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Doctors as touts

I suspect everyone has things they’d like to believe about themselves that are probably not really true.  We all have our happy fictions, some closer to reality than others.  Perhaps we’re not as funny or handsome or clever as we’d like to think, but it helps us get out of bed in the morning to think so anyway.

For my part, I’d love to think that I am flinty and discerning.  I’d love to tell myself that I would never make any clinical decision for any reason other than that it was clearly indicated for the patient’s best interest.  Whatever the blandishments and enticements a pharmaceutical company might wave before me, I would stick with cheaper, older and better medications instead of their new, brand-name alternatives.  Other doctors would succumb, either with happy ease or due to subtle suggestibility, but not me.

This is probably not true.

I only ever went to one Yankees game when I was living in New York City.  I’m not much of a sports fan, so attending games was never high on my list of things to do with my leisure time.  That said, I like baseball well enough, and with the right company would happily go if invited.

So when box seats right by the third base line were offered to me, I gladly took them.  As it happened, my brother was visiting, and what better experience could I offer than that?  The seats were free, and were offered to me and a few other residents when the usual beneficiaries of the owners’ largesse demurred.

The seats belonged to a drug company.  They were fabulous, and their proximity to the field helped me get a good-enough look at Derek Jeter to cement a bit of a celebrity crush.

Now, pharmaceutical reps weren’t allowed to ply residents at my hospital with gifts and free meals and whatnot.  But apparently this ban didn’t apply to the attending physicians/administrators.  (Make of that what you will.  I did not find it wholly surprising.)  I don’t know how often they found themselves taking in a game or whatever other trinkets and treats they might have been offered, but there I was that one night when there were no other takers.  I don’t think it’s unreasonable to conclude that such gifts were not novel to them.

For as long as I’d been cognizant of the issue, I’d always found the free gifts that drug companies gave to doctors unseemly.  Taking the tickets that night didn’t feel particularly unethical, as they were cast-offs and I don’t think we even knew which company had given them.  I’d like to think, were such offers a regular thing, I’d have had the fortitude to turn them down.

But man, that was a fun way to see a ballgame.

The question was mooted for me, because just as I was leaving residency the pharmaceutical industry voluntarily adopted guidelines banning such gifts as sports tickets and trips to exotic locations.  In 2009, they stopped giving out little things like pens with their drugs’ names on them.  I always used to say “Show me a drug rep pen, and I’ll show you a cheap doctor.”  But some of those pens were pretty nice.

I’d like to think I’d have turned it all down, anyway.

Earlier this week, GlaxoSmithKline announced that it would stop paying doctors to give talks promoting its drugs.  Since such talks are ostensibly educational, they have persisted despite the ban on outright gifts.  If you wanted to listen to a doctor talk to you about the wonders of Advair, Glaxo was happy to pay one to tell you about them.

These talks are different from lectures that physicians might deliver at an academic conference, for example.  Those talks are meant to be free from any kind of bias, whereas a lecture sponsored by a drug company (though also technically supposed to be “free” of “bias”) cannot plausibly claim to be.  However, whenever a doctor on the payroll of a pharmaceutical company does deliver an academic lecture (or submit a study for publication), he or she is required to disclose that relationship to the audience at the outset.

You know who pretty much never hears about those relationships?  Patients.

At my previous job, drug reps would sometimes stop by with samples and to chat amiably with us.  Since samples really can be helpful for patients who might benefit from the medication but are not be able to afford it if they lack insurance that covers it, there was a plausible patient benefit to these visits.

Nevertheless, I was usually pretty frosty.  I had specific objections to how certain companies marketed their products, and I was all but overtly hostile to their reps.  But then there was the eye drop guy.

He was affable and charming.  Honesty demands I disclose that he was also cute.  He was there to drop off samples of two different drops, one for ears and one for eyes.  I didn’t mind so much when he stopped by.

The ear drops actually had a clinical benefit that made them superior to various alternatives.  The eye drops, however, were to treat conjunctivitis.  Conjunctivitis is usually viral, and even if there is a bacterial cause it almost always goes away on its own.  I hate prescribing eye drops, though sometimes I do if the parents really want them.

I’d like to think the handful of times I prescribed those expensive new drops, it was because I thought they were clinically indicated.  They were certainly more convenient to use than cheaper alternatives, and there were a few cases where patients didn’t get better on the latter.  I’d like to think it wasn’t because I knew that chummy drug rep could access my prescribing information, cheerfully provided by the AMA, and would know that I never prescribed his medication.  I never accepted more than a handshake from the man, and it would be horrifying to think that I would ever prescribe a medication simply so some relative stranger would like me better.

I haven’t prescribed those expensive drops a single time since taking my new job, where I interact with drug reps not at all.

As I mentioned, I am genuinely hostile to what I consider to be the insidious influence of pharmaceutical companies on physician behavior.  The AMA’s policy of selling prescribing data to Big Pharma is one of my cardinal reasons for not being a member.  Perhaps I flatter myself, but I sincerely hope that I am more resistant than most to whatever lures they might dangle in front of me to sway my own practices.  Lord knows, I’d never be a part of a drug company’s speaker bureau (full disclosure: I’ve never been asked) and those few sponsored meals I attended as a resident were too mediocre to tempt me to attend more.

I’d like to think that about myself.  And I’m sure pretty much every other doctor would like to think so, too.  I suspect few physicians would readily admit “One thing I’ll say about myself, I sure am credulous!”  We all want to think our minds are air-tight, our clinical judgment unimpeachable.

Nobody wants to think they’re an easy mark.

But the drug companies weren’t flying doctors to Aruba for the hell of it.  Glaxo wasn’t paying doctors to shill for their medications because physicians are just such eloquent speakers.  Even the little notepads and pens, gimcrack bits of office flotsam, probably influenced far more prescribers than would care to admit it.  The drug companies employed those methods because those methods worked to increase sales of their drugs.

Whatever GlaxoSmithKline’s reasons for abandoning its payments to doctors, I applaud the move.  As with the earlier industry decisions to voluntarily give up festooning physicians with free swag, I imagine the company wants to get out in front of potential restrictions that might have been placed on such practices in the future.  Since “drug companies pay doctors to tout their medications” certainly sounds bad, with ever-increasing demands for transparency in the medical community it’s plausible that calls for a mandatory ban would have arisen sooner or later.  Best to make it seem as much like a choice as possible.

Patients are entitled to the best clinical judgments we can render.  It is our ethical obligation to them to choose the most effective and least costly from all our possible options.  Anything that skews those judgements away from patient care and toward a profit margin should be strenuously avoided.  I hope Glaxo is only the first member of the industry to abandon the problematic practice of using doctors as touts.

Because I’m sure those doctors on the pharmaceutical payroll would tell you that they never let that relationship influence their clinical decision-making.  But we all have stories we like to tell ourselves.

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21 thoughts on “Doctors as touts

  1. This is an excellent post, Russell. Which is pretty close to a content-free comment, but I imagine the rest of ’em are also just sitting there in appreciation without much content to add. So thank you.

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  2. It was a long time ago now, but I recall reading a book about the history of TV advertising that mentioned a study done not too long after TV sets had become a household staple. The researchers asked the respondents how much their purchasing decisions were affected by TV commercials, and the vast majority said they were hardly affected at all; but the company data the researchers had acquired that gave the before/after sales when a TV ad campaign was begun for a product generally showed a very large increase in sales.

    I might be mixing up the studies, but I think this one might also have found that they got a more credible answer when they asked people how much they thought their friends were affected by the advertising.

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  3. It’s not just doctors: I am at least once a season offered awesome hockey tickets by a forensic accountant. Sometimes I accept them and enjoy the games. Do I steer forensic accounting work his way? You bet. I’ve used him for appropriate cases. I hope I’ve only selected his firm for cases in which it is appropriate to use that level of forensic accounting service. But I do certainly think of him a lot whenever there is heavy lifting to be done on the accounting side for pretty much any case. (Also, unlike the rep who came to visit Dr. Saunders, I wouldn’t describe him as “smoking hot” although I’m sure his spouse thinks he’s cute.) It’s fair to say that he’s captured a degree of my goodwill with the enticements, enticements which have nothing to do with his (considerable!) abilities as a professional.

    A difference between the lawyer being cultivated by a forensic accountant and a doctor being cultivated by a pharma company, though, is that the lawyer retaining the accountant is making a relatively infrequent sort of decision, and one into which substantial amounts of affirmative consideration and deliberation are typically made. The doctor, who usually only has five to ten minutes of face time with the patient, of necessity must move faster, make decisions faster, and move on to the next patient. Another difference is the sort of client whose litigation needs forensic accounting is likely to be more sophisticated with respect to these sorts of decisions and commitments than is a patient in a doctor’s office — the information imbalance is greater in the medical situation than the legal one.

    So perhaps doctors are actually more vulnerable to this sort of thing than other professionals. It’s a matter of degree, though, rather than of kind.

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  4. I have never been in a position to receive gifts from people trying to influence my workplace decisions, but I’ll tell anyone who’s listening: box seats near home plate, and you can have whatever you want.

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  5. For years Big Pharma has been justifying the price of **sexy** new drugs by the cost of R&D, while spending substantially more on advertising than they do on said research and development. Meanwhile, they make huge profits selling antibiotics to factory farms which increases the growth rate of farm animals… but also contributes largely to the epidemic of antibiotic resistant organisms. To add to that, there hasn’t been a significantly new class of antimicrobials (that is, one which bacteria don’t already have a mechanism for resistance against) for something like 15 years.

    Pharmaceutical companies are more interested in high margin products that patients have to take for the rest of their lives. They’re more interested in peddling us the next Viagra than doing something concrete about a post antibiotic world where your child can die from a strep throat.

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  6. It’s true that Strep. pyogenes is fairly susceptible to most antibiotics, but other species form the genus have been gaining resistance (Group B Strep, a source of morbidity in newborns for example, is showing increasing resistance to penicillin… ).

    The point being is that our arsenal against microbes is becoming ineffective and the industry that produces it doesn’t appear to see it as an urgent problem.

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    • Oh, I was just in one of my pedantic moods.

      My understanding of the problem with no new antibiotic classes being discovered is that there are only so many ways of getting at a bacterium to kill or disable it, and that most of the efficient ways of doing so have already been exploited to their full potential. Now, I am no microbiologist nor pharmacologist, so my knowledge is pretty limited. But there may be more to lack of new antibiotic classes than simple industry indifference, and I imagine a well-tolerated new antibiotic would be a major seller.

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  7. For what it’s worth, Russell, we’re all marks. Knowing that you are is the first step towards catching yourself before you step all the way in it.

    Marketing is about creating a bias. The methods of doing this are legion, and in addition to being teachable, some people out there are just naturally goddamn good at it, without knowing a thing about the underlying psychology of any of it.

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  8. Agreed. It’s done because it works. I’ve been in my doctor’s office several times when a rep has come in. Always female, always very well put together-nice suit, etc. Always very attractive…usually blonde.

    “just dropping off some samples…does dr. x have some time?”

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    • I wonder if it’s any coincidence that our good doctor only mentions male reps? Do they know he’s gay and sending more appropriate eye candy? Cause I doubt the kind of leggy blonde you speak of would have much subliminal effect.

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      • There were plenty of well-turned-out women who visited the office. I tried to be cordial, but aloof. The one who repped for a company I abjectly despise got the coolest reception.

        The rep I mentioned in the OP had been coming to that office before I joined them. They didn’t send him just because he was cute and there was a new gay doctor, I’m pretty sure. But I don’t think it’s a coincidence that his being cute had a subtle effect on my desire to have him think well of me, and I have no doubt that pharmaceutical reps are generally rather attractive for this reason.

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  9. I used to room with someone who had worked on the same floor of a building as a pharmaceutical firm. He said the pharmaceutical company hired their marketing people for (among other things) their looks – everyone in that office was model-level good-looking. So there’s a good chance the company the eyedrops-guy worked for hired him in order to get that kind of effect.

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