Brian Morton: Faulty pledge

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.