Rx for Change: Waiting Room Activism

By Adrianne Fugh-Berman
Rx for Change (Nov/December 2005)

“Even the scale I was weighed on had the name of a drug on it – a weight loss drug,” said my friend, after visiting her doctor. If it’s any consolation, the ad wasn’t directed at her. A doctor’s scale is a more extravagant present than the mugs, pens, Post-it notes, and clocks usually on display in doctor’s offices, but they all serve the same purpose: to keep the names of specific drugs uppermost in the subconscious of the doctors who are surrounded by the ads.

It’s no secret that pharmaceutical companies provide food, entertainment, trips, and funding to physicians in practice and physicians in training (a term that covers both residents and medical students). A recent study found that third year medical students received one pharmaceutical company-sponsored gift, or attended a sponsored activity each week. Medical residents attend up to eight lunches or rounds (lectures) sponsored by industry each month of their training.1 Physicians in training aren’t sneaking off duty to go to these events; attendance is often required. Most of the speakers are chosen by the medical school or hospital, but the drug reps (who prefer to be called pharmaceutical representatives) may choose some of the speakers, and/or be permitted to give an advertising spiel before the feature presentation.

Studies consistently show that promotion increases prescribing of targeted drugs; studies also consistently show that most medical students, residents, and physicians believe that their prescribing habits are not affected by interaction with pharmaceutical companies.

Wonder why drug prices are so high? Pharmaceutical promotion of the most expensive drugs is the main reason, and the primary method of pushing expensive drugs is via the 100,000 drug reps in the country – about one for every six doctors. On average, drug reps make more than $75,000 a year, plus bonuses, a company car, and an expense account. A recent Government Accountability Office (GAO) report found that drug costs now account for 10.7 percent of health care expenditures.2 And that number doesn’t include the costs of complications caused by inappropriate prescriptions.
Doctors aren’t evil. Most docs are hardworking, overburdened, and really want the best care for their patients — but they don’t have time to read medical journals and so they depend on information from drug reps, who are cheery and attractive and conveniently come right to the office, and may bring lunch for the staff. Doctors don’t realize how much they are manipulated. The relationship between pharmaceutical companies and medicine is both close and complex; pharmaceutical company largesse has become institutionalized in medical culture.

Let’s not blame individual physicians for a systemic problem. Entitlement is so embedded in medical culture that, in 2000, the American Medical Association (AMA) planned to fund an educational campaign for doctors about the ethics of accepting industry gifts, with, you guessed it, pharmaceutical company money. That decision, greeted with merciless hilarity by the media and the public, was later reversed.
The AMA, never a paragon of public health values, states in its current guidelines on Gifts to Physicians from Industry: “Many gifts given to physicians by companies in the pharmaceutical, device, and medical equipment industries serve an important and socially beneficial function”(3). Hmm. Most doctors really wrestle with the questions of whether to see drug reps and what to accept from them. But even doctors who refuse the junket trips and expensive meals have no problem taking notepads and pens from pharmaceutical companies because they are inexpensive. That’s an AMA-endorsed position; the guideline on gifts states that: “Individual gifts of minimal value are permissible as long as the gifts are related to the physician’s work (e.g., pens and notepads)”(3).
Drug company paraphernalia is so ubiquitous in offices that the docs don’t even notice it, at least consciously. But it’s a dead giveaway that the doc sees drug reps, and seeing drug reps is the biggest risk factor for prescribing the most expensive and most marketed drugs. The evidence that your doctor sees drug reps will be on his or her desk, because reminder ads only work their subliminal magic when they are constantly in front of the intended victim.

That’s where you come in. When you see drug rep droppings in your doctor’s offices, treat it like the evidence of the pestilence it is. You don’t have to be confrontational; you could say, for example, “Doc, I’m concerned that having ads for drugs on your clock and mug and notepads and pens and jelly bean jar makes it look like you’re bought and paid for by pharmaceutical companies. Do they pay you a lot to advertise their products?” After the doctor denies being paid, you can raise your eyebrows and say: “So, let me get this straight…you’re advertising their products for free?”
Got a doctor’s appointment? Arm yourself with information from www.nofreelunch.org and a great blog called Health Care Renewal (www.hcrenewal.org) and take advantage of the time in the waiting room to organize the other patients sitting there. Maybe patient pressure can help doctors kick the drug rep habit.

References

1. Zipkin DA, Steinman MA. “Interactions between pharmaceutical representatives and doctors in training. A thematic review.” J Gen Intern Med. 2005; Aug 20(8):777-86.
2. Government Accountability Office. Price Trends for Frequently Used Brand and Generic Drugs from 2000 through 2004. http://www.gao.gov/new.items/d05779.pdf Accessed 9/24/05.
3. AMA. “Gifts to Physicians from Industry.” Chicago, IL: AMA. Available online at: http://www.ama-assn.org/ama/pub/category/8484.html

Other Sources

Chren MM, Landefeld CS. “Physicians’ behavior and their interactions with drug companies. A controlled study of physicians who requested additions to a hospital drug formulary.” JAMA. 1994: Mar 2;271(9):684-9.

Lurie N, Rich EC, Simpson DE, et al. “Pharmaceutical representatives in academic medical centers: interaction with faculty and housestaff.” J Gen Int Med. 1990;5:240-243.

Wazana A. “Physicians and the pharmaceutical industry: is a gift ever just a gift?” JAMA. 2000;Jan 19;283(3):373-80.

Sierles FS, Brodkey AC, Cleary LM, et al. “Medical students’ exposure to and attitudes about drug company interactions: a national survey.” JAMA. 2005;294:1034-1042.E-8.061