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During training, I was told, when you’re out to dinner with a doctor, “The physician is eating with a friend. You are eating with a client” — former drug rep
A NEW alliance called No Advertising Please has just kicked off in Australia, and in the lead-up more than 100 doctors from across the country have already pledged to ban pharmaceutical representatives from their surgeries for the next 12 months.
No Advertising Please (NAP) is the initiative of Brisbane GP Dr Justin Coleman, who has won support for the new group from some influential Australian academics and educators, and strong endorsement from the Consumers Health Forum.
Like others supporting the campaign, Coleman is motivated by evidence showing that doctors who expose themselves to marketing tend to prescribe more costly drugs and less appropriately, and by the growing availability of more independent sources of drug information like NPS MedicineWise.
“We want to discourage routine acceptance of promotion”, says Coleman, stressing there is no aim to demonise pharmaceutical companies, which provide many life-improving medicines.
Industry reacted strongly to the new NAP campaign late last week, with comments implying doctors who don’t see reps may be vulnerable to law suits. In a media release Medicines Australia chair Dr Martin Cross said “the idea that you can ignore information from a pharmaceutical company that has conducted extensive research and development to help treat disease is laughable at best and negligent at worst”.
Colleagues at Bond University’s Centre for Research in Evidence-Based Practice stopped seeing drug reps long ago, and they’ve welcomed the emergence of NAP. “We’re not anti-drug and this isn’t anti-pharmaceutical industry”, says Professor Chris Del Mar. “On the contrary, drugs are the mainstay of the different forms of treatment we deliver in primary care. We’re just bothered by the advertising and in particular the advertising that goes through drug reps.”
Professor Paul Glasziou argues there’s a great “opportunity cost” when doctors spend precious medical education time with reps, instead of seeking independent evidence, or meeting in journal clubs with colleagues.
“If I was a patient I’d want to see a doctor who kept up to date by looking at the best evidence, not necessarily by seeing drug reps. When I go to a doctor I want the best treatment, not the latest treatment.”
The Consumers Health Forum also welcomes the initiative as an important sign doctors’ prescribing decisions might be based more on the best independent evidence and less on marketing spin. “It can only boost the level of trust patients place in their doctors to see a NAP poster in their waiting rooms”, says CHF chief executive officer Adam Stankevicius.
For many years, drug reps have provided sustenance to prescribing doctors, offering food, flattery and friendship, along with what appears to be the opportunity to keep up with the latest information. But scandals over misleading promotion where benefits have been hyped or harms played down — think Vioxx, Tamiflu or Avandia — means more doctors are seeking to satisfy their information needs elsewhere.
A growing number of whistleblowers have also raised questions about marketing techniques used by sales representatives — former drug reps in Australia and elsewhere who have revealed how seduction happens, how “key opinion leaders” are groomed and used, and how even sceptical doctors are won over with sophisticated sales strategies.
At the same time a new global push for transparency has culminated in the US Sunshine Act, which will require every payment to every doctor to be made available, with names and numbers on a searchable website.
Australia is dragging its heels, but such transparency reform here is surely inevitable. It was only a couple of years ago that a survey conducted for GlaxoSmithKline found that 50% of Australians consider drug company payments to doctors to be bribes.
For drug companies these are tricky times. One response to changing community expectations has been the rise of the role of “medical science liaison” folk within companies — better trained and ostensibly more separated from the commercial arm, but nevertheless employees who help deliver shareholders a return on investment.
Justin Coleman is hoping that specialists as well as GPs will sign the pledge not to see reps. “After all that work and study, specialists rightly have a position of influence”, says Coleman, “but that privileged position brings responsibility, as the decisions they make about a medication has flow-on effects for GPs and their patients. It’s important those decisions are based strongly on evidence rather than marketing.”
Whether or not No Advertising Please takes off in a big way, with a budget about 1 billionth of the annual spend on drug marketing in Australia, it’s certainly likely to be cost-effective!
Ray Moynihan is a Senior Research Fellow, Bond University
Competing interest: Ray Moynihan is a long-time author and writer on medical matters and has helped launch the new alliance, No Advertising Please.
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During my long years of practice I always saw the drug reps if I could. I would enter into a debate where I believed there information was questionable.I even stated I would not use the product if I felt it was no improvement and even in one case because I felt the advice was dangerous (and suggested that my opinion be reported). On many occasions there input wasquite helpful and more easily understood than through other means. As to the question of it increasing costs, when in the mid 80s generic drugs were being pushed some of my patients were talked into using them with results that caused me to send in over 20 reports of problems. When in frutration I rang the Commonwealth Health Officer he stated that he had metioned the problem to the ‘powers to be’ but they were only interested in the economics. The interesting part was that the patients had the same problems changing from one generic to another. All are not equal. In many cases it doesn’t matter but in quite a few it finished with a rush to emergency (fortunately no deaths).
In my 45 years of general practice there would have been as many corrections of the advice received from “best practice” sources as from drug firm sources. Doctors should have the professional nous to “smell a rat” from either.
In 1998, my colleagues and I monitored the interaction of consenting Australian pharmaceutical representatives and GPs. Sixteen audio-recordings, detailing 64 medicines, were obtained; 38 of the 64 products were prescription-only medicines. Information on indications and on dosage and administration was commonly provided by drug reps, but information on other areas of drug knowledge, particularly product risk, was minimal. Thirteen presentations contained at least one inaccuracy when compared with Australian Approved Product Information. Presentations did not always comply with current guidelines in the Code of Conduct. In addition, GPs rarely questioned drug reps. Fifteen years later, I am unaware if the situation has changed. It would be interesting if this research was replicated by Medicines Australia Monitoring committee or others.
Banning reps completely is, proverbially, throwing out the baby with the bathwater. I have always approached Reps from the position that I can learn something, but always remembering that they are selling a product. We also have to acknowledge that they have a very important part to play in prosthetics and equipment for interventional doctors and surgeons. The days of accepting gifts and other inducements rightly have gone, and we can approach all industry promotions with a healthy scepticism and our medical knowledge, but not with arrogance to think we can’t learn something useful, or be stimulated to research or enquire further into issues that arise out of discussions.
I am now retired from O&G but believe I developed a nice relationship with drug representatives. I was never disdainful of representatives, unlike a group of GP’s I knew about in London. The representative would arrive at the group’s morning tea time,
First up, there was a lot going on in the MJA in the late 1960’s, early 1970’s about drug companies selling our names & addresses to mailing company databases. The companies all denied it. So when I returned from my postgraduate work in UK and set up in private practice, I rang each and every drug company pertinent to my specialty and asked to be placed on their mailing list. Since I set up in a medical centre, this permitted me to give varying perms and combinations of my professional address. I tabulated which address I gave to whom. It turned out there were three mailing co’s. This resulted in a letter I had published in the MJA in 1972 entitled, “The sale of doctors’ names and addresses.”
Secondly, my staff would make appointments with representatives from major companies and some lesser ones with more specialised products in my field. That worked reasonably well, always honouring the appointed time not to keep them waiting too much. Until one day, one of them never turned up, never rang nothing. That’s the day I stopped seeing representatives like this.
Thirdly I only saw representatives where I RANG THE COMPANY seeking details of some new drug in my field. That has worked
I have declined to see drug reps for many years. However they are welcome to drop off reprints of journal articles and other printed product information in my surgery. I read what is relevant to my practice at my leisure and in conjunction with articles published in leading peer-reviewed journals. In that way I avoid the sales techniques of the pharmaceutical industry. I also generally decline offers of hospitality by the pharmaceutical companies, although this can be unavoidable when major conferences have drug company sponsorship. I am happy with this approach and do not see the need to sign a pledge, join a group or impose my personal values on others.
This is the conclusion of the paper sited
“With rare exceptions, studies of exposure to information provided directly by pharmaceutical companies have found associations with higher prescribing frequency, higher costs, or lower prescribing quality or have not found significant associations. We did not find evidence of net improvements in prescribing, but the available literature does not exclude the possibility that prescribing may sometimes be improved. Still, we recommend that practitioners follow the precautionary principle and thus avoid exposure to information from pharmaceutical companies.”
In short there is no evidence to conclude that seeing Drug Reps is good or bad for the doctor or patient. Doctors ae highly trained, fairly intelligent and have usually been exposed to Drug Reps for many years. What makes for a good doctor and good prescribing is not related to seeing or not seeing Drug Reps. What we don’t need is another group of doctors pontificating about what other doctors need to do – there’s plenty of that going around already.