The Informed Hospitalist in the 21st Century
The literature clearly documents that the pharmaceutical industry influences physician prescribing habits. Hospitalists can take a four-prong approach to help counteract these effects:
1. Academic Detailing
Medical educators can shield residents and medical students from the influence of pharmaceutical representatives by limiting or prohibiting contact, or they can teach trainees how to effectively manage such interactions through academic detailing. As stated above, Ferguson found that policies limiting access to drug detailers did not affect the subsequent likelihood of future physician and pharmaceutical representative interactions (21). It might be wiser to teach trainees how to manage their interactions with the drug representatives and thereby take control of the situation. In order for doctors to effectively manage such interactions, we must learn how to evaluate the literature and interpret the information given to us by representatives. Watkins found that both attendings and residents feel that they should learn how to critically evaluate promotional materials, recognize potential conflicts of interest, and consider how patients perceive physician-pharmaceutical relationships (22). Previous studies have found that educational interventions can have a significant effect on the attitudes of medical students and residents towards pharmaceutical marketing and drug detailers (23,24).
One way to evaluate pharmaceutical literature is to have academic detailing of the clinical studies and statements made by pharmaceutical detailers at sponsored events. During these academic detailing conferences the drug in question can be compared to other drugs in the class, and indications and differences should be mentioned if they exist. This should be done in the presence of both an attending who is very familiar with the drug and drug class in question and a hospital pharmacist. If this is done in a small setting, the medical students and residents can take turns critically evaluating the presentations. This approach is comparable to teaching medicine at the bedside; learners develop a deeper appreciation and understanding by experiencing various situations first-hand.
An additional benefit of critically evaluating pharmaceutical representative presentations is that when they know that the information they provide will be closely scrutinized, pharmaceutical representatives will have an incentive to provide more accurate information.
2. Cost Sensitivity
One of the many topics that can be discussed by the hospital pharmacist or attending is the price of the given drug. In discussing price, two critical points must be evaluated. The first is the price-benefit ratio of the given drug and the second is the financial situation of the patient. Physicians should always have the patient’s best interest in mind. However, this does not mean that cost should not be considered when making therapeutic decisions. Rather, a more practical therapeutic decision can be made with cost in mind. Cost is the major factor to some patients when determining whether they will fill their prescriptions. In such an instance, if cost is taken into consideration when writing the prescription, a physician is more apt to write a prescription for a less expensive medication (if one exists).
3. Three-Way Transparency
In order for hospitalists to effectively interact with the pharmaceutical industry, it must be realized that medical professionals are not victims of the marketing strategies of the pharmaceutical industry; rather, we are accomplices. We often fail to acknowledge the role medical educators and professionals play in this problem. Many years ago, Troyan Brennan called for transparency, stating “Conflict will remain with us. Physicians’ relationship with the pharmaceutical industry must be better managed” (25). However, Brennan did not offer any proposals on a better management system. Our current management system of disclosure of conflict has become obsolete. It has become a ritual practice in academia to acknowledge that one may have a conflict of interest, but this does nothing to address the real issue: the conflict of interest itself. Hospitalists can adopt a three-way transparency between the patient, colleagues, and the pharmaceutical industry where all conflicts are fully disclosed, rather than simply stating that a conflict might exist.