Bedside and Conference Detailing
Interactions with pharmaceutical representatives (drug detailers) often begin in medical school and proceed throughout a physician’s career (12,14). In 2003, the pharmaceutical industry spent more than 13 billion dollars on promotional activities for doctors, an average of about $10,500 per physician. There is one drug detailer for every 4.7 office-based physicians. Interactions include conferences with free lunch, personal visits by drug detailers, sponsored CME workshops/seminars, sponsored dinners, sponsored scientific conferences, sponsored research, direct gifts (e.g., cash payments for prescribing a given medication), and indirect gifts (e.g., subsidizing a trip to a medical conference). These interactions evolve from merely lunches and pens early in a physician’s career to positions as a consultant and advisory board honoree as the relationship matures. Some physicians view such exchanges as helpful and informative while others view it as unethical (2) and harmful.
Hospitalists, residents, and medical students alike believe their interactions with drug detailers, and the small gifts that they receive, do not influence their behavior (14,15). Wazana found that as physicians continue to receive gifts from drug detailers, they become even less likely to believe that the gifts can influence their behavior (16). Many physicians believe that their interactions with drug companies are beneficial not only to them but also to their patients. However, studies have found that this is in fact not the case. Physicians who interact with pharmaceutical representatives prescribe newer and more expensive drugs, rather than cheaper and equally effective generic drugs (16,17). There are a significantly higher number of prescriptions written for the drugs manufactured by pharmaceutical companies who sponsor a given CME activity than pharmaceutical companies who do not. A rise in prescription expenditures (17), as well as an increase in irrational prescribing, often follows in-house exposure to drug detailers (16).
The enormous amount spent on marketing can also be used as further proof of the pharmaceutical industry’s avarice. However, we often fail to acknowledge the role that medical educators and professionals play in this problem. Pharmaceutical companies are profitable because of our prescribing habits. For example, many medical professionals prescribe expensive “me too” drugs that often offer little if any benefit over cheaper established or prototypical drugs. Our actions encourage what we claim to be bad behavior by the pharmaceutical industry.
It is often argued by the pharmaceutical industry that these “me too” drugs have a different side effect profile, may improve compliance in long-term treatment, or will reduce cost when compared to the prototype drug. This is true in some instances, as exemplified by the wide array of anti-hypertensives and the even wider array of side effect profiles. However, there are many instances when this is far from the case. If a financial incentive did not exist for pharmaceutical companies to introduce “me too” drugs, the pharmaceutical industry would not do so unless the drug being introduced provided a substantial clinical advantage over the prototype drug. As a result, the pharmaceutical industry would be spending their time, effort, and finances on research aimed at finding new and innovative cures.
Proposed Solution to the Problem
In an effort to remedy this situation, many professional societies (as well as the pharmaceutical industry itself) have established guidelines on the interactions between the pharmaceutical industry and physicians. The AMA has established guidelines responsible for the regulation of gifts bestowed on physicians by industry (18). The Pharmaceutical Research Manufacturers of America has established similar guidelines known as the PhRMA Code (19). Increasingly, many professional organizations have taken it upon themselves to establish their own code of conduct. However, there remains a low level of awareness of the guidelines (15) that are currently in place, and some of the pharmaceutical companies have chosen not to abide by the PhRMA Code. In response to the increasing influence pharmaceutical companies are having on the medical decision-making process, many training programs are adopting policies to limit the contact between pharmaceutical representatives and physicians in training. This is being carried out at both the undergraduate and graduate medical education levels (20). The effects of such restrictions are currently unknown. McCormick found that physicians who trained in institutions with such policies were less likely to find information from pharmaceutical company representatives useful (20). However, Ferguson found that being trained in a program with a policy that limited access to pharmaceutical sales representatives did not affect the subsequent likelihood of future physician-pharmaceutical representative interactions (21).