Dr Geoffrey Spurling from the University of Queensland recently reported for Croakey on a systematic review investigating the impact of pharmaceutical promotion. The authors concluded that medical education should be disentangled from the pharma industry.
He subsequently published this opinion piece in Australian Doctor magazine which may be of interest to Croakey readers.
Geoffrey Spurling writes:
The man in the suit was congenial and efficient as he rolled out sandwiches, pens and clocks while the doctors ignored him and watched his promotional video. I was 16, on work experience at a suburban Brisbane GP surgery and had been invited in for lunch — quite an honour.
What struck me was how rude the doctors were while receiving gifts from the pharmaceutical sales representative. The usual etiquette of expressing gratitude was clearly not in operation in this interaction.
I went on to study medicine at the University of Queensland and enjoyed many drug company-sponsored dinners and events. A night out with your mates and senior colleagues with free alcohol and food was quite irresistible for a cash-strapped medical student. All it cost was a signature for the pleasant sales representative and sometimes a brief presentation about some product or other. I started to expect them. When you are a busy junior doctor, why would you go to a meeting if lunch wasn’t provided?
I became interested in interactions between pharmaceutical companies and doctors after working with Medecins Sans Frontieres in Honduras on a project dealing with Chagas’ disease. The drugs available for this neglected disease of poverty represented a type of market failure as they were developed for veterinary medicine, were only partially effective and had many side effects.
When I returned to Australia, I came to see interactions between pharmaceutical sales reps and doctors through this prism and became concerned that the primary motivation of large, highly profitable pharmaceutical companies is the shareholder rather than doctors. Indeed, it would not make sense for companies to spend $57 billion dollars on promotion in 2004 in the US alone if there was not a share-holder return on this investment.
First, I audited our general practice’s interactions with industry and found that the most heavily promoted drug on post-it notes, pens, models, clocks was … Vioxx!
Each of the seven GPs in our practice was spending at least 40 minutes of consulting time per month on pharmaceutical sales representative visits.
Along with a few other members of Healthy Skepticism, I then spent the next five years conducting a systematic review of all the public scientific literature over the past 40 years, looking at the impact on prescribing of all forms of pharmaceutical information including promotion from sales representatives. Many doctors deny that they are influenced by sales representatives but think that most of their colleagues probably are. We found many studies showed associations between prescribing and sales representative promotion.
I think doctors need to accept that we are more vulnerable to persuasion techniques than we realise. The pharmaceutical industry claims that their information is educational and beneficial. What really surprised us was that we could not find even one study supporting this. We found no clear benefit to prescribing from pharmaceutical promotion and some associations with harm to prescribing. If promotion was a drug, then I think patients would not want their doctors to take that drug.
Pharmaceutical information can also be harmful if it wastes physician’s time or creates a conflict of interest that the public doesn’t like. I was not thrilled to see the cover of a BMJ edition in 2003 portraying doctors as pigs at the trough waited on by pharmaceutical sales representatives characterised as weasels. Some doctors say that seeing reps is okay because they have strict rules for the interaction: “they have to bring lunch”, “they can talk only about new products”, “they have to provide references for their claims”, “I just take the samples but don’t listen to the information”.
My practice manager certainly does not want pharmaceutical sales representatives taking up valuable Medicare-revenue-generating time.
I think it is in the best interests of my patients if I use my precious time by going to independent sources of information. Like the man who recently visited me from the National Prescribing Service. He didn’t give me a pen and he wasn’t wearing a suit, but he told me when to prescribe and also when not to prescribe.
After all this, I only have two rules for pharmaceutical sales representatives: One is to treat them with respect and the other is to not see them.
Dr Spurling is a member of Healthy Skepticism, and senior lecturer in general practice at the University of Queensland.
• This article was first published in Australian Doctor