Doctors as touts
I suspect everyone has things they’d like to believe about themselves that are probably not really true. We all have our happy fictions, some closer to reality than others. Perhaps we’re not as funny or handsome or clever as we’d like to think, but it helps us get out of bed in the morning to think so anyway.
For my part, I’d love to think that I am flinty and discerning. I’d love to tell myself that I would never make any clinical decision for any reason other than that it was clearly indicated for the patient’s best interest. Whatever the blandishments and enticements a pharmaceutical company might wave before me, I would stick with cheaper, older and better medications instead of their new, brand-name alternatives. Other doctors would succumb, either with happy ease or due to subtle suggestibility, but not me.
This is probably not true.
I only ever went to one Yankees game when I was living in New York City. I’m not much of a sports fan, so attending games was never high on my list of things to do with my leisure time. That said, I like baseball well enough, and with the right company would happily go if invited.
So when box seats right by the third base line were offered to me, I gladly took them. As it happened, my brother was visiting, and what better experience could I offer than that? The seats were free, and were offered to me and a few other residents when the usual beneficiaries of the owners’ largesse demurred.
The seats belonged to a drug company. They were fabulous, and their proximity to the field helped me get a good-enough look at Derek Jeter to cement a bit of a celebrity crush.
Now, pharmaceutical reps weren’t allowed to ply residents at my hospital with gifts and free meals and whatnot. But apparently this ban didn’t apply to the attending physicians/administrators. (Make of that what you will. I did not find it wholly surprising.) I don’t know how often they found themselves taking in a game or whatever other trinkets and treats they might have been offered, but there I was that one night when there were no other takers. I don’t think it’s unreasonable to conclude that such gifts were not novel to them.
For as long as I’d been cognizant of the issue, I’d always found the free gifts that drug companies gave to doctors unseemly. Taking the tickets that night didn’t feel particularly unethical, as they were cast-offs and I don’t think we even knew which company had given them. I’d like to think, were such offers a regular thing, I’d have had the fortitude to turn them down.
But man, that was a fun way to see a ballgame.
The question was mooted for me, because just as I was leaving residency the pharmaceutical industry voluntarily adopted guidelines banning such gifts as sports tickets and trips to exotic locations. In 2009, they stopped giving out little things like pens with their drugs’ names on them. I always used to say “Show me a drug rep pen, and I’ll show you a cheap doctor.” But some of those pens were pretty nice.
I’d like to think I’d have turned it all down, anyway.
Earlier this week, GlaxoSmithKline announced that it would stop paying doctors to give talks promoting its drugs. Since such talks are ostensibly educational, they have persisted despite the ban on outright gifts. If you wanted to listen to a doctor talk to you about the wonders of Advair, Glaxo was happy to pay one to tell you about them.
These talks are different from lectures that physicians might deliver at an academic conference, for example. Those talks are meant to be free from any kind of bias, whereas a lecture sponsored by a drug company (though also technically supposed to be “free” of “bias”) cannot plausibly claim to be. However, whenever a doctor on the payroll of a pharmaceutical company does deliver an academic lecture (or submit a study for publication), he or she is required to disclose that relationship to the audience at the outset.
You know who pretty much never hears about those relationships? Patients.
At my previous job, drug reps would sometimes stop by with samples and to chat amiably with us. Since samples really can be helpful for patients who might benefit from the medication but are not be able to afford it if they lack insurance that covers it, there was a plausible patient benefit to these visits.
Nevertheless, I was usually pretty frosty. I had specific objections to how certain companies marketed their products, and I was all but overtly hostile to their reps. But then there was the eye drop guy.
He was affable and charming. Honesty demands I disclose that he was also cute. He was there to drop off samples of two different drops, one for ears and one for eyes. I didn’t mind so much when he stopped by.
The ear drops actually had a clinical benefit that made them superior to various alternatives. The eye drops, however, were to treat conjunctivitis. Conjunctivitis is usually viral, and even if there is a bacterial cause it almost always goes away on its own. I hate prescribing eye drops, though sometimes I do if the parents really want them.
I’d like to think the handful of times I prescribed those expensive new drops, it was because I thought they were clinically indicated. They were certainly more convenient to use than cheaper alternatives, and there were a few cases where patients didn’t get better on the latter. I’d like to think it wasn’t because I knew that chummy drug rep could access my prescribing information, cheerfully provided by the AMA, and would know that I never prescribed his medication. I never accepted more than a handshake from the man, and it would be horrifying to think that I would ever prescribe a medication simply so some relative stranger would like me better.
I haven’t prescribed those expensive drops a single time since taking my new job, where I interact with drug reps not at all.
As I mentioned, I am genuinely hostile to what I consider to be the insidious influence of pharmaceutical companies on physician behavior. The AMA’s policy of selling prescribing data to Big Pharma is one of my cardinal reasons for not being a member. Perhaps I flatter myself, but I sincerely hope that I am more resistant than most to whatever lures they might dangle in front of me to sway my own practices. Lord knows, I’d never be a part of a drug company’s speaker bureau (full disclosure: I’ve never been asked) and those few sponsored meals I attended as a resident were too mediocre to tempt me to attend more.
I’d like to think that about myself. And I’m sure pretty much every other doctor would like to think so, too. I suspect few physicians would readily admit “One thing I’ll say about myself, I sure am credulous!” We all want to think our minds are air-tight, our clinical judgment unimpeachable.
Nobody wants to think they’re an easy mark.
But the drug companies weren’t flying doctors to Aruba for the hell of it. Glaxo wasn’t paying doctors to shill for their medications because physicians are just such eloquent speakers. Even the little notepads and pens, gimcrack bits of office flotsam, probably influenced far more prescribers than would care to admit it. The drug companies employed those methods because those methods worked to increase sales of their drugs.
Whatever GlaxoSmithKline’s reasons for abandoning its payments to doctors, I applaud the move. As with the earlier industry decisions to voluntarily give up festooning physicians with free swag, I imagine the company wants to get out in front of potential restrictions that might have been placed on such practices in the future. Since “drug companies pay doctors to tout their medications” certainly sounds bad, with ever-increasing demands for transparency in the medical community it’s plausible that calls for a mandatory ban would have arisen sooner or later. Best to make it seem as much like a choice as possible.
Patients are entitled to the best clinical judgments we can render. It is our ethical obligation to them to choose the most effective and least costly from all our possible options. Anything that skews those judgements away from patient care and toward a profit margin should be strenuously avoided. I hope Glaxo is only the first member of the industry to abandon the problematic practice of using doctors as touts.
Because I’m sure those doctors on the pharmaceutical payroll would tell you that they never let that relationship influence their clinical decision-making. But we all have stories we like to tell ourselves.