Case and Commentary
Jun 2006
Case
Dr. Martinez has joined a new rural primary care practice that is affiliated with the academic health center where she just completed her training in general internal medicine. Although nervous about the responsibilities she now has as a practicing physician, she is excited to be working on a daily basis with the medical director of the health clinic, one of her favorite and most trusted mentors, Dr. Francis. The clinic is staffed by two other internists, a physician assistant and three nurses.
Dr. Francis asked Dr. Martinez to be responsible for organizing educational events for the staff including arranging conferences with pharmaceutical sales representatives. A firm believer in the principles of evidence-based medicine, Dr. Martinez relies upon the best-available medical literature for her therapeutic recommendations and is highly skeptical of the educational benefits of pharmaceutical sales presentations. In her experience, the information provided by representatives is usually misleading or, worse, inaccurate. In fact, she was pleased to learn that the academic health center where she did her residency recently decided to bar drug representatives and equipment vendors from visiting its staff without appointments.
During her first few weeks at the clinic, Dr. Martinez was shocked to have received more than two dozen phone calls and e-mails from pharmaceutical sales representatives. After congratulating her on joining the new clinic, they went on to offer her free educational seminars for the staff as well as lots of potentially useful free samples—including a new antihypertensive, birth control pills and allergy medications.
Dr. Martinez schedules a meeting with Dr. Francis to discuss these various offers. He understands her concerns about the validity and substance of the educational material distributed by the drug reps but reminds her that many financially strapped rural patients must pay out of pocket for their medications. Establishing good rapport with some of these pharmaceutical companies and getting a regular supply of free drug samples could be of enormous benefit to our patients, argues Dr. Francis.
Commentary
Dr. Martinez is right to be skeptical about the value of using pharmaceutical representatives for continuing medical education. Her viewpoint is supported by national organizations like the American College of Physicians [1]. Let’s face it: all initiatives from pharmaceutical companies include the goal of marketing their products [2]. They’re hard to escape; a “white coat check” at one teaching hospital found items bearing pharmaceutical company brand names in the pockets of 97 percent of residents [3].
How will Dr. Martinez handle what sounds like a difference of opinion with her mentor and new partner? I hope she realizes that her commitment to evidence-based practice and unbiased sources of information are part of why she was recruited and hired. Teachers learn from their students, and older physicians look to new partners for help in keeping up to date. I would encourage her to give her views freely and directly. If Dr. Francis is unconvinced, she can still do what is right for her. The office receptionist could say, “some doctors in our practice see reps and others don’t.” She can also respect her partners’ views; we don’t all have to do everything the same way.
Samples: Just How Helpful?
The controversy in this case relates to the “free” sample medications Dr. Martinez is offered. In surveys, both residents and practicing physicians think samples are ethically more acceptable than gifts like meals, pens and reflex hammers because they “help” patients [4]. But do they?
In the short term, samples are helpful for patients who would otherwise go without medication. But sample drugs are more expensive than over-the-counter or generic alternatives, and physicians have a strong tendency to continue to prescribe what a patient is already taking rather than switch to a drug they would normally prefer [5]. Patients quickly develop brand loyalty. So what is helpful and free in the short run will probably increase costs later.
What about the effect on Dr. Martinez? Most physicians believe they can do what’s right for their patients and resist the same marketing that influences their peers [6]. In other words, we think we’re all above average (as in the fictional Lake Wobegon) and somehow immune from advertising pressure. At our clinic, we looked at this in a randomized trial [7]. We divided our residents into two groups, one with and one without sample access, and made a list of heavily advertised drugs that showed whether a less expensive generic or over-the-counter alternative was available. We found that the residents with sample access were less likely to prescribe unadvertised drugs or over-the-counter drugs. They developed expensive prescribing habits that may be hard to change later.
Also, some ethicists worry that giving patients a gift with significant monetary value puts a different spin on the patient-physician relationship, creating an imbalance of power rather than working toward a partnership based on mutual responsibility.
Other Ways to Assist Patients
Dr. Martinez’s choices include using samples regularly, never using samples, or using them rarely and only as a last resort. Her decision will be easier if she can identify other ways to help her patients manage drug costs.
She could learn the costs of drugs she commonly uses (easily available online) and make a habit of choosing the least expensive alternatives. Because patients often keep their financial worries to themselves, she could decide to do this for all her patients.
She could form the habit of regularly discontinuing medications that aren’t necessary. Some patients seem to accumulate medications like barnacles.
When asking what medications her patients are taking, she could include the question, “Do you have any trouble getting them?” A nod, or even a raised eyebrow, could signal the need for further questions and perhaps a referral for help. She could be aware that certain demographic groups, such as the elderly, low-income patients and members of minority groups are especially likely to “stretch” medications to save money [8].
She could propose a more systematic approach for her group practice. Realizing that circumstances vary, I will describe some things we’ve tried in our inner-city clinic, where many patients don’t speak English and almost half report not taking prescribed medications because of cost.
One of our receptionists now dedicates one morning a week to helping selected patients fill out paperwork for the “free drugs by mail” programs that most major pharmaceutical companies offer indigent patients. This provides an opportunity for our triage nurses to refer patients for assistance and builds good will.
We hired a part-time social worker to find out whether patients qualify for Medicaid and guide them through enrollment. This employee also signs up patients for Medicare Part D and answers questions about importing drugs from outside the U.S. To come up with her salary, we organized a fundraiser and successfully competed for some philanthropic funds. We were surprised how many people in our community were willing to contribute. Even the mayor showed up.
We asked a local pharmacy to provide a list of the cost of some commonly used medications for hypertension and posted this information by the X-ray view box where doctors would see it every day. We also posted guidelines for hypertension treatment. After 16 months, we were using more thiazides and fewer calcium channel blockers. The average cost per drug decreased for our patients while hypertension control rates improved [9].
We stay in touch with friends working in similar clinics and listen for new ideas.
Some of our doctors have had conversations with local leaders, including members of the state legislature, about the problems our patients face. We don’t have all of the answers, but we can perhaps help them understand the extent of the problem.
We strongly considered refusing all samples, a recommendation with which we sympathize [2]. Instead, we decided to keep our sample cabinet but limit what’s in it to a few essential drugs. We use it mostly with patients who are waiting for the “free drugs by mail” to arrive, usually about a month. We don’t give samples to patients whose insurance covers medications. We don’t give samples when a less expensive drug in the same class is available generically or over the counter. We do have obligatory conversations with the drug representatives, but keep them brief and in the hallway.
This compromise isn’t perfect but it’s workable, for now.
References
- Coyle SL. Physician-industry relations. Part 2: organizational issues. Ann Intern Med. 2002;136(5):403-406.
- Brennan TA, Rothman DJ, Blank L, et al. Health industry practices that create conflicts of interest. JAMA. 2006;295(4):429-433.
- Sigworth SK, Nettleman MD, Cohen GM. Pharmaceutical branding of resident physicians. JAMA. 2001;286(9):1024-1025.
- Gibbons RV, Landry FJ, Blouch DL, et al. A comparison of physicians’ and patients’ attitudes toward pharmaceutical industry gifts. J Gen Intern Med. 1998;13(3):151-154.
- Chew LD, O’Young TS, Hazlet TK, Bradley KA, Maynard C, Lessler DS. A physician survey of the effect of drug samples availability on physicians’ behavior. J Gen Intern Med. 2000;15(7):478-483.
- Steinman MA, Shlipak MG, McPhee SJ. Of principles and pens: attitudes and practices of medicine house staff toward pharmaceutical industry promotions. Am J Med. 2001;110(7):551-557.
- Adair RF, Holmgren LR. Do drug samples influence resident prescribing behavior? A randomized trial. Am J Med. 2005;118(8):881-884.
- Steinman MA, Sands LP, Covinsky KE. Self-restriction of medications due to cost in seniors without prescription drug coverage. J Gen Intern Med. 2001;16(12):793-799.
- Adair R, Callies L, Lageson J, Hanzel KL, Streitz SM, Gantert SC. Posting guidelines: a practical and effective way to promote effective hypertension treatment. Jt Comm J Qual and Patient Safety. 2005;31(4):227-232.
