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THE “pledge” of the No Advertising Please campaign to refuse to see pharmaceutical company representatives is an emotive approach that, because of politically correct connotations, has captured the media’s attention.
The unstated implication is that the GP is unable to critically examine what’s presented by the rep or that drug reps are the GP’s sole source of information or education relating to pharmaceuticals.
Let me state upfront the AMA’s view:
- It is open to any doctor to decline visits from pharmaceutical company sales representatives
- Some doctors see these visits as sales pitches while others use them as opportunities to increase their knowledge on certain medicines
- Some patients receive benefits from free access to pharmaceutical sample packs that the representatives sometimes leave with doctors
- The education events that pharmaceutical companies host are one, but not the only, source by which doctors learn about new medicines and improvements to existing medicines
The AMA has a position statement on the medical profession’s relationship with the pharmaceutical industry.
The pledge is unnecessary and demeaning given the World Medical Association Declaration of Geneva, which says, in part: “I will practise my profession with conscience and dignity; the health of my patient will be my first consideration; … I will maintain by all the means in my power, the honour and the noble traditions of the medical profession”.
New graduates affirm this oath (or similar), so at what point do they lose their intellect and therefore need to make such a banal pledge?
My contention is that GPs must use their skills and training to inform and educate themselves for the benefit of their patients using all the resources of information available — whether written or verbal, from a pharmaceutical company, a learned college, a clinical guideline, a research paper or clinical trial reports.
Are doctors influenced by the pharma rep visits? Well yes, simple logic attests to that and there is evidence supporting changes in doctors’ behaviour.
So let’s look at the evidence, rather than accepting it without scrutiny, to see what it is actually saying? Do the conclusions reached and publicised on the No Advertising Please (NAP) website have the rigour expected given their stance?
The evidence section of the website mixes personal observations with quotations and citations from the literature that are not always interpreted appropriately.
The prime study quoted is a systematic review of mainly observational studies, which would be placed at a Level lll or more likely Level lV in levels of evidence hierarchy. An editor’s summary published with the review in PLOS Medicine acknowledges that the observed effects do not allow a causal interpretation and it doesn’t assure that the time-direction of the association is clear.
“Because most of the studies included in the review were observational studies — the physicians in the studies were not randomly selected to receive or not receive drug company information — it is not possible to conclude that exposure to information actually causes any changes in physician behavior”, the editor’s summary says.
Other studies quoted on the website, which are used to extrapolate US market behaviour to the Australian health system, are inappropriate as the regulatory environment here is different. Most of the data are also more than 10 years old so don’t take account of recent regulatory changes.
It is disingenuous to suggest that all pharmaceutical materials are of dubious quality and contain misleading information. Do we not believe the product information?
Blaming pharma reps for overdiagnosis and overtreatment is simplistic as these are multifactorial problems that often relate to other issues such as inappropriate extrapolation of guidelines.
I don’t doubt that pharmaceutical marketing influences clinician behaviour but I challenge the assertion that it is a uniformly negative influence — the current evidence does not support this.
Censorship or prohibitions are not acceptable as methods for professional behavioural change, which is effectively the purpose of the NAP pledge. It is naive to suggest that doctors who sign the pledge will as a consequence “source best independent evidence”.
There are multiple systemic issues that need to be addressed to change GP prescribing behaviour, and limiting it to a pledge that blames one sector of the health care industry distracts from and avoids examination of the real-world causes of poor prescribing.
Dr Brian Morton AM is a GP practising in Sydney and chair of the AMA Council of General Practice.
Thanks Rose
I couldn’t agree more with your comments about the marketing influence on specialists as well. The ‘No Advertising Please’ campaign is equally directed at specialists and has never limited itself to GPs. We also recognise that drug reps are only one piece of the puzzle when it comes to increasing the role of independent evidence and decreasing the role of marketing.
Other commentators have pointed out the related issues of marketing influence over guideline working parties, ‘key opinion leaders’, pharmacists, sellers of supplements and alternative health practitioners, all of which are also important. Many members of the ‘NAP’ campaign are also actively involved in some of these other areas.
We felt it was ideal to launch at a conference which a few of us would be attending anyway (we are scattered all over Australia and have no budget whatsoever), and the RACGP were kind enough to offer us a place to launch at GP14. It is not surprising, therefore, that media reports focussed on GPs, but the information on our website refers to doctors generally.
It is ridiculous to blame GPs as the main target of drug company influence, when our patients are being prescribed expensive new drugs by specialists who appear to me to be obviously influenced by drug companies to prescribe the most expensive new drugs in high doses , such as the oral anticoagulants in place of Warfarin, which is much cheaper, and according to NPS data , has a lower incidence of certain bleeding, and is reversible, which is most relevant in rural areas without transfusion services. If patients have been stabilised for years on Warfarin, with monthly INRs which can be done at the Pathology service, GP, rural ED, I see no need for the expensive new drugs.
High doses of expensive lipid-lowering agents are being prescribed by specialists to patients whose cholesterol is below normal, and to patients who have never seen a dietician.
It is the same with the antipsychotic medication, such as Seroquel, which some private specialists prescribe for elderly patientss who are not psychotic.
Roaccutane is prescribed by some Dermatologists as a first-line drug for acne.
Some Paediatricians and some Psychiatrists after a five to ten minute consultation are handing out Ritalin and Dexamphetamine which is being sold, injected, etc,
Whether some private specialists are prescribing to guarantee a clientele, or they believe the drug company propaganda , I do not know.
I do know that the GP is not the only doctor influenced by drug companies.
As a junior, recently fellowed GP who has signed the pledge, I feel strongly about freedom of choice for registrars. Like patient decisions about medical treatment, every doctor should make an informed choice about seeing drug reps.
First, we should be informed, and reading the evidence summary on the NoAdvertisingPlease page is a good start. Second, we need to feel free to choose. I know as a GP Registrar, when my supervisor saw drug reps, I felt an obligation to see the reps too. They occupied my lunch space, after all – to not see them would have felt confronting. I have been fortunate to have since trained in practices where my supervisor did not see reps, and instead saw NPS educators etc. The improvement in learning quality was a revelation to me. I worry many GP registrars do not receive this drug-rep free experience. I hope, through the NAP campaign, that doctors will inform themselves, so that perhaps not seeing reps can become just as normal as seeing reps is now, and our future GPs can have a truly free, informed choice.
I have signed the pledge and am also a co-author on the review by Geoff Spurling.
The review aimed to bring together the best available evidence on the effects of pharmaceutical representatives on doctors’ prescribing. Given that we can’t randomise doctors to seeing reps or not seeing them, the review is the best available evidence and shows that at best prescribing is not improved and probably is harmed.
The published evidence is helpful, but what convinced me to stop seeing drug reps was my own experience. There was a consistent gap between the evidence I was seeing in journals and the evidence given to me by drug reps, always biased in the drugs’ favour. The ways that companies did this included not using appropriate comparators, not using clinically important outcomes, not reporting the side effects seen in trials, and the list goes on and on. Once I realised that there were better sources of information, I stopped seeing the drug reps and freed up my time to do things that might benefit my patients more.
Drug reps are called SALES-representatives for a reason – hence they are neither paid educators nor is their performance measured by how patient outcomes improve in their GP cohort – it is measured and remunerated solely on increased SALES/prescriptions – independent of research, best evidence or indeed best practice.
So as asked above, could Dr Morton explain what exaclty is the evidence/NNH/NNT to support his notion that we should regularly free up some of our precious spare time to listen to a carefully crafted sales-pitches delievered to change our prescribing towards increased sales, not improved outcomes?
I have signed the pledge, and have been involved in the campaign.
Contrary to Brian Morton’s assertion that “The unstated implication is that … drug reps are the GP’s sole source of information or education relating to pharmaceuticals,” there is quite a comprehensive page on the website that discusses other sources of information (http://noadvertisingplease.org/evidence/where-do-i-find-better-independe…). These sources of information are independent, and often don’t overstate benefits and understate risks, crucial information for all prescribers. Given that drug reps often overstate benefits and understate harms, I’d much rather get higher quality, independent information and education, as it is a much better use of my time.
Even if Dr Moreton doesn’t think the evidence on the NAP website is very good evidence, he cites none at all in favour of his position. As doctors, we are quite used to working in situations of imperfect evidence, and my reading of the current state of the evidence is that there is no evidence anywhere that suggests our prescribing is improved by seeing reps, and some evidence suggesting it is worse. Perhaps more importantly, there is also evidence that suggests we all believe we are very good at resisting the charms of advertising, though we believe others aren’t. We can’t all be right!
Perhaps swearing the Declaration of Geneva makes us immune to advertising, but another ancient piece of medical wisdom – do no harm – should make us cautious. It wasn’t the reps who warned us about Vioxx, Avandia or Pradaxa.
NAP doesn’t seek to ban reps, just to help inform individual doctors’ choiices, exactly as Dr Morton states.
I think it is positive and rational that Dr Brian Morton accepts that drug reps influence prescribing and it is reasonable to critique the results of observational studies though it is hard to imagine how one might design an independent randomised controlled trial of pharmaceutical promotion. I also agree with Dr Morton that doctors are unlikely to be uniformly negatively influenced. Our systematic review, which he cites didn’t make this finding. The pharmaceutical industry often says that doctors are way too clever to be hoodwinked by marketing and to some degree I agree. I think doctors are quite a hard sell compared to other consumers. However, doctors are told they are clever over and over from when they are medical students and I think there is a great danger that we lose a vital ability for self-critique. There is evidence that doctors (admittedly North-American but I am not sure that they are all that different to Australian doctors) rate information from pharmaceutical companies as good or excellent when important safety information was missing (http://www.ncbi.nlm.nih.gov/pubmed/23558775).
What was clear from our systematic review was that evidence of educational benefit from pharmaceutical promotion was lacking. I think doctors are aware of NPS radar as an independent source of information about new drugs (as opposed to Womens Weekly) and I had a great detailing session this morning on asthma from an NPS representative. We get in these habits from medical school of seeing pharma as our source of information. It becomes part of our culture – normalised and hard to imagine otherwise. The findings of our review indicates that we would serve our patients and use our time better if we use independent sources of information.
Dr Morton criticizes the PLOS Medicine systematic review of research quoted by the NoAdvertisingPlease group, but does not offer a single piece of evidence in its place. The question for a GP is: Is there any evidence that seeing pharmaceutical representatives will improve my care of patients?The systematic review found that the answer from the available evidence suggests is “no: either there is no impact or prescribing is worse”. Given the limited hours for CME, isn’t it sensible to focus on educational methods that improve practice? Does Dr Quittner really think clinicians would not find out about a cure for Ebola unless “company representatives” visited? That demeans clinicians learning abilities and the capacity of independent information sources to inform us.
The effect of rep visits:
Rep visits increase prescribing costs
Rep visits reduce generic prescriptions
Caudillet al Arch Fam Med 1996. Lurie et al J Gen Intern Med 1990. Peay Peay Soc Sci Med 1988. Bower & Burkett J Fam Pract 1987. Haayer Soc Sci Med 1982.
A belief that there is no influence is associated with greater influence
Peay & Peay Soc Sci Med 1988. Wazana JAMA 2000;283:373-80
GREAT NEWS – A PHARMACEUTICAL COMPANY HAS JUST INVENTED A NEW LIFE-SAVING DRUG.
They spent $millions on research in the finest medical institutions supporting some of the world’s best medical minds.
BAD NEWS:
This treatment to cure the Ebola virus, or halt Melanoma or prevent birth defects will not be explained or promoted to some doctors, who will not permit company representatives to speak with them.
No doubt those doctors will read about the new drugs in the Womens Weekly or daily tabloid…and eventually they may even find it in their erudite medical journals (of course they will eschew the lightweight free medical mags with their tainted advertorials).
The goose which lays the golden egg of medical progress has indeed been killed by political correctness.