Here’s what I remember. It was 14 years ago, and I was a junior doctor working in psychiatry. Some colleagues planned a dinner as an end-of-term celebration and, despite reasonable incomes, they decided that the dinner should be “free” – sponsored by a drug company, and thus attended by the company’s representative (a “drug rep”).
I went, and during the meal the drug rep stood up to deliver the “educational” content for the evening. “Did you know,” he asked, “that my drug is good at preventing malnutrition?” This seemed a puzzling claim for an antipsychotic medicine. He continued: “Because when you prescribe my drug, I get paid, and I can feed my family.” To an audience of strained smiles, he sat down, indicating that the evening’s educational formalities were complete.
At the time I thought this was an embarrassingly poor example of education. But I am now thankful to that drug rep, as this incident helped to expose for me the charade that industry-sponsored education can sometimes be. It helped me decide to avoid drug reps and to instead get my prescribing information from independent sources.
A new campaign, launching today, encourages more doctors to do the same.
Problems with medicines
I am not a critic of the entire pharmaceutical industry. Some medicines are very useful, and many of my encounters with my patients involve prescribing. Without medicines, many of my patients would be more unwell.
But problems exist with the development of medicines, and with our knowledge of how best to use them. In a for-profit environment, drug research follows potential profits. It may focus on production of “me-too” drugs (those offering little or no advance on existing drugs) rather than tackling more pressing but less profitable global health needs.
And a lot of research studies rely on the assumption that changes in easily measurable things will translate into real benefits to patients – for example, that a drug that lowers blood sugar will prevent complications in patients with diabetes, or that a drug that improves cholesterol readings will avert heart attacks. These assumptions can sometimes be right, but sometimes are quite wrong.
These problems are systemic, and can’t be entirely blamed on the pharmaceutical industry. But the industry is a key player, and these issues seriously beleaguer attempts at practising good evidence-based medicine. And with US$7-20 billion spent annually on drug reps in the United States alone, reps form a huge part of the industry’s marketing strategy.
In many doctors' offices around the world today, drug reps will be setting out food on a table for hungry doctors, in the hope of some promotional lunchtime chatter.
Why do doctors see drug reps? Research says GPs find drug reps a convenient and timely source of information, with some appreciating the personal, social interaction with the reps. Many doctors are aware of possible biases in information from reps, but many believe they are capable of sorting “the wheat from the chaff” themselves, even if they think many of their colleagues are suckers.
I don’t think drug reps are evil people; in fact, many of them are pleasant people who are no doubt doing their job well. But the purpose of that job is to increase medication sales. My responsibility is to prescribe medicines in a manner optimal for the health of my patients. These two purposes may conflict. Doctors need impartial, evidence-based information on medications. We should not confuse education for marketing.
Are we told the whole truth about medicines by drug reps? The evidence says we are not. A recent study from the US, Canada and France found that only a small minority of drug rep visits included “minimally adequate safety information”. Another recent study from Australia and Malaysia found that information about medication risks was often missing.
Drug reps often promote the newest medicines, still under patent and ripe with potential profit. But the newer the drug, the less we may know about long term side effects – and sometimes these can cause serious harm. It is often wise to be slow to prescribe new drugs.
Those free lunches aren’t really a gift – ultimately they are paid for by patients and taxpayers. And it’s hard not to feel cynical about drug reps when I learn about their methods. Retired drug reps share illuminating insights about their tactics for influencing doctors, tailored to various personality types. Doctors may find reps friendly, but according to these accounts, they are being manipulated.
Do drug reps affect prescribing?
The issues above might not matter if doctors were immune to problematic information from the pharmaceutical industry. But are they? This is a question that several colleagues and I tried to answer recently in a systematic review. We collected all the available studies looking at links between doctors' exposure to information from drug companies and their prescribing.
We found that, where links were found between information exposure and prescribing changes, they tended to be in the direction of more prescribing, more expensive prescribing, and lower quality prescribing.
This doesn’t mean drug rep visits are never useful. I can imagine situations, when public health and commercial interests align, where reps might be helpful. But our thorough review of the world’s evidence gave us no confidence that this was usually the case.
The No Advertising Please campaign
For all these reasons, I’m one of several doctors throwing their weight behind the new No Advertising Please campaign, vowing to avoid drug reps for a year. This should be reasonably easy for me, as I’ve been trying to avoid them for years – though no doubt I’ll be occasionally ambushed in tea rooms and corridors. Meanwhile, I’ll keep buying my own lunch, and relying on independent sources of medicines information.
If you’re a prescriber, you can sign up too. Otherwise, when you next find yourself being written a prescription, perhaps you could ask the person signing it where they get their information on medicines, and why.