Debate in The Register-Guard about gifts from pharmaceutical industry to doctors

Reformers resist aggressive drug marketing tactics

By Tim Christie

The Register-Guard

Published: March 2, 2008

Dr. Gail Hacker still remembers the pitch she got from a pharmaceutical sales representative early in her medical career.

“If I put my next five hypertensive patients on his drug, he would send me and my husband out to a nice dinner,” she said.

Hacker, a family physician who now works at Lane Community College’s health clinic, says she declined the offer. But she says it opened her eyes to the lengths to which the pharmaceutical industry would go to promote its products. And it led her to swear off all the freebies that the industry routinely bestows on doctors and their staffs, from pens and clipboards inscribed with drug names, to free lunches and drug samples.

“I can afford my own pen,” she said.

Hacker is among a growing number of doctors, lawmakers and public interest groups who are fighting back against the pharmaceutical industry’s aggressive marketing.

Groups such as Nofreelunch.org and the Prescription Project are working to curb the influence of the pharmaceutical industry, which spent nearly $30 billion marketing its wares to consumers and doctors in 2005, including $18.4 billion for drug samples, according to a 2007 study in the New England Journal of Medicine. About $6.7 billion was spent on direct marketing to doctors.

A study published last year in the New England Journal of Medicine found that 94 percent of doctors have some type of relationship with the pharmaceutical industry, 83 percent received food in the workplace, and 78 percent got free drug samples. More than one-quarter were paid for consulting, giving lectures or signing up patients for drug trials.

The Oregon Academy of Family Physicians, representing 1,300 doctors around the state, announced last week that it would no longer accept financial support from the pharmaceutical industry, swearing off unrestricted grants for continuing education seminars, sponsorship of events or advertisements in its publications. But individual members can still see pharmaceutical reps at their discretion.

“This is about taking the institutional view that as a professional medical society, we are committed to decision-making that is based on scientific evidence,” said Kerry Gonzales, the group’s executive director. “We want to avoid even the perception of influence or impropriety.”

The Eugene-Springfield area’s two largest medical practices, PeaceHealth Medical Group and Oregon Medical Group, both have policies intended to curb the influence of pharmaceutical representatives, but neither has outright bans on gifts or drug samples.

“We don’t encourage any kinds of gifts,” said Michelle Anderson, OMG’s director of patient and clinical support. “We encourage staff not to accept them.”

OMG requires pharmaceutical reps to wear a name badge while in clinics, and it doesn’t allow them to bring lunches, although they can bring snacks if they’re hosting a talk on a particular medication.

“The providers like to get the information about what’s out there,” she said. “But they are going to prescribe” a particular drug “because it’s the best thing for the patient, not because of any incentive program.”

At PeaceHealth Medical Group, gifts such as pens, pads and coffee mugs are discouraged, but not banned, said Bobbe Picolet, manager of clinic operations for the group’s family medicine program. Reps are barred from clinic hallways, waiting rooms and drug cabinets.

“They’re not happy about it, but they’re complying,” she said. “They know things are coming down. They’re trying to be as nice as they can.”

Doctors finally just grew weary of the aggressive marketing, she said.

“Integrity-wise, it’s not the right thing to do,” she said.

When it comes to drug samples, PeaceHealth Medical Group will accept only those drugs that are in its formulary — certain classes of medicines that are proven effective and affordable, “We don’t accept the newest” drugs, she said. “A patient gets on a high-powered (new) drug and they can’t afford it” when the samples run out.

Picolet said meals are prohibited unless accompanied by a pre-approved continuing education program. Reps are not allowed to bring in lunch for the clinic staff to pitch a new drug, she said.

“It can’t just be a pharmaceutical sales rep making a sales call,” she said.

Gifts such as pens, pads and coffee mugs are discouraged as well, she said.

At McKenzie-Willamette Medical Center in Springfield, pharmaceutical representatives can be seen only by appointment, and only to present information on drugs already in the hospital’s formulary, spokeswoman Debi Farr said. The hospital doesn’t take any drug samples. Reps can bring meals for staff if they’re connected to an education event, which occur once or twice a month, she said. The hospital has no policy barring gifts such as pens and mugs, she said.

River Road Medical Group, with four doctors and three physician assistants, is too small to have a policy on dealing with drug reps, said one of its doctors, Lorne Bigley, but he has his own rules.

Bigley said he doesn’t talk to pharmaceutical representatives unless they’ve got a brandnew drug in a brandnew class. He doesn’t accept pens, mugs or other gifts. He doesn’t accept drug samples unless it’s a medication that he already prescribes.

Rather than be swayed by sales pitches, Bigley said he would rather prescribe medicines that are proven to work and to be cost effective.

And he packs his own lunch. When drug reps bring lunch for the office, he won’t eat it.

“If I eat it I feel obligated to listen to them,” he said.

Ken Johnson, senior vice president of the Pharmaceutical Research and Manufacturers of America, defended industry gifts to doctors, saying it was “insulting to suggest that doctors would prescribe medications based on who gave them a slice of pizza, a pen or a medical dictionary.”

And in fact, many of the gifts the industry confers on doctors might be considered token: a pen or pad of sticky notes, a coffee mug or a deli sandwich. But studies show that even small gifts can influence doctors’ prescribing practice.

“Even those little gifts create a sense of obligation,” said Dr. Gary Chiodo, chief integrity officer at Oregon Health & Science University in Portland. The industry “wouldn’t be doing those things ifthey didn’t work.”

Social science research has shown that the impulse to reciprocate for even small gifts is a powerful influence on people’s behavior, wrote the authors of a January 2006 article in the Journal of the American Medical Association that called on doctors and academic medical centers to change their ways.

“Individuals receiving gifts are often unable to remain objective; they reweigh information and choices in light of the gift,” wrote the authors, who included leaders of Harvard, Columbia, Tufts, University of Washington and University of California medical schools.

Researchers who looked specifically at the relationship between doctors and the pharmaceutical industry found that receiving gifts is associated with positive physician attitudes toward drug company representatives, the researchers said. The rate of drug prescriptions by physicians increases substantially after they see sales reps, attend company-supported education meetings, or accept samples.

The authors called for a ban on all gifts, meals, payment for travel to or time at meetings, and payment for participating in education meetings.

“The standing of the (medical) profession, as much as the integrity of the pharmaceutical and medical device industries, is jeopardized by allowing obvious conflicts to continue,” wrote the authors.

OHSU is among the institutions that took notice. The state’s only medical school is close to adopting a revised policy toward freebies, following the lead of institutions such as Harvard, Yale and Vanderbilt, which have adopted “zero-tolerance” policies on industry gifts, said Chiodo, the integrity officer.

The revised policy will allow doctors and medical students to accept “not so much as an ink pen,” he said.

“I think we’re now in a situation where the health care profession needs to eliminate even the appearance of a conflict” of interest, he said.

OHSU’s medical students in particular feel strongly about rejecting the marketing freebies, he said. “They clearly had a much stronger feeling that it should be zero tolerance,” he said. “They can see how even small things might either influence or create the appearance of influence.”

Johnson, the industry spokesman, said the PhRMA ethics code bars its representatives from providing any form of entertainment to doctors, and that only modest meals should be provided when the reps meet with doctors. The code also states that gifts must not exceed $100 in value and should benefit patients or support a medical practice, he said.

Physicians who meet with drug company representatives learn about drug side effects and how to use medicines, Johnson said. Dispensing free samples helps doctors figure out which medications to prescribe.

“The simple fact is company representatives help physicians provide effective patient care,” he said.

Critics say that, on the contrary, aggressive marketing by pharmaceutical representatives can undermine the quality of care doctors provide to patients.

Case in point: Vioxx.

After the nonsteroidal anti-inflammatory drug was approved for treatment of arthritis and other chronic pain conditions in 1999, Merck engaged in a costly marketing war that pitted Vioxx against rival drug Celebrex.

Five years later, Merck pulled Vioxx off the market after it was linked to a higher risk of heart attacks and stroke. More than 2 million Americans were taking Vioxx when Merck pulled the plug.

“Anyone who took Vioxx and had a heart attack could lay some claim to the fact that this was related to the marketing of the drug, not only to consumers but to physicians,” said Rob Restuccia, executive director of the Prescription Project, a Boston-based nonprofit organization working to curb the influence of pharmaceutical marketers.

Patient care suffers when doctors prescribe new, heavily promoted yet unproven drugs, overlooking cheaper, established drugs that often are equally effective, Restuccia said.

Many doctors are reluctant to stop accepting them, because they can provide poor patients with drugs they might not otherwise afford.

But the patients most likely to benefit from free drug samples are not the poor but rather the insured and the well-off, according to a study published last month in the American Journal of Public Health.

Among all persons who received drug samples in 2003, 82 percent had health insurance all year, while 18 percent were uninsured for all or part of the year. And 72 percent of sample recipients had income of 200 percent or more of the federal poverty line, while 28 percent had income less than 200 percent of the poverty line.

That study prompted the Prescription Project to call on physician groups and academic medical centers to stop accepting drug samples or strictly regulate and limit their use.

The goal of samples is not to provide free medicine but to initiate product use, Restuccia said. Rarely does a patient receive all the samples they need, particularly for a chronic condition, he said.

“We know that by getting the samples, doctors feel compelled, feel obligated to prescribe the drugs,” Restuccia said.

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Guest Viewpoint

Drug company reps face unfair misconceptions

By Tom Smyly

Published: March 19, 2008 12:00AM

The latest joke going around the medical community is about a letter to “Dear Abby”:

“Dear Abby: Please help me out with my problem. I have fallen in love with a beautiful young woman and I plan to ask her to marry me. However, I have a checkered family history that I have not yet revealed to her.

“My father has done time for dealing drugs, and his father was a bootlegger. My grandmother ran a house of prostitution, and my mother worked there. My sister is in drug rehab, having had her children taken away from her. One brother is a pharmaceutical sales representative, and the other is doing time in the state pen for robbing elderly people of their retirement savings.

“My question for you: How do I tell my girlfriend that my brother is a pharmaceutical sales rep?”

My question for everyone who read the report about pharmaceutical representatives in the March 2 Register-Guard: When did I become the bad guy?

Each day, thousands of people like me go into doctors’ offices and try to engage the physicians in a discussion regarding products that have beneficial effects on patients’ lives. The doctors, who are highly educated people, take this information, combine it with their knowledge and expertise, and decide what is best for the patients under their care.

To say that it happens any differently than that is just not correct. In fact, doctors are more limited and influenced by their patients’ insurance plans than any other measure.

Misconceptions about the pharmaceutical industry abound. A few months ago I read in a men’s health magazine that one must really question what a doctor is prescribing for them because the pharmaceutical representative may have treated the doctor to a strip club the night before.

Recently, I read in a medical journal an article about how to deal with pharmaceutical reps, advising that it always be remembered that the representatives are only being nice because they want something.

I have been in the business for more than 25 years. While I have seen a couple of instances of questionable behavior, I can honestly say that I have never had a doctor prescribe one of my products without believing that it was in their patient’s best interest. And while I am sure there are the inappropriate promises made once in a while, pharmaceutical reps are very limited in what they can say and claim about their products. For the most part, representatives stay within these laws and regulations.

It is absurd to think that a doctor will make a prescribing decision based on receiving a turkey wrap from a company, or on whether they like the rep or not. Even the common misconception that male doctors are more apt to prescribe products that are promoted by attractive female reps is just generally not true. I have found doctors to be ultimately concerned about the well-being of their patients, both physically and financially.

There is a crisis of health care in this country, but pharmaceutical companies are part of the solution, not the problem.

The fact is, new medications save and improve lives. The fact is, medicines keep people out of the hospital and allow them to avoid many types of surgery. The fact is, pharmaceutical companies give away millions of dollars to the uninsured. My company gave away more than $237 million in its patient assistance program in 2005 alone. The fact is, only 11 cents of every health care dollar spent in the United States are spent on prescription drugs. And the fact is, according to the National Bureau of Economic Research, for every $18 spent on a newer drug, there is an overall reduction of $129 in nondrug spending.

It is incumbent on everyone involved in the health care industry to work together to provide high-quality, affordable health care to everyone.

And remember, I treat health care professionals professionally and in a friendly fashion because, well, because I’m a nice guy.

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Tom Smyly of Eugene is a pharmaceutical sales representative for Novartis.

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LETTERS IN THE EDITOR’S MAILBAG

Published: March 19, 2008

Drug samples play a vital role

I am outraged that reporter Tim Christie did not get all the facts regarding pharmacy samples and the great need that is fulfilled with these samples in his March 2 story.

Instead, he wrote from a doctor’s perspective that is 20 years behind the times.

I manage an OB-GYN clinic and welcome all drug representatives, their samples and, yes, the free pens, sticky pads and even the occasional lunch for the providers and office staff to hear the latest information on new products. Not only this, but the guest speakers in a particular field who have the expertise and knowledge to help our patients are welcome.

With a lot of people not having a pharmacy benefit, these samples help them with needed medication they otherwise would not receive. These samples are used to see if a particular drug will work for a patient before they have to pay out of pocket for the drug and find out it is not effective.

As for the studies that show gifts affect doctors’ decisions, if this study is accurate, then I wouldn’t want that person for my doctor. No one wants a robot.

Lastly, Christie should have investigated the effect of TV commercials on patients. Patients come to their appointments and demand a certain drug they saw on TV, regardless of whether it would be effective for them in their care.

Until universal coverage is available to all, I say keep the samples coming.

Bonnie Kuhn

Eugene

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Guest Viewpoint

Pharmaceutical freebies for doctors aren’t free

Published: March 27, 2008 12:00AM

By Gail Hacker

I did not seek publicity regarding my stance on the acceptance of “free” gifts from pharmaceutical representatives (Register-Guard, March 2). I was sought out by reporter Tim Christie because he discovered that I am the only local physician who has chosen to join nofreelunch.org, a nonprofit organization dedicated to discouraging relationships between doctors and the drug industry that may influence prescribing habits and drive up the cost of medical care.

During my interviews with Christie I made it abundantly clear that I did not take as much issue with the pharmaceutical industry for offering “free” items and meals to physicians and their staff — although they certainly contribute to the problem — as I do with the physicians who accept them. I also recognized the beneficial contributions of the pharmaceutical companies, such as their patient assistance programs and their research and development of new medications. That does not excuse unethical marketing techniques.

For these positions I’ve been accused of being a doctor who is “20 years behind the times.” This is a serious accusation. The doctor who does not keep abreast of the nearly daily changes in medicine is a dangerous doctor. As a board certified family physician, and as a recently appointed clinical assistant professor of family medicine at Oregon Health and Science University, I not only pride myself on remaining up to date on clinical medicine, I am required to demonstrate that knowledge every seven years on a specialty board exam. I am also required to document at least 50 hours of continuing medical education every year. No other specialty board has higher education and recertification requirements.

I cannot understand how educated people can honestly deny that the acceptance of gifts — pens, cups, and paper tablets; lunches for doctors, nurses and even non-prescribing staff members who have no clinical need to learn about the latest information on new products; dinners at restaurants where most patients can’t afford to eat — does not contribute to the incredibly high cost of medical care.

Someone is paying for this marketing, estimated to be well in excess of $7 billion last year. That someone is the patient. Patients pay for these gifts every time they go to the pharmacy to pick up a prescription.

As the medical director of the Lane Community College Health Clinic and a regular volunteer physician at Volunteers in Medicine, I am acutely aware of the needs of the uninsured poor. More than 75 percent of the patients I see at LCC have no health insurance, and none of the patients I care for at VIM have insurance.

Yes, I do offer samples to some of these patients — although it is amazing how little interest the pharmaceutical representatives have in our clinic. But the problem with offering samples, which are offered only on newer and more expensive brand-name medications, and never on generics, is that once a patient has been started on them they can’t afford to continue.

And it doesn’t always follow that new is definitely better for all patients. Most can do just fine without taking the bright, shiny, new pill. And there have been too many examples recently of the new pill causing problems, leading to patient injury and subsequent withdrawal of the medication from the market. Generic drugs have stood the test of time.

An alternative to offering samples of expensive new medications is to order stock bottles of medications that are prescribed frequently in a particular practice.

Most generic medications can be purchased by clinics at reasonable prices. Patients who need to start a new medication can receive a trial supply of the medication, free of charge, to see how they respond. If they do well, they can fill a prescription at a local pharmacy for $4 a month. If they don’t do well, a more expensive medication may be in order. Most pharmaceutical companies offer generous patient assistance programs to qualified patients on some, but definitely not all, of their medications. This is the approach we have chosen, and it works very well.

I do not take issue with utilizing samples appropriately or with helping a patient with the patient assistance paperwork. This is marketing that helps improve patient care.

I do take issue with marketing that is purely marketing. There is no reason that a physician, whose average income is well above that of most patients, should encourage or accept “free” gifts in any form that does not have some direct positive impact on patient care.

Physicians can afford office supplies and food. Physicians can read journals to get unbiased updates on medications. And if physicians choose to get medical information from a representative of a pharmaceutical company, they can certainly do so without being fed.

Until, if, or when universal coverage is available, it is incumbent upon us all to do what we can to control the cost of medical care while providing good health care to all.

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Gail Hacker, M.D., is medical director of the Lane Community College Health Clinic.

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