Drugmakers, Doc­tors Get Co­zier

Gifts Con­tinue, Con­tacts In­crease De­spite Guide­lines

The Washington Post Sunday - - National News - By Christo­pher Lee

De­spite ef­forts to curb drug com­pa­nies’ avid court­ing of doc­tors, the in­dus­try is work­ing harder than ever to in­flu­ence what medicines they pre­scribe, send­ing out sales rep­re­sen­ta­tives with greater fre­quency and ply­ing physi­cians with gifts, meals and con­sult­ing fees, ac­cord­ing to sev­eral new pa­pers.

One study pub­lished in the New Eng­land Jour­nal of Medicine last week found that 94 per­cent of doc­tors have some type of re­la­tion­ship with the drug in­dus­try — most com­monly ac­cept­ing free food or drug sam­ples, which about 80 per­cent of physi­cians did. More than one-third of the 1,662 physi­cians who re­sponded to a sur­vey con­ducted from Novem­ber 2003 to June 2004 re­ported be­ing re­im­bursed by the drug in­dus­try for costs of go­ing to pro­fes­sional meet­ings or con­tin­u­ing med­i­cal ed­u­ca­tion, and 28 per­cent said they had been paid for con­sult­ing, giv­ing lec­tures or sign­ing up pa­tients for clin­i­cal tri­als.

Two other pa­pers ex­am­ined in de­tail the strate­gies that phar­ma­ceu­ti­cal rep­re­sen­ta­tives, or “de­tail­ers,” use and how ef­fec­tive the in­dus­try is at in­flu­enc­ing doc­tors.

“We now know that vir­tu­ally ev­ery doc­tor in the United States has some form of re­la­tion­ship with the phar­ma­ceu­ti­cal in­dus­try,” said Eric G. Camp­bell, lead re­searcher of the New Eng­land Jour­nal of Medicine study and an as­sis­tant pro­fes­sor of medicine at Har­vard Med­i­cal School. “They are com­mon. A quar­ter re­ceive hon­o­raria or some form of pay­ment for their ser­vices, and that was much higher than we ex­pected.”

Con­tacts be­tween doc­tors and drug sales­peo­ple have jumped from the av­er­age of 4.4 per month re­ported in 2000, Camp­bell and other re­searchers found. In the sur­vey pe­riod, drug rep­re­sen­ta­tives met with fam­ily prac­ti­tion­ers an av­er­age of 16 times a month, with car­di­ol­o­gists and in­ternists nine or 10 times a month, with pe­di­a­tri­cians eight times a month and with sur­geons four times a month. Only anes­the­si­ol­o­gists, who saw the rep­re­sen­ta­tives twice a month, ap­pear to be meet­ing with the in­dus­try less of­ten than be­fore, the study found.

As those num­bers sug­gest, the com­pa­nies shower more at­ten­tion on cer­tain doc­tors, the re­searchers said. Car­di­ol­o­gists — whose pre­scrib­ing pat­terns tend to in­flu­ence pri­mary care doc­tors — were more likely to be paid for con­sult­ing and other ser­vices than were fam­ily prac­ti­tion­ers, pe­di­a­tri­cians, anes­the­si­ol­o­gists and sur­geons, the study found.

“When I send some­body to a car­di­ol­o­gist, if he puts some­body on a medicine, I’m not go­ing to change it,” said co-au­thor David Blu­men­thal, a gen­eral in­ternist and the di­rec­tor of the In­sti­tute for Health Pol­icy at Mas­sachusetts Gen­eral Hospi­tal in Bos­ton. “If they use a par­tic­u­lar agent, I’m more likely per­son­ally to pre­scribe that agent be­cause I fig­ure the guy is an ex­pert and he has got some rea­son for pick­ing that brand as op­posed to some other brand.”

The ties be­tween doc­tors and drug com­pa­nies are deep­en­ing de­spite vol­un­tary guide­lines to curb ex­cesses, adopted in 2002 by the Amer­i­can Med­i­cal As­so­ci­a­tion, the Amer­i­can Col­lege of Physi­cians, the Ac­cred­i­ta­tion Coun­cil for Con­tin­u­ing Med­i­cal Ed­u­ca­tion and the Phar­ma­ceu­ti­cal Re­search and Man­u­fac­tur­ers of Amer­ica. The in­spec­tor gen­eral of the De­part­ment of Health and Hu­man Ser­vices is­sued sim­i­lar guid­ance in 2003.

Un­der the in­dus­try code, gifts must be worth less than $100 and should pri­mar­ily ben­e­fit pa­tients — items such as stetho­scopes or med­i­cal dic­tio­nar­ies. Meals should be “mod­est” in cost, and a physi­cian’s spouse should not be in­cluded. Gifts of cash or tick­ets to sport­ing events are in­ap­pro­pri­ate. Con­sult­ing ar­range­ments must be for real ser­vices, and doc­tors should not be paid for lis­ten­ing to mar­ket­ing pitches.

“Clearly, ad­e­quate safe­guards are al­ready in place,” Ken John­son, se­nior vice pres­i­dent of the drug in­dus­try as­so­ci­a­tion, said in a state­ment. “The goal is to make sure the fo­cus of con­ver­sa­tions be­tween com­pany rep­re­sen­ta­tives and physi­cians re­mains pro­vid­ing ac­cu­rate in­for­ma­tion about medicines.”

A for­mer in­dus­try in­sider, how­ever, painted a dif­fer­ent pic­ture in an ar­ti­cle last week in PLoS Medicine, a jour­nal pub­lished by the Pub­lic Li­brary of Science. Shahram Ahari, a for­mer drug com­pany rep­re­sen­ta­tive, and physi­cian Adri­ane Fugh-Ber­man wrote that the es­ti­mated 100,000 rep­re­sen­ta­tives who visit doc­tors’ of­fices look for de­tails such as fam­ily pho­tos or hob­bies that they can use to forge a re­la­tion­ship. They use food, gifts and money to make of­ten-over­worked doc­tors feel more ap­pre­ci­ated — and more loyal to the com­pany’s drugs. If a physi­cian will not meet with them, the rep­re­sen­ta­tives of­ten woo the of­fice staff with flat­tery and meals.

“Phar­ma­ceu­ti­cal gift­ing . . . in­volves care­fully cal­i­brated gen­eros­ity,” Ahari and Fugh-Ber­man wrote. “Many pre­scribers re­ceive pens, notepads, and cof­fee mugs, all items kept close at hand, en­sur­ing that a tar­geted drug’s name stays up­per­most in a physi­cian’s sub­con­scious mind. High pre­scribers re­ceive higher-end presents, for ex­am­ple, silk ties or golf bags.”

Drug com­pa­nies also pur­chase pre­scrip­tion records from phar­ma­cies and, with the help of an Amer­i­can Med­i­cal As­so­ci­a­tion data­base, iden­tify in­di­vid­ual physi­cians’ pre­scrib­ing pat­terns and rank doc­tors based on how many pre­scrip­tions they write, the au­thors wrote.

The tac­tics work. An­other study in PLoS Medicine last week found that vis­its by de­tail­ers prompted nearly half of 97 physi­cians to in­crease pre­scrip­tions of gabapentin, a drug ap­proved to treat seizures. In many cases, the drug rep­re­sen­ta­tives were push­ing non-ap­proved, or “off-la­bel,” uses of the drug, the study found.

A study in the Jour­nal of Gen­eral In­ter­nal Medicine in Fe­bru­ary found that physi­cians in fo­cus groups said that they un­der­stand the po­ten­tial con­flicts of in­ter­est but that they still view their meet­ings with drug de­tail­ers as in­for­ma­tive and ap­pro­pri­ate. Such find­ings sug­gest that vol­un­tary guide­lines are in­ad­e­quate, re­searchers wrote.

In an in­ter­view, one Dis­trict-based physi­cian, or­tho­pe­dic sur­geon Peter E. Lavine, said that drug rep­re­sen­ta­tives used to visit his of­fice daily but have cut back in re­cent years to stop­ping by about twice a week. The con­duct guide­lines have elim­i­nated most ex­cesses, Lavine said, and many doc­tors view the ses­sions as a way to learn about side ef­fects and how drugs com­pare.

“The vast ma­jor­ity of physi­cians ap­pre­ci­ate the in­for­ma­tion but find them [de­tail­ers] as a nui­sance,” said Lavine, chair­man of the Med­i­cal So­ci­ety of the Dis­trict of Columbia.

“They al­ways tend to come in the mid­dle of the day when you are busy see­ing pa­tients, and it’s very dif­fi­cult to break away and talk to them. And if they’ve bought lunch for the staff, then you are sort of ob­li­gated to give them a lit­tle bit of your time. I think they cer­tainly have a valu­able ed­u­ca­tional ben­e­fit. I don’t think that physi­cians are go­ing to change their pre­scrib­ing pat­terns for free sam­ples.”

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