Friday, January 27, 2006

Gifts That Keep on Giving

I must admit that I am a little creeped out every time I visit my primary care physician. It's not that she's obese and therefore is a bad role model for me. It's how cluttered her office is with pharmaceutical company trinkets such as note pads, pens, wall charts, etc. More often than not, there's a pharmaceutical sales rep or two sitting in the waiting room or trying to blend into the wall paper as they wait for the doctor to give them a minute or two.

It is at these times that the advice from Marcia Angell, MD, former editor in chief of The New England Journal of Medicine, and author of the book The Truth About the Drug Companies (
see review) comes to mind. She urges readers to ask their doctors this question: "Do you make time for visits from drug company representatives?" If the answer is yes, Angell says you should consider changing doctors.

Despite my doctor's obesity and proclivity to accept pizza from pharma sales reps, I am not considering changing doctors. After all, she has been known to have literally saved the lives of at least two people in my town -- one of them a neighbor and friend of mine. I also think she was as helpful as my cardiologist in lowering my cardiovascular risk factors (and she didn't even prescribe any brand drug!).

You can understand, therefore, why I am a little bit ambivalent about claims that pharma gifts to physicians have a negative impact on patient outcomes. That is one of the claims made by "a group of influential doctors" in a recent article in the Journal of the American Medical Association (JAMA; see the story in the NY Times: "
Doctors Urge Ban on Gifts From Drug Makers").
What do you think? Take Pharma Marketing Network's online Pharma Gifts to Physicians Survey.
The authors cite the following types of gifts that they wish banned: meals; payment for attendance at lectures and conferences, including online activities; CME for which physicians pay no fee; payment for time while attending meetings; payment for travel to meetings or scholarships to attend meetings; payment for participation in speakers bureaus; the provision of ghostwriting services; provision of pharmaceutical samples; grants for research projects; and payment for consulting relationships.

What would the world look like if pharma gifts (free lunches, etc.) to physicians were banned? [Of course, even the authors realize that "ban" is slightly too autocratic; as one author remarked, "It's a free country."]

According to the authors, such a "ban" would cure all that ails the delivery of healthcare in the US. For one thing, physician decisions would become more "evidence-based" and result in better patient outcomes. From what I have been hearing, evidence-based medicine is not embraced by many physicians for a variety of reasons and none have to do with pharma gift giving. For example, whose evidence is it? How good is the evidence? How long does it take this evidence to filter down to the practitioner in the form of guidelines? What about creativity and knowing when to apply new solutions?

The problem with pharma marketing to physicians is that it combines gift-giving with a hard-sell approach. Often, the sales rep does not or cannot deliver any useful, believable evidence-based information to doctors. "Docs shouldn't make any time to see reps unless they have something new to say," says Richard Vanderveer, Pharma Marketing News
Advisory Board member. "And industry executives should stop running to conferences on improving physician access and should think more about how rep visits can be more valuable to docs."

Drug Samples
The other target of the authors is the provision of free drug samples to (certain) physicians. Samples undoubtedly are an effective means of gaining access to physicians (see, for example, "
Intelligent Online Sampling Strategies"). Why? Because physicians want them and find samples useful to get patients started on treatment and even depend on samples to treat patients that can't afford the medication. [BTW, who knows what will happen to sample giving once Medicare Part D gets into full swing.]

The proliferation of free drug samples as a physician access tool is a sad testimony to the failure of physician marketing in general. So, I am not totally in favor of free samples, nor do I favor an outright ban. I see the benefit, but drug companies need to wean themselves away from this door-opener gift to physicians and think of new ways to gain access.

Research Grants
The authors go to great pains to carve out from their "ban" the biggest gift of all: research grants to physicians, especially physicians at academic medical centers (AMC's). That gift should keep on coming, according to the authors, BUT money should go the AMC to administer and allocate to deserving faculty; grants to individual physicians should not be made, according to the authors.

Never mind that this would turn the academic grant machine on its head, but I think it could stifle academic freedom as well. Would faculty critical of an AMC's policy on abortion, for example, get less or more of the grant pie do you suppose? Also, what pharma company in its right mind would fund research not tied to its own products? Get real!

BTW, I've seen firsthand the clout that pharma research grants have at AMC's. Some pharma companies threatened to without grants to medical schools in Texas if the state passed a medical privacy act that would greatly restrict pharmaceutical marketing in Texas. It was amazing how fast AMC's joined Pharma's effort to amend the law and save their grants! I could imagine the same thing happening should AMC's impose a sweeping ban on gifts to students and physicians as the JAMA authors propose.
Take the Survey
The authors have some good points to make about other types of gifts. There's enough fodder there for at least 3 or 4 other posts to this blog! But before I venture into that, I would like to have your opinion on the issue of pharma gifts to physicians. Therefore, I ask you to complete the online
Pharma Gifts to Physicians Survey. If you have interesting comments and give me permission, I will include them in a future post.

1 comment:

  1. Anonymous1:04 PM

    AMA board chair, Dr. Duane M. Cady, commented on the JAMA article saying, "Drug and medical device makers can play a role in educating physicians about new products." The argument almost leaves the impression that the tens of billions of dollars the drug industry spends annually should be thought of as some kind of public education expense.
    Fine, but the drug company sales reps are measured by their performance – and not by giving doctors a pop quiz to determine their level of education after the drug company “educator” has made an educational visit. Here’s an example: drug reps pushing Nexium – and doctors prescribing it – when there’s an alternative available for a fraction of the cost over the counter. Another: drug companies getting doctors to prescribe Vioxx in huge numbers, though the drug was likely appropriate for a much smaller population of people with severe arthritis and gastrointestinal bleeding.
    Who doesn't have great respect for physicians -- they do a difficult job that requires constantly aquiring the newest information. But they’re only people – and doctors seem to recognize the effect that gift-laden education has. According to the Times: "Surveys show that most doctors do not believe that these gifts influence their medical decisions, although most believe that they do affect their colleagues' medical judgment."
    Read more:


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