Saturday, March 29, 2008

Free lunch with whine

Predictably, after the CMAJ's editorial about pharma influence over physician behavior, industry has fired back. In a letter to the Globe and Mail yesterday, Rx&D CEO Russell Williams sputters:

Canada's Research-Based Pharmaceutical Companies (Rx&D), an industry association that represents major drug firms, has had a code of conduct for many years that specifically bans offering gifts or other incentives to gain influence with health-care professionals.

Anyone who has evidence of a violation may lodge a formal complaint, the results of which are posted publicly on our website.

Well, Mr. Williams, no one accused your crew of being blatant about it. You may not be offering free vacations or rounds of golf (anymore), but there are still plenty of less extravagant freebies to be had. It reminds me of the old joke attributed to Winston Churchill. As I mentioned in my last post, the local reps are more than happy to buy us supper (and line up to do so.) Of course, this is in the context of supporting "legitimate" educational endeavours, such as Grand Rounds.

There are also the lavish lunches the reps buy for our office staff. But those couldn't possibly be considered an influence on physicians, could they? Let's not be naive. A cozy relationship with my staff earns drug reps access to physicians' schedules and coveted appointment times.

A particularly devious technique is using office staff as go-betweens. Last month, one of my staff (knowing full well that I rarely see reps) stepped into my office and held out a business card asking, "Can you see him? He just bought us lunch." Wow, maybe next time, they'll start sending doe-eyed orphans with chronic diseases to plead their case. Or a fluffy kitty with a big satin ribbon around its neck. (FYI: I declined the offer to be educated.)

Mr. Williams, don't get so upset about about the CMAJ editorial. It was directed at physicians, not at your industry. Despite your letter to the contrary, we already know that your members' interactions with physicians are designed to influence behaviour and market your product. That's a given.

What's in question is how physicians should respond. What is our responsibility to our patients and society in general?

If your industry truly believes its stated objective -

To educate health professionals and consumers in the optimal use of medications

- then put your money where your pious protests are. Tally up everything you currently spend on marketing/promotion/education and give that amount to the proposed Institute of Continuing Health Education. No strings attached.


Ian Furst said...

Another common one is "buy 10 XXX at cost and we'll send a free TV/MP3, whatever". Pharmaco is only one part of the equation. What about medical suppliers, companies that make implantable devices, etc.... Also, and not to put to fine a point on it, have you ever met an ugly drug rep?

Joe Black said...

'Don't criticize someone until you've walked a mile in their shoes...because then you are a mile away, and you have their shoes.' –Anon”

How about some constructive thoughts on the subject of the “Rep”?

Am I selling my soul to the pharmaceutical devil if I accept the Tim Horton’s cup of coffee (which is very cold by the time it gets here, but nothing that a microwave cannot fix) and the sandwich between patients? Should I mind the opinion of two Big-City specialists and a magazine editor? They probably even have access to a 24 hour pharmacy!

But it bothers me, so that is why I post this comment.

The Reps cannot organize a CME here – not enough doctors, and too far away. My last CME was an episode of House on TV. Now if the Pharmaceutical Company would sponsor a locum to come work here for a weekend so I can attend a CME – that would be nice. Unethical?

In-between patients they will stand at the desk - Hi John or Suzy (who is no oil-painting but she has a nice voice) how are you? Do you mind to sign my book doctor? I left some more samples of Drug X, and I am taking back the expired samples of Drug Y. See you in three months!

This hardly sound like a conspiracy to sell a certain drug, but yes – it influences us. The drug on the sample shelf will to a certain extent determine what the next patient who fits the criteria will use.

If the “Rep” went through the trouble to travel this distance to a rural-remote practice, he or she deserves the courtesy of a quick “Hi” or “Bye”

The sample room is stocked with Statins, Blood pressure medications, Oral contraceptives etc. And yes, the “Sample Express Fax” gets filled every time we receive it – samples get delivered, but never the stuff we really need. We have ointments and laxatives to supply a small country.

For the benefit of the patient:

“Your cholesterol did not respond to the conservative treatment – So here is 6 weeks samples of drug X, have your cholesterol checked in 4 weeks and see me in 5 weeks, and we will see if there was no side effects and a good response we will continue.”

“Use this sample of antibiotics till the pharmacy opens after the weekend and you can fill your prescription.”

“Here is two weeks supply of that expensive drug for dementia till the EDS gets approved”

“You have to fail a trail of H2-antagonists before EDS will approve the use of a PPI. Here is two weeks worth of PPI samples in the meantime. Your gastroscopy is booked, but it will be in six months from now, you know”

“Doctor – you have admitted Mrs. YY, and we can only get the Big City Hospital to deliver this after the weekend – Do you have some samples in your office?”

And some just plain cannot afford certain medications. (Take my whole supply – The rep will kill me if she finds out though….)

For the physician’s benefit?

Is this efficient patient care?

Am I helping people or am I now part of the axis of evil?

Walking to the sample office and getting a sample of a drug that I am familiar with (that is why the samples get updated so frequently) – Am I now doing the right thing?

Would I have prescribed this if the sample was not available? (Or are all Statins and Ace-Inhibitors actually created equal and since I have a choice of about 6 types on the shelf I am not so guilty anymore)

It is actually easier to scribble the Rx on a script pad than to walk to the sample room. And it works for us. And for the patients.

Maybe I should attend a CME. Then I can be entitled to an opinion. ER is on in two minutes – time for some Mainpro 2 points.

Joe Black said...

You have now ruined it for me. Everywhere I look or read there is something about big Pharmaceutical companies:

Joe Black said...

And it gets worse:
Former Drug Sales Rep Tells All

drug rep, sales, salesmanShahram Ahari, who spent two years selling Prozac and Zypraxa for Eli Lily, told a Senate Aging Committee that his job involved "rewarding physicians with gifts and attention for their allegiance to your product and company despite what may be ethically appropriate."

Ahari claims that drug companies often hire former cheerleaders and ex-models, as well as former athletes and members of the military, even if they have no background in science.

During their five-week training class, Ahari says he was taught sales tactics such as:

* How to exceed spending limits for important clients
* How to be generous with free samples to leverage sales
* How to use friendships and personal gifts to foster a "quid pro quo" relationship
* How to exploit sexual tension

Ahari claims that he's even heard stories about sales reps helping to pay the cost of a doctor's swimming pool, or taking a doctor to a nightclub where a hostess was paid to keep him company.

For this work, sales reps often earned more than researchers. On top of a base salary of $50,000 for starting reps, Ahari says, "there were four quarterly bonuses, an annual bonus, stock options, a car, 401K, great health benefits, and a $60,000 expense account."

* ABC News March 12, 2008

Joe Black said...

And worse still...

Dr. Mercola's Comments:
Shahram Ahari must be one of the drug companies’ worst nightmares; he is one of the few who has witnessed the corruption firsthand, and then moved on to speak out about it.

By now, it’s old news that drug companies use extreme sales tactics to influence doctors’ prescribing habits, but to hear the extent of just how far things go -- buying doctors’ swimming pools or using sexual innuendos to make sales -- is still shocking.

"The nature of this business is gift-giving," Ahari said, and indeed it seems that in the world of pharmaceuticals, everything has a price.

Your Doctor Probably Has a Relationship With a Drug Rep

It is the rare physician who refuses to meet with drug sales reps. In fact, as of April 2007, the percentage was just 7 percent of U.S. doctors.

Even I met with drug reps until the year 2000, at which time I just refused to see any. Before that I was actually a paid speaker for the drug companies. They would fly me to various physician education events around the country and pay me a VERY generous stipend to lecture to these groups. That was more than two decades ago, before I was able to remove myself from their very powerful brainwashing techniques -- and I was finally able to understand the truth of what they were doing.

So there is a very good chance that the doctor you see right now is being subjected to similar intense sales tactics like the ones Ahari describes. According to one study published in The New England Journal of Medicine:

* 94 percent of doctors have some type of relationship with the drug industry
* 80 percent of doctors commonly accept free food and drug samples
* One-third of doctors were reimbursed by the drug industry for going to professional meetings or continuing education classes
* 28 percent of doctors have been paid for consulting, giving lectures, or signing their patients up for clinical trials

Drug reps can be very sneaky. According to a report in PLoS Medicine co-authored by Ahari:

“Physicians who refuse to see reps are detailed by proxy; their staff is dined and flattered in hopes that they will act as emissaries for a rep's messages.”

Clearly these are no ordinary sales meetings; this is psychological warfare.

Sales Reps are Trained to Brainwash Doctors

Pharmaceutical sales reps are trained in tactics that are on par with some of the most potent brainwashing techniques used throughout the world, according to the PLoS report. Said Ahari:

“It's my job to figure out what a physician's price is. For some it's dinner at the finest restaurants, for others it's enough convincing data to let them prescribe confidently and for others it's my attention and friendship ... but at the most basic level, everything is for sale and everything is an exchange.”

Drug reps must target doctors because it is only through a physician that a consumer can purchase their product. Although in the United States they have also ramped up their direct-to-consumer ads on television and in magazines, their real “meat and potatoes” comes from their marketing directly to physicians.

This is why drug companies spend $4 billion each year on direct-to-consumer ads in the United States, but $16 billion to influence physicians. That is $10,000 for every single doctor in the United States.

The Drug Sales Rep Ambush

Most doctors don’t even stand a chance against a seemingly innocent drug sales rep. They appear friendly, eager to please, and knowledgeable about their product, and most physicians think there is no harm in accepting a free sample here, or a free lunch there.

Well, studies have shown that those free samples and lunches DO impact doctors' prescribing habits. So you can imagine what a more lavish gift -- like a free vacation, “consulting fee” or even companionship -- can do.

What they don’t get to see is the well-oiled machine that is controlling these reps, and ultimately the physicians as well, like marionettes.

From the instant a drug rep enters your office, the ambush is underway. Says Ahari:

“A photo on a desk presents an opportunity to inquire about family members and memorize whatever tidbits are offered … these are usually typed into a database after the encounter. Reps scour a doctor's office for objects -- a tennis racquet, Russian novels, seventies rock music, fashion magazines, travel mementos, or cultural or religious symbols -- that can be used to establish a personal connection with the doctor.”

In their PLoS Medicine report, Ahari and Adriane Fugh-Berman, an associate professor in the department of physiology and biophysics at Georgetown University Medical Center, even put together this chart of the specific tactics used to manipulate physicians.

What is the Moral of the Story?

Your doctor may have the best intentions in the world, but if they are being visited by drug reps, there is a strong likelihood they have been influenced by highly skilled, multinational, self-serving corporate interests and their opinions about prescription drugs are likely highly biased as a result. This can certainly happen even at a subconscious level, and the end result is a higher tendency to prescribe the drugs that have been marketed to them.

This is why I remind you often, taking ownership for your own health by leading a healthy lifestyle, and only resorting to drugs as a last option, is the key to surviving, and thriving, in the 21st century.