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It’s Raining Gifts

The New Physician November 2000
If you think drug marketing is all about newspaper ads and 30-second spots, think pens and dinners instead.


David Boyd, a premed senior at Florida International University, says the events he attends with a nurse-practitioner mentor are all the same: It’s a quiet Tuesday night in the restaurant—one of the nicest in town. The maitre d’ is busy though, seating folks like you—premeds, medical students, residents and physicians—in a private dining room. You say hello to a few colleagues from the area. Talk turns to golf games, good movies and medical practices. Your dinner date wanders off to chat with a friend she spies in the corner.


A bow-tied waiter arrives with bottles of wine: “Red or white, sir?” he asks, and that is the last time you will see the bottom of your glass, “perhaps in an attempt to flutter your consciences,” Boyd says. Just as you are starting to feel heady from the merlot in your glass, here comes the fast-talking drug rep, and after handshakes all around, she launches into her spiel—something about an impending antibiotic launch from her company. You can’t help thinking she sounds like the woman on the home shopping network.


Thank God, there’s the waiter again, this time bearing hearts-of-palm salads for all—thus ending the brown-nosing portion of this evening. As left-behind lettuce leaves melt into vinaigrette on mostly empty glass plates, the program begins. A physician you’re not acquainted with has been paid handsomely to talk about cutaneous fungal infections and the best treatment for them. The drug rep happens to sell one of the discussed products. And yes, while slides of toe fungus are not the best dinner viewing, what the heck? It’s a free meal.


As the presentation wraps up, Mr. Bow-tie is back with prime rib, followed by crème brulée and coffee. Despite the caffeine boost, only a few people ask questions of the presenter. You pick up some free samples of the toe-fungus treatment on the way out and call it an evening.


And what an evening it was. Bought and paid for by your friendly neighborhood pharmaceutical rep. Friendly? You bet. There’s money to be made out there, and she’s just the gal to do it. But she’s not the only rep doing this. A central Florida physician received seven invitations to drug rep-sponsored events during a six-week period this summer. And an evening like the toe-fungus dinner is only one way pharmaceutical companies market their wares—six hours at a Saturday morning discussion on the treatment evolution of atrial fibrillation would have netted the Florida physician $500 for attending plus a $50 stipend for travel, courtesy of 3M Pharmaceuticals.


TO MARKET, TO MARKET


Pharmaceutical companies spend more than $11 billion annually on drug promotion and marketing, according to Dr. Sidney Wolfe, Public Citizen’s Health Research Group director. Marketing and administrative functions cost drug companies about 33.5 percent of their total sales, according to the Henry J. Kaiser Family Foundation. (Most pharmaceutical companies lump both marketing and administrative expenditures together, making actual promotion figures difficult to calculate.)


About $5 billion of that goes directly to drug reps who dole out an estimated $8,000 to $13,000 per physician in gifts, drug samples and meals. Another $1.9 billion is spent on direct-to-consumer advertising.


These figures have been steadily rising in recent years. Promotional spending by pharmaceutical manufacturers consumed $5.4 billion in 1995, doubling to its current $11 billion mark in just four years.


The pharmaceutical dollars have infiltrated every stage of medical training: premed, medical student and residency. They have impacted many of the continuing medical education (CME) courses physicians in 34 states need to complete to keep their licenses. And some people are crying foul. Dr. Gordon Schiff, director of clinical quality research at Cook County Hospital in Chicago, calls the money drug companies spend on physicians a bribe to get them to alter their prescribing practices. “If you accept a bribe, you go to jail for that, right? So what’s the difference?”


A GIFT BY ANY OTHER NAME


The most effective approach to pharmaceutical marketing is a combination of good public relations, journal advertisements and physician visits and gifts by company representatives, says Dr. Peter Mansfield, a general practitioner in Australia and director of the Medical Lobby for Appropriate Marketing (MaLAM), an international organization dedicated to promoting more responsible drug marketing practices.


And while Mansfield doesn’t condone the practice, right now “the most effective individual component of promotion is one-to-one meetings of doctors and drug company representatives,” he says. The types of meetings are varied: lavish dinners like the one in the toe-fungus scenario, weekly lunches for all the staff in a clinic or hospital department, chance calls on an individual practitioner complete with token gifts like pens, clocks and tote bags—the list goes on. But the procedure is often the same: In the name of educating the physician to a new treatment, the company representative’s mission is to influence prescribing practices.


But that doesn’t really happen, says Dr. David Kaplan, an anesthesiologist at New England Medical Center in Boston, who admits he’s been to “numerous” lunches and dinners, as well as accepted gifts such as pens, notepads and books from drug reps. “My practice of…anesthesiology has not been swayed by these gifts,” he says. “In fact, I can’t even remember which drug rep has represented which product! My decisions remain based on the clinical scenarios with which I am faced daily.”


Kaplan is like a lot of physicians who say that while they interact with the reps on a regular basis, their practice is no worse off for it. In fact, some say it’s better, pointing to fully stocked drug closets—courtesy of visiting reps—that often provide their indigent patients drugs they would otherwise go without.


That’s hogwash, Schiff says. “Medical students and doctors have all kinds of ways of deluding themselves,” he says. “To counter that, I think people should be a little more honest about what’s going on.” He points to regulations from the Joint Commission on Accreditation of Healthcare Organizations that discourage individual doctors in hospitals from dispensing drug samples.


Problems arise when drug reps, pushing newer and more expensive drugs, influence doctors to prescribe medications they are not as familiar with, Schiff says. “People are getting side effects from being prescribed drugs we don’t know much about.” As an example, he points to the thalidomide crisis of the late 1950s: In an attempt to relieve morning sickness, physicians in 40 countries outside the United States prescribed this drug to pregnant women. The drug was later found to have caused their babies to be born with missing arms, legs and external ears and was pulled from the market worldwide. Schiff says many of the victims turned out to be doctors’ wives who got the drug from representatives visiting their husbands’ practices.


Dr. Robert Goodman of New York Presbyterian Hospital doesn’t buy the sample argument either. His organization, No Free Lunch, works toward getting physicians to stop accepting what he calls bribes from the pharmaceutical industry. “The sample by far is the most important thing they do,” he says. “The samples are purely marketing.” New York Presbyterian recently banned drug samples altogether, citing tracking difficulties in the event of a recall.


The sample issue is a tough one for practicing physicians faced with patients who lack prescription drug insurance coverage. “It seems to be a catch-22,” says Dr. Deborah Huang, a George Washington University (GW) medical school graduate applying for the 2001 Match. “There are times you want to send the patient out the door with the drug, because then they are going to take it.”


And while physicians can say drug rep interaction doesn’t influence them until they are blue in the face—and many do—a study published in the Journal of the American Medical Association (JAMA) in January found otherwise. The study uncovered numerous negative outcomes, including the inability to identify misleading claims about new medications; rapid preference and prescribing of new drugs; physician requests to alter formulary lists, despite facts indicating that the new drugs had few or no advantages over existing ones; and increased prescription rates and fewer generic prescriptions in favor of newer, more expensive drugs.


Still, the industry defends its actions. “Most companies are going to want you to know about their product,” says Jeff Trewhitt, a Pharmaceutical Research and Manufacturers of America (PhRMA) spokesperson. He says the marketing makes physicians aware of the options they have and advises them to treat the visits as a source of needed information.


In fact, the JAMA study did find that physicians who interacted with drug representatives also had an improved ability to identify the treatment for complicated illnesses.


But education-by-drug-rep is exactly the problem, say critics, contending that the salespeople—who are biased to their own products—can’t provide a balanced picture of competing medications. Schiff suggests the Medical Letter and guides offered by the U.S. Pharmacopeial Convention as sources of unbiased drug information.


But not every physician sees a problem with learning about a drug from a rep or at a sponsored dinner. “Of course they are trying to promote one or more drugs that their company sells, but I have also learned some useful information as a result,” Kaplan says. “Some of the speakers that they have sponsored have been quite good, and some of the books I have received have been very helpful.”


Dr. Margaret Planta, a family physician in a large clinic in Silicon Valley, says she actually uses the drug reps’ bias to play them off of one another. She will question each one about why his drug is better than a competing company’s, and when the competing company’s rep shows up, she questions him about what the other one had to say.


GET 'EM WHILE THEY'RE YOUNG


Practicing physicians aren’t the only ones wrangling over interaction with pharmaceutical representatives. Residents, medical students, even premeds feel the pinch. The JAMA study reported that 80 percent of medical students have at least been given a book from a drug company, while the same percent of residents had a meal courtesy of the industry. Premeds are generally exposed to the reps through volunteer work at clinics and hospitals.


“Drug companies have a long-term interest in influencing medical students to accept promotional activities such as free lunches so that they can be influenced more easily in the future,” says MaLAM’s Mansfield. “Also, promotion is more influential if it is the first or last word that you hear on the subject. Consequently, some companies will be keen to get to medical students first.”


This rush to get to him was sharply felt by Dr. David Grande when he began his internship in internal medicine at the University of Pennsylvania this summer. His orientation schedule included a lunch sponsored by a Pfizer representative who presented his spiel and then handed out gifts to the attendees: a canvas bag, a new white coat, pens and other trinkets.


“One thing that struck me in medical school—and it is more magnified now that I have started my residency—is that there is a tremendous amount of gift giving, freebies and lunches purchased on my behalf by the pharmaceutical industry,” he says. “It goes far beyond a drug rep buying lunch for a noon residency program. It’s bar nights, baseball games, trips and really extravagant stuff.”


Extravagance ran rampant at a party a local drug rep threw for Penn’s new residents. The event, hosted at Dave and Buster’s (think Chuck E. Cheese’s for adults), included dinner and a $50 game card for each attendee.


Dave and Buster’s has been getting a lot of business from the drug industry lately. Across the state in Pittsburgh, Pfizer hosted a similar party for the neurology residents at the University of Pittsburgh. “This one nauseated me,” says Jon Rittenberger, a third-year Pitt medical student who learned of the evening from his resident in his neurology rotation. The event was like the one in Philadelphia: drinks, dinner and a game card. The event, organized through the teaching hospital, struck an ethical cord with Rittenberger. “I have trouble believing that this has no effect on scripting,” he says.


The influence the pharmaceutical industry has over med students and residents—those still in the learning process—is becoming more clear to Rittenberger as he begins working his way through his clinical years.


“I’m seeing the brand name of drugs for the first time,” he says. So when a Janssen Pharmaceutica rep targeted Rittenberger during a call to the neurology department, he looked at it as an educational experience, a chance to find out a little more about an antipsychotic drug he knew in the generic form of haldol. The rep left him with a pen advertising the brand name medication Risperdal. “It’s a memory aid, but it’s a biased one,” he says of the pen, adding that it is just this type of scenario that the pharmaceutical industry can use to justify “their gajillion dollars they spend” on this type of marketing. Doctors are “supposed to be looking at all their options,” he says. “What if another drug rep didn’t get to talk to me, and I don’t know about their drug?”


And a pen is a minor tool. “Drug companies invest huge amounts of money on free lunches and gifts because they know that reciprocal obligation is an effective method for influencing attitudes and behaviors,” says Mansfield. But he also believes that while more experienced physicians may be better able to sort the wheat from the chaff in making prescribing decisions than students and residents, even he gets misled at times. Therefore, it would be nearly impossible to immunize students from the “adverse influence of drug promotion,” he says.


Trewhitt doesn’t really see the influence. “I would hope that buying lunch does not buy their soul,” he says. “Even though someone is a new, young doctor, [he] did not get there by being dumb.”


Pitt requires its medical students to take ethics classes to discuss just this sort of thing, and Rittenberger says he has learned from them. “There seems to be a line,” he says. “A lot of people just seem to find a place where they are comfortable.”


Rittenberger says he can already see how residents find that comfort zone. “I can see where they’re coming from,” he says. “They need the money. These are the people making $30,000 [a year] with $100,000 to $200,000 debts.” So he says he understood when one of his residents told him about a $100 payoff he got from an industry rep for listening in on an hour-long conference call about a product. “To the [residents’] credit, they’ll take a pen and they’ll eat the doughnut, but they won’t carry a Prozac pen when they go see a patient,” Rittenberger says. “By and large we do a decent job. If the drug sucks, we just won’t prescribe it.”


Still, it can be pretty hard for physicians-in-training to avoid the reps altogether if they want to. Huang says GW required attendance at a noon conference where a drug company provided lunch—but not the speaker—and set up a table to market its products outside the conference room.


At the University of Connecticut School of Medicine and others around the country, Glaxo Wellcome offers its Pathways Evaluation Program, a three-and-a-half-hour workshop available to third-year students to help them choose their areas of specialization. The course, which is not mandatory at Connecticut but is at other schools, is taught by two faculty members, and while funding for the course comes from Glaxo, there are no company representatives there.


Other companies give large gifts to medical schools for research and building projects. Eli Lilly—which refused repeated requests to comment on this subject except to say that it doesn’t market its company to medical students—gave a $2 million gift to the Indiana University School of Medicine.


Many critics say this type of gift-giving isn’t all bad. For example, Grande says he thinks it is good for drug companies to support educational programs. “If their gifts are truly altruistic, companies should be willing to support educational programs without influencing the content and without promoting their drug products,” he says.


‘JUST SAY NO’


So what’s a young, impressionable physician-in-training to do? First, you may want to read up on the guidelines on physician gifts from the drug industry. Oh? You didn’t know they exist? Well, you aren’t alone. The JAMA study found that only 23 percent of residents and 62 percent of physicians know about them, and those who are aware of them don’t use them as a reason not to accept gifts.


In case you’ve missed the advice, here’s a synopsis: The guidelines, adopted by the American Medical Association in December 1990—only to be picked up by PhRMA two days later—state that gifts should be of a benefit to patients and not of significant value. Texts, modest meals and other gifts are OK; cash is not. Gifts from drug reps should be related to the physician’s work, and money should only exchange hands to cover participation at CME events, and then not if it goes toward travel expenses to get to the event. (The money should go first to the conference organizer and then to the attendee, because a direct link from drug rep to physician “could influence the use of the company’s products.”) Scholarships are OK only if the medical school decides who should get them, and finally, if strings are attached, the gift is a no-go.


Rep. Pete Stark (D-Calif.) isn’t waiting for more widespread voluntary adherence to these guidelines. In an effort to curb the amount of money spent on pharmaceutical marketing, the congressman has introduced legislation to eliminate a little-known pharmaceutical-company tax break regarding physician gifts and benefits. While drug sample giveaways would continue to offer a company a tax incentive, Stark estimates the legislation would reverse the 40 percent reduction in taxes the pharmaceutical companies currently enjoy.


“The pharmaceutical industry reaps billions in profits every year and certainly does not need excessive tax breaks,” Stark said in introducing his legislation. He says the money spent on marketing would be better spent on research and development, which is also subject to a tax credit.


Erin Dunnigan disagrees marketing dollars are better spent elsewhere. In finishing up a joint M.B.A. and premed program at Notre Dame, she has taken a hard look at pharmaceutical marketing. And while she finds the strategy objectionable from an ethical standpoint, business is business, she says, calling the tactics nothing more than “smart marketing.”


“Should pharmaceutical companies abandon these efforts to let the market know about the latest developments? Of course not,” she says. “Why should they develop drugs that will only go unnoticed?”


Trewhitt might think the industry has found a friend in Dunnigan. He says marketing increases sales, which fund research and development of new drugs. If only these claims that cuts in marketing dollars would allow for more and cheaper drugs were true, he says. The industry spent more than $24 billion on research and development (R&D) in 1999, which he says is much more than promotional spending.


But it can’t be much more, according to figures from the Kaiser Family Foundation. R&D actually accounts for 17 percent of drug companies’ total sales; administration and marketing accounts for 33.5 percent.


Like Stark, Mansfield would like to see these imbalances addressed through policy. He suggests developing methods for measuring the appropriate use of drug therapies and rewarding drug companies according to their contributions. “MaLAM would like to see drug companies receiving less money per tablet sold and more money for their contribution to achieving health targets,” he says.


Both he and Stark may be underestimating the pharmaceutical industry lobby’s impact on legislation, however, and it is not likely to support either of these plans. In the meantime, Schiff recommends a simpler approach. “Just say no,” he says. “In 25 years [of practice] I’ve had no conversation with a drug rep.” This self-discipline is even more impressive when you consider that as a member of Cook County Hospital’s formulary committee, he is the physician every rep in the area would be beating a path to.


Schiff certainly recognizes the mental anguish the “to take or not to take” question can cause in medical students and residents. But it shouldn’t be a difficult dilemma. “Rather than tormenting themselves with whether they should feel guilty, just don’t get involved in all that,” he says. “There’s an easy answer.”
Jennifer Zeigler is a senior writer with The New Physician. Editor’s note: Look for a story on direct-to-consumer drug marketing in an upcoming issue of The New Physician.