?” Ha! You know this is going to bring a comment by CJD… Balancing conflicts of interest is at the heart of a physician-patient relationship. If your patient need surgery, do you refer to your golfing buddy or that asshole at the university? Do you use that fancy new diagnostic machine you are making payments on (and that reimburses sooooo well…) or do you wait and see? Do you ask the patient to come back and see you in a month, just to make sure she is doing well, or do you trust her judgment on whether to return? Do you order that extra blood test because Medical Economics had an article about someone who was sued when they didn’t? Good doctors do their best to put the patient first, whether or not there was a visit by the drug rep. Bad docs have plenty of opportunities to make a buck off a patient’s ignorance, whether or not drug reps are banned.

Regarding attorneys–my understanding is that there are unethical ones out there. There are unethical doctors out there too. I really don’t know which is more prevalent, but both groups are a blight on civilization.

Sure there are “organizations with a vested interest in physicians prescribing cheaper drugs.” They are called insurance companies, pharmacy benefit managers (PBMs) and retail drug stores. All of them save money or have a higher profit margin on generic drugs. Insurance companies and PBMs coerce the patient by forcing them to pay more for some drugs, and retail drug stores encourage pharmacists to substitute generics unless the physician writes specifically not to.

In my opinion these practices have just as much potential for poor healthcare outcomes as drug detailing because they:
1) target the patient instead of the (presumably) more knowledgable doctor,
2) have little accomodation for individual patient differences, unlike the decisions of a good doctor, and
3) are so biased in favor of dollars that even acknowledged inferior substitutes are promoted (look at the rush to simvastatin).

Attempting to parse Jennifer L.’s post, I think she is saying 1) The FDA is lousy and does not provide “an honest regulatory framework,” 2) The most important problem are the lies so many people are shoving “down our throats.”

The first issue–the capability of the FDA to assure drug quality–is an important one. Too bad most of the supporting statements are recycled media pap. The fact is that the only perfect drug is the one that hasn’t been tested. As Dr. Toub mentioned above, all drugs have side effects. And testing in even 10,000 clinical trial subjects won’t reveal every problem that occurs when millions of people take a drug. But new drugs ARE tested, quite extensively, and for the right patients the risk is low. Certainly the risk-benefit ratio is a lot lower than drinking booze and smoking cigarettes in a bar, and then driving without a seatbelt–all of which are subject to other regulatory regimes in the U.S.

The Vioxx issue is less a regulatory failure than a representation of patients’ (and doctors’) desire for a magic pill, exacerbated by some overpromising by Merck. And while it certainly looks like Vioxx adds to the risk of heart disease, we don’t really know where it stands among all the other NSAIDS out there. It is likely the whole class of drugs has effects on heart disease, including over the counter ibuprofen and naproxen.

So what do you do? In the pursuit of perfect drug safety does the FDA yank ibuprofen and naproxen until comparative testing is completed in a decade or so? Oh, and did you know one of the most dangerous drugs in terms of hospitalizations for overdose is acetaminophen (Tylenol)? Yep, it can kill your liver, and at a comparatively low multiple of the effective dose. So maybe the FDA should yank that too, as well as aspirin, which is well known to cause Reye’s Syndrome in kids. Too bad that we will be left with sugar water and caffeine for pain.

The fact is that there is no perfect solution. The FDA can mandate testing, but no one can make drugs perfectly safe. Doctors are paid to understand when to prescribe drugs, select the right ones for the patient in front of them, monitor for effects (good and bad), and modify the treatment as necessary. If a doctor doesn’t want to take the time to do a good job prescribing drugs he/she should turn in his/her license and do something else. Low reimbursement is no excuse–if money is more important than the patient, go do something else that pays more.

As for the lies? Sure there is selective omission of facts, spin, and even some misinformation. Outright fabrication seems to be rare–and is prosecuted. Hysteria over ‘everyone’ lying is akin to “Bush Lied about WMD!” We are awash in information. Each side tries to spin the facts to support their cause. But if someone puts lipstick on a pig, are you going to kiss it? And if you do, whose fault is it?

Name: Pam from West Virginia
Mail: pamwv41@yahoo.com
Website: None
What a fantastic blog! From a patient’s perspective it seems as if it behooves one to get as informed as possible about one’s medications.
Unfortunately there is so much conflicting information out there, that one ultimately must trust that their doctor has done his/her research and knows what he or she is doing.
Statins are the new “wonder drug” on the block. I, personally read the pros and cons and decided to go with the Vytorin offered.
I gave it a month or two in spite of hives, headache, irritibility, and calf pain. I finally stopped it. Quality of life is more important than preventing an imagined medical catastrophe based on an LDL of 125. Diet and exercise may be a better alternative. I have also stopped Bextra, Vioxx, Celebrex, and Lisinopril because of the side effects. I wish more doctors would write prescriptions that looked like this:

Aerobic exercise 1/2 hr b.i.d.
Vegetables and fruits 5 servings daily

get the message.
My last doctor didn’t dare tell me to diet. She was 300 plus pounds herself.

Now I have another issue to rant about.
I can’t get Prevacid as my insurance company has a deal with Nexium. Prevacid costs $450 for a 90 day supply. Well now I get mine from India. It is called Lanzap….a generic prevacid. It’s only $40 dollars.

Why should a doctor be persuaded to use a drug that is not the best drug for their patient, but is the best deal for them. Sad World