Hi, my name is Russell. Today’s special is Vyvanse.

I would love to believe that, as a physician, the only thing that influences my choice of treatment for my patients is the science that supports it.  Despite the cajoling and back-slapping and free chazerai that festoons my office, I am uniquely invulnerable to the pressures of pharmaceutical representatives when they visit to tout their wares.  Others may fall victim to their Jedi mind tricks, but not me.  Nope, nothing but science and my patient’s welfare on my mind when I pull out my prescription pad.

All of us like to tell ourselves this kind of thing.  We who have made it through medical school and residency and into our own practices must surely be intelligent and canny enough to see through the sales pitches of drug reps, even if we avail ourselves of the free food and swag they often bring along.  Susceptibility to the wheedling of the people who are paid to promote the use of new, expensive medications must be a sign of weakness, and we are loath to admit any such weakness in ourselves.  I am no different than anyone else in my need to believe this about myself.

Of course, it turns out we’re wrong:

Drug companies provided more than $7 billion worth of pharmaceutical samples in 1999, most of these the newest, most expensive products. In the same year, the industry spent almost $14 billion promoting its products in the United States. Calcium channel blockers are heavily promoted to physicians as antihypertensive agents, and perhaps this promotion explains why they are so heavily prescribed. Many physicians will deny this, saying that pharmaceutical promotion, be it pen or penne, has no effect on their prescribing behavior. But the medical literature abounds with studies suggesting that promotion does affect behavior.
For example, Avorn and colleagues surveyed internists in the Boston area on their use of 2 classes of drugs, the propoxyphene analgesics and peripheral and central “vasodilators.”  Although these agents were heavily promoted as effective, the medical literature was clear that they were neither effective nor offered any advantage over currently available therapy. Nevertheless, most physicians believed these agents to be effective—even those who claimed to rely more on scientific, as opposed to commercial, sources.
Chren and Landefeld compared physicians who had requested additions to the hospital formulary (cases, n=40) with those who had made no such requests (controls, n=80).7 Physicians who had made requests were much more likely than the controls to have met with pharmaceutical representatives (odds ratio, 5.1; 95% confidence interval, 2.0-13.2). In addition, physicians who had interactions with specific companies were more likely to request drugs made by these, rather than unfamiliar, companies.  [emphasis added]

Drug reps do influence how we practice, no matter how much we like to tell ourselves that they don’t.  I hate to accept that this is true for me personally, but honesty trumps pride and demands that I do.  Which I why I found this recent Supreme Court ruling so disheartening.

NINA TOTENBERG: The court’s sweeping decision in the Vermont case will send ripples far beyond the marketing of pharmaceuticals. The ruling also marked the court’s first excursion into data-mining and applied a strict legal test to limits on speech, even in the context of government regulation.

Here, the government’s regulations were those that require pharmacies to keep records of all doctor prescriptions, and the legal question was what kind of limits can the government put on the sale of that information.

Indeed, pharmacies can and do sell those doctor prescription records to data-mining companies, with patient identifiers removed, and the data-mining companies in turn sell the information to drug-makers for use in targeting doctors to prescribe more brand-name instead of generic drugs.

When doctors in Vermont found out their prescription records were being sold this way, they went to the state legislature, which enacted a law barring the practice. The data-miners and the pharmaceutical companies then challenged the law in court, contending that the state had unconstitutionally singled out marketing for different treatment, allowing researchers and cost controllers to have access to the data but not commercial data-miners and pharmaceutical companies.

Today, they won when the U.S. Supreme Court struck down the Vermont law as unconstitutional. Writing for the six-member court majority, Justice Anthony Kennedy said the Vermont law, both on its face and in its operation, imposes a burden based on the content of the speech and the identity of the speaker. He dismissed the state’s justifications, that the law was aimed at keeping medical costs down, at protecting medical privacy, physician confidentially and the integrity of the doctor-patient relationship.

Full disclosure: I signed on to an amicus brief in support of a similar law in Maine.  I find prescription data mining highly objectionable.  If I had to choose between allowing pharmaceutical reps to use my prescribing information to target their pitches to me and avoiding contact with them outright, I will choose the latter (NB. Justice Kennedy’s full opinion).  There is a role for drug reps to disseminate information about new medications, and I don’t begrudge the pharmaceutical industry its right to promote its products.  But when those companies can see what I’m prescribing and try to use that information to pressure (or reward) me, then their influence becomes pernicious and unwelcome.

Medications occupy a unique space in the realm of consumable goods.  Unlike just about anything else one can buy, those who wish to take them must find a professional with particular expertise to agree that they are appropriate for any given condition.  Physicians and other prescribers are entrusted with our roles as gatekeepers for these potentially toxic (and often expensive) products because it is presumed that we will always and only be motivated by what is truly in our patients’ best interests.  When we start making decisions based upon how effectively drug reps have plied us with food and other goodies (and we do), then we undermine the basis for the trust patients give us.

I am no legal analyst, and do not style myself an expert on Supreme Court jurisprudence.  I happen to think it is absurd to conflate a particularly invasive form of corporate marketing with free speech, but what do I know?  Whatever the constitutional merits of this ruling, it does no favors to patients or efforts to contain healthcare costs.

Russell Saunders

Russell Saunders is the ridiculously flimsy pseudonym of a pediatrician in New England. He has a husband, three sons, daughter, cat and dog, though not in that order. He enjoys reading, running and cooking. He can be contacted at blindeddoc using his Gmail account. Twitter types can follow him @russellsaunder1.


  1. > But when those companies can see what I’m prescribing
    > and try to use that information to pressure (or reward)
    > me, then their influence becomes pernicious and
    > unwelcome.

    Would this be less objectionable if they had to document what they were doing?

    If so, what sort of documentation would suffice?

    • It would not be less objectionable to me, because I can’t imagine any significant number of people would care enough to check. Documentation would create another layer of tedious bureaucratic busywork, but I have a hard time believing it would have any real-world impact on the behavior of pharmaceutical reps or providers.

      • Sort of like how HIPAA was supposed to protect everyone from every form of data mining, but ended up just being another damn piece of paper that the patient had to sign and the office had to retain in their file. Because every time someone wants the data it turns out that HIPAA doesn’t apply for some reason; about the only thing it stops is companies just straight-up buying copies of people’s files from the doctors’ offices.

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