Pharmaceutical industry marketing to physicians: what’s the big deal?

June 4, 2008

pharmfree.jpgCommentary by Jatin Roper, MD, PGY3, NYU Internal Medicine and Nitin Roper, MSIII, University of Connecticut School of Medicine

Pharmaceutical companies play a vital role in improving the public health through drug discovery. These for-profit entities are in the business of selling their products to physicians and patients. If you’re a physician, the images of drug marketing are ubiquitous: the attractive, vivacious sales representative who always seems happy to see you; the sea of purple tote bags at the last national gastroenterology meeting (can you guess the drug advertised on them?); photos in medical journals of fit runners reaching their goal blood glucose.

You may not be as aware of the numbers behind the images. In 2004 US pharmaceutical sales totaled $235.4 billion, of which 24% was spent on marketing of existing drugs, over twice the expenditure on research and development of new compounds. Of the industry’s $57.5 billion marketing budget, 36% was spent on visits to physicians by industry representatives (“detailing”), 28% was spent on drug samples for doctors to give to patients, while only 7% was used for direct to consumer advertising. (Gagnon MA, Lexchin J. The Cost of Pushing Pills: A New Estimate of Pharmaceutical Promotion Expenditures in the United States. PLoS Med 2008). Physicians themselves become extensions of the drug advertising apparatus by accepting thousands of dollars to give lectures, with the implicit expectation that they promote the company’s drug (Carlat D Dr. Drug Rep. The New York Times Magazine Nov 25, 2007). Clinical researchers are offered something money can’t buy: authorship on manuscripts reporting drug trials which have been written by company employees (referred to as “ghostwriting”) (Ross JL et al. JAMA 2008;299:1800-1812).

Generations of physicians have become accustomed to lunches, pens, and dinners as a sign of gratitude for their hard work. Drug representatives, however, are paid to increase prescriptions. As one former drug representative wrote, “It’s my job to figure out what a physician’s price is. For some it’s dinner at the finest restaurants, for others it’s enough convincing data to let them prescribe confidently and for others it’s my attention and friendship…but at the most basic level, everything is for sale and everything is an exchange.” (Fugh-Berman A, Ahari S. Following the Script: How Drug Reps Make Friends and Influence Doctors. PLoS Medicine 2007)

So drug companies spend a lot of money marketing to physicians. What’s the big deal? The problem is that marketing works. Gifts of any value to physicians create a tacit expectation that they return the favor; these incentives may result in bias in clinical decision-making that affects patient health and increases health care costs. Many doctors agree that gifts influence other practitioners, but insist that they do not affect their own practices. The public, meanwhile, is as appalled with drug companies wooing doctors as they are with lobbyists “donating” money to politicians’ campaigns. In 2002 the pharmaceutical industry, fearing national legislation, voluntarily limited their marketing gifts to those of less than $100 in value, while explicitly allowing unfettered drug sample distribution, “ghostwriting,” and unlimited payments for physician speakers. The magnitude of these payments is staggering and continues to increase. In Minnesota, where most monetary gifts to physicians are publicly reported, at least 700 providers received more than $10,000 between 1997 and 2005, while the average internal medicine doctor received $1000, and the average cardiologist $2300 (Harris G, Roberts J. Doctors’ Ties to Drug Makers Are Put on Close View. The New York Times March 21st, 2007.

The public (and physician community) is increasingly aware of the conflicts of interest posed by gifts to physicians. The American Medical Student Association (AMSA; www.amsa.org) and No Free Lunch (www.nofreelunch.org) have for many years reached out to medical students and residents to avoid drug industry gifts. In 2006 Brennan et al. published an influential article urging academic medical centers to ban gifts of any value from the pharmaceutical industry, prohibit payments to physicians for speaking, allow free drug sample distribution only via a central repository, and allow unrestricted educational and research funds with limitations (Brennan TA. et al. Health Industry Practices That Create Conflicts of Interest. JAMA 2006;295:429-433. AMSA was the only professional medical society to endorse these recommendations until a task force of the American Association of Medical Colleges (AAMC), which included several chief executives of pharmaceutical companies, recently recommended that all medical schools ban pharmaceutical gifting to physicians (link: http://www.aamc.org/research/coi/industryfunding.pdf and http://www.nytimes.com/2008/04/28/us/28doctors.html).

A number of academic medical centers have independently done so to varying degrees (a partial list includes University of Pennsylvania, Stanford, Columbia, University of Pittsburgh, U Mass, the VA system, Boston Medical Center, University of Michigan, UC Davis, and Bellevue Hospital Center). We are working to implement similar regulations at our own institutions (NYU Medical Center and University of Connecticut), and anticipate that the remaining academic medical centers in the United States will soon do so as well. However, until professional groups such as the American Medical Association (AMA) adopt strong conflict-of-interest policies, the pharmaceutical industry will continue to spend billions of dollars on influencing the clinical decisions of our community physicians.

“To increase public awareness and hold academic medical centers accountable for their policies, AMSA recently developed a scorecard which grades academic hospitals’ policies on gifting from the pharmaceutical industry. The grading system has already grabbed the attention of hospital leaders (doctors aren’t accustomed to failing tests) and the New York Times.

3 Responses to Pharmaceutical industry marketing to physicians: what’s the big deal?

  1. David T Mintz on June 12, 2008 at 12:22 pm

    Marketing to consumers is an insidious way of circumventing the label of conflict of interest. It is effective and dangerous.

  2. Dan on June 15, 2008 at 2:45 am

    You Have Now Been Sampled

    While the pharmaceutical industry’s image and reputation has and appears to continue to suffer, added damage has expressed itself with costly patent expirations. Yet the big pharma task forces still insist that reps provide incredible value, and the more the better, as the drug reps are the givers of gifts, and reciprocity in the form of prescriptions just has to occur.
    As a big pharma ex drug rep for over a decade, which during that period the number of drug reps actually tripled, the drug rep’s vocation has become more ridiculous, and possibly void of any true sense of accomplishment due to their customers preventing them from interaction or even presence in order for the drug reps to follow directives of the health care givers, and not their own employers, which is to influence their prescribing habits via direct dialogue along with the giving of gifts. The job has become nothing more than doing lunches and leaving samples at offices, for the most part. My perception formed from my own analysis of how drug reps operate in today’s environment in the medical community has led me to draw such conclusions, which I believe to be accurate.
    So they may be named at times in different ways, these promoters will be referred to now only as drug reps, which number close to 100,000 in the U.S. presently, it is believed, yet is probably less now due to big pharma cutting thousands of reps recently. The cost to the pharmaceutical industry of these drug reps is around 5 billion dollars a year. Income for each rep grosses close to or above 100,000 grand a year on average, along with great benefits and a company car, as well as stock options as they gladly work from their homes and set their own hours, which I understand is much less than 8 hours a day.
    The main function these days of drug reps, I believe, is primarily to offer doctors various types of inducements of a certain value that are not gifts, but bribes, by definition. The drug sampling of doctors may be considered an inducement, and a rather valuable one for the drug rep, as many believe that these samples are what ultimately influence the doctor’s prescribing habits over anything else, including statements from drug reps. This may be why the drug industry spends around 20 billion every year on samples. Yet I want to be clear on what I am saying: drug reps are some of the smartest people you will meet that do in fact have great paying jobs with great benefits. Most importantly and my opinion, I believe most reps really WANT to do well for their employers, yet are prohibited from doing so now because of how their employers are now viewed in their medical community.
    Many years ago, drug reps have used their persuasive, yet ethical, abilities to influence the prescribing habits of doctors in an honest and ethical manner, as they focused on the benefits for the doctor’s patients with a particular drug that the detailer may promote to such a doctor. However presently, most health care providers now simply prevent drug reps to speak with them- now this is especially true when they are in clinic treating and assessing patients. More and more medical establishments are completely banning drug reps from their locations, and I speculate that this is occurring for many reasons, which may include the following:
    The doctors lose money. Doctors are normally busy, so their time is valuable. As a drug rep, you are an incredible waste of their time. Yet they will accept your samples still. The credibility you possibly have thought you had and were perceived as such by doctors as a drug rep is no longer viewed to exist to any noticeable degree by the prescriber. For example and this is based on my experience and my colleagues, doctors view any information you may provide to them as biased and embellished. In my opinion, based on information and belief, their view regarding their assessment of you as a drug rep is accurate due to the statistical gymnastics the employers of drug reps engage in, which effectively and ultimately is permitting and encouraging the drug reps to lie to the doctor and likely are unaware of the statements stated by them are misleading. Doctors by their very nature seek answers objectively. And doctors do in fact find out about drugs through other methods besides the representative of the drug’s maker, such as the internet and experience with certain medications. Most drug reps in this country in particular mostly hire drug reps based on such qualities as the candidate’s looks as well as their personality, overall. Furthermore, it is possible that pharmaceutical companies desire their drug reps to be obedient and to not question what is asked of them. Upon speculation, this can be possibly determined by the background of the candidate, which may indicate they seek popularity as well as are money driven. In addition, most drug reps do not have degrees remotely related to any aspect of anything of a scientific or clinical nature.
    During my decade as a drug rep, I would encounter on very rare occasion another rep that may have been a nurse or researcher, and this is concerning that others do not have similar backgrounds because the type of training necessary is rare for a drug rep. In fact, based on my opinion, many do not particularly care to acquire education related to such medical or clinical topics. They learn the basics in order to sell their promoted products. Yet anyone who has ever worked with doctors in a clinical setting, or in a hospital working in a clinical nature, likely they would agree that a drug rep should want to and seek all related to the complexities involved in the restoration of another’s health.
    Many drug reps, it is believed, are void of any complete interest in medicine completely, and I believe this to be necessary. In addition, ethical considerations due to their possible deliberate ignorance created by the necessity of what they are required to say or do by their employers may be viewed as a disturbing fallacy as well. This allows them with the encouragement and coercion of their employer to embellish the benefits of their promoted products at times in addition to offering inducements to doctors in various ways- most of all of which are rather covert, yet performed and issued to select prescribers upon instruction of their employer. Examples may be creating a check from your company to a certain supporting doctor and handing this check to thank a doctor for supporting your company’s products for doing little if anything for your employer to justify this check. Or tangible items are given to such prescribers, such as TVs or DVDs which may or may not be utilized in a particular doctor’s office. It happens often, such activities.
    From the drug rep’s perspective, it is unlikely they will even consider the possibility to question their pharmaceutical employer due to the great risk of losing income and benefits that they are unlikely to acquire at another place of employment. Because of their consistent and conscious effort to keep their high-paying jobs, the drug reps always appear overtly anxious to please their superiors- regardless of any ethics or legalities regarding any activity they may be required to perform. With big pharma in particular, each drug rep is given a variety of budgets, such as a chunk of cash for doctor office lunches that they are required to spend in a certain period of time. Another chunk of cash may be assigned to a rep to pay assigned or registered speakers of their employer to speak to other prescribers about a disease state related to the drug rep’s promoted product. These activities, in my time with big pharma, were never monitored or questioned by managers or superiors. What I did notice is that my annual raises were greater than others according to the amount I spent for that particular year, as this, according to a big pharma company, was a very objective and noticeable variable with securing and keeping your employment in big pharma.
    While legally risky, the drug companies continue to dispense to their reps these large budgets their drug reps are in effect coerced to dispense with complete autonomy and possibly the spending can be fabricated, which is too complicated to fully explain. This design perhaps is why there are now various state and federal disclosure laws that are presently being considered to mandate the release of all funds dispensed from pharmaceutical companies as far as why a company’s funds were spent and for what reason or method. Because, according to the lobbyists of pharma companies, they consistently insist that whatever they spend always is for the benefit of public health. As mentioned earlier, presently such activities are quite covert. Yet if such laws are mandated, it is likely the accounting of pharma companies will become rather creative and incomplete. In summary, as a big pharma drug rep, my budgets were unlimited, and I typically spent more than I made though the activities I have mentioned so far. And this is not an isolated case.
    Another issue is what is referred to as data mining. The American Medical Association sells this prescribing data on individual doctors to pharmaceutical companies or pharmacies, by providing others identifying numbers of a particular doctor, such as a state license number or DEA number, which allows them to track the scripts a doctor writes not far from real time availability. This data shows the volume of scripts of a particular doctor and what the doctor has been prescribing for the doctor’s patient for their disease state, and this data reveals competitor products to the drug rep as well. Aside from being deceiving and dishonest, the data allows a pharma company to ‘reward’ those doctors who support their products, while treating the other doctors with ‘neglect’, which means the non-supporters of a pharma company will not receive any inducement or remuneration from a particular pharma company. The data, by the way, only reflects numbers linked with particular products, and fortunately is free of patient names- this data that is provided to all drug reps. What has been described is the method typical with all big pharma companies, in my opinion, and I worked for three of them. It appears to be manipulative in a psychological paradigm- a combination of Pavlovian responses combined with positive and negative reinforcement.
    So such methods create a toxic culture required to be absorbed by those members of such a pharma company. Furthermore, the tactics implemented by pharma companies vacuum the judgment of prescribers, which may prevent patients from receiving objective treatment. Yet on the most basic level, it is the samples left with prescribers that ultimately determine their prescribing habits- with various inducements to some doctors running close in second place. Yet remarkably, prescribers are prescribing more and more generics, which typically are not sampled to prescribers. I find this comforting that the manipulation efforts of the pharma industry are not as effective as they believe they are in a rather delusional way. Yet what is happening now in regards of branded meds vs. generic meds, insurance companies are flat out paying doctors to switch patients to a generic if one is available, as well as initiating generic medication treatment for their patients. I speculate they are paying doctors for this as a response of what pharma has been doing for quite a long time. From a clinical paradigm, if a medication is providing desired treatment and good tolerability for a particular patient, one could argue it would be unethical to switch treatment for financial gain, further complicated by the fact that most patients are aware that insurance company payments to doctors for this even occur.
    It is likely and I believe that most drug reps are good and intelligent people who unfortunately are coerced to do things that may be considered corruptive to others in order to maintain their employment. In other words, the drug reps have compromised their integrity, ultimately.
    It seems that external regulation is necessary to prevent the drug companies from allowing the autonomy of drug reps that exists, with their encouragement, which forces the reps to do the wrong thing for the medical community, possibly. Because it is obvious that internal controls with such corporations exist on paper often, but clearly are discouraged to be enforced. It is possible that these pharma companies falsely believe that being an ethical company would make them a company without excess profit. One can only speculate on their true motives. Yet it appears that overt greed has replaced ethics with this element of the health care system, which is the pharmaceutical industry, as illustrated with what occurs within these companies. However, reversing this misguided focus of drug companies is not impossible if the right action is taken for the benefit of public health. Likely, if there are no drug reps, there is no one to employ such tactics mentioned earlier. Because authentically educating doctors does not appear to be the reason for their vocation. This is far from being the responsibility of a pharmaceutical sales representative. Perhaps most frightening is that most drug reps fail to dig deep enough to realize that what they do at times may damage public health.

    “What you don’t do can be a destructive force.” — Eleanor Roosevelt
    Dan Abshear
    Author’s note: What has been written was based upon information and belief.

  3. mr reporting software on February 17, 2013 at 12:41 pm

    very interesting observation from Mr. Roosevelt. Indeed its the pharma companies’ responsibility to train Reps so that they can add value inside a clinic

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