No free lunch

Wednesday, April 25, 2007

Dr. Eric Campbell and his colleagues at Harvard Medical School and its Institute of Health Policy have researched doctors and their interactions with drug companies and it should come as no surprise that docs and drugs go hand in hand. This week, in the New England Journal of Medicine, he writes that 83% received free food, 78% free drug samples, 35% were reimbursed for medical education and 28% were paid to give lectures. The implication is that physicians are so influenced that they will make unwise decisions for their patients.

It’s important that I have complete disclosure before I vent my spleen. I have accepted a meal from a drug representative and I have also given lectures for two drug companies, Merck and Glaxo.

That said, it’s venting time. I believe myself to be an ethical person. I also believe that my colleagues in medicine are also ethical and just and have their patients’ best interest in mind every time they operate, write a prescription or sit down and talk with them. I do not think that my colleagues can be persuaded by a pen emblazoned by a drug logo, that they would abdicate their primary responsibility. On the other hand, pharmaceutical companies would not market to physicians, nurses and hospitals if it did not work. They also would not market directly to patients if it did not work.

Let me give an example about the type of incentives that occurred in my ER two weeks ago. The maker of Lovenox, an injectable blood thinner, laid out a buffet of sandwiches, chips and soda for the ER staff. Two representatives sat in the room, ready to answer questions about the drug. It is an interesting marketing ploy. They have 100% of the market, with no competition. When people develop blood clots in their legs or in their lungs, the treatment is to anti-coagulate or thin their blood. Warfarin, a pill taken by mouth is the drug of choice, but it takes a few days for it to get to appropriate levels in the blood stream. As a bridge, patients used to be admitted to the hospital for intravenous heparin, a thinner that works immediately. People would stay in hospital for 3 or 4 days until the warfarin did what it was supposed to do. Lovenox does the same thing as heparin, but it is injected in the skin twice a day, meaning people can be treated at home. The drug reps job is to help the nurses sort out the logistics of giving Lovenox as an outpatient. The sandwiches do little to influence decision making, because the drug is standard of care.

Sometimes, there are plenty of options, like treating infections with antibiotics, or esophageal reflux with acid blockers. The drug reps try to influence doctor prescribing patterns. According to the New England study, the potential to influence a specialist may allow that specialist to further influence other doctors who refer patients to him. Fair point, but consider the two issues that I understand to be true. First, most states require mandatory generic substitution unless specifically requested and second, most insurance plans have their own ideas of what drugs they will pay for. And for those people without insurance, I try hard to find affordable alternatives.

Not long ago, I gave lectured to area family doctors about acute asthma care. The evening was paid for by a drug company and my presentation reviewed standard of care assessment and treatment protocols. The information did not highlight any drug or device and I was not contacted by any of the drug representatives to discuss content.

I do not want to consider myself holier-than-thou, but the idea that I can be bought, bothers me. If a drug representative that visits with me in the hospital for 5 minutes that is considered undue influence. But if the drug company buys a full page layout in the New England Journals of Medicine, that’s just advertising. I’m not certain I understand the difference.

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