Healthy Skepticism Library item: 20291
Warning: This library includes all items relevant to health product marketing that we are aware of regardless of quality. Often we do not agree with all or part of the contents.
Publication type: Journal Article
Messmer JJ, Parnes B, Westfall JM
Influence of pharmaceutical companies
The Journal of Family Practice 2000 Dec; 49:(12):1154
http://www.jfponline.com/Pages.asp?AID=2666
Abstract: To the editor:
In the September 2000 issue of JFP, Dr. Westfall1 provides another voice suggesting that there is something inappropriate in pharmaceutical companies’ methods of advertising to physicians. He is one of many over the years who has expressed concern that physicians’ prescribing decisions are influenced by pharmaceutical company gifts.
I have followed this debate since 1973 when some of my fellow first-year medical students refused to be “bought by drug companies” that wanted to give us black bags (some people still used them then), ophthalmoscopes, and stethoscopes. I wondered how anything we thought about a particular drug at that point would mean anything. I did not believe that in a few years I would wait for the first opportunity to pay back their generosity by prescribing one of their products.
If physicians prescribe a product in return for consideration from a pharmaceutical company rather than because they believe it is the appropriate medication, then the fault lies with our choice of candidates for medical education. If a physician is so naive as to believe everything a pharmaceutical representative says just because of a trip to a show or a nice dinner, that physician is to be pitied.
Of course I realize that pharmaceutical representatives would like to influence our prescribing behavior. That is the purpose of advertising. Will we allow pharmaceutical companies freedom to advertise as other business concerns in America do? Is there something special about advertising speech because pharmaceuticals are used for a noble purpose compared with, for example, beer?
If we allow pharmaceutical manufacturers the same freedom of speech as other companies in America, we cannot condemn gifts as a means of advertising. My day is spent caring for patients. Since I do not have the time to have more than a superficial conversation with a pharmaceutical representative between patients; they make an appointment. I allow one 15-minute visit per day unless I call the representative to provide some specific information. If the representative wishes to bring lunch for the office, he or she is free to do so. If prescribing a particular product is expected in exchange, they will never be allowed to return.
When an extended time is requested for a detailed presentation, providing entertainment or meals is an accepted means of marketing in many businesses. I do not see the logic in an a priori rejection of this method for physicians.
Rather than condemn advertising speech, I believe it would be better to train our physicians to be more discerning in what they believe. We tend to accept what people tell us because we know we would not intentionally deceive. We must realize the purpose of the pharmaceutical representative’s visit and handle it professionally. I resent anyone telling me that I may not receive information as I choose because I am not capable of acting responsibly on it. That is censorship at its worst.
John J. Messmer, MD
Palmyra, Pennsylvania
REFERENCE
Westfall JM. Physicians, pharmaceutical representatives, and patients: who really benefits? J Fam Pract 2000; 49:817-19. To the editor:Dr Westfall makes a convincing case of the often troubling relationship between clinicians and pharmaceutical companies as epitomized by the use of drug samples. However, I believe he has underestimated the value of drug samples in the care of medically indigent patients.
The high cost of prescription medications, especially for the poor, has become a major obstacle to providing high-quality care to patients. In one study,1 more than 50% of African American households with incomes less than 185% of the federal poverty level reported that they could not afford prescription medications. The strategies employed by those households to cope with this problem include borrowing money to buy medications, rationing medications so that they last longer, or simply not filling the prescription (we often refer to these strategies as “noncompliance”). For the poor elderly this issue has become the subject of a national policy debate on the Medicare medication benefit.
Dr Westfall correctly acknowledges the availability of the pharmaceutical industry’s patient assistance programs that provide medications at no cost to qualifying medically indigent patients. In addition to the Web site noted in the editorial (Pharmaceutical Research and Manufacturers of America), other sites are attempting to increase access to this useful service (rxassist.org, needymeds.com, rxhope.com). Some institutions that serve a large number of medically indigent patients have been able to provide a nearly full formulary using these programs. For example, this has been successfully accomplished at the medical center with which I am associated, the University of Colorado Hospital.
Unfortunately, the process of obtaining these free medications can be time consuming (and therefore costly), and there can be delays of up to 8 weeks until the medications are delivered. Drug samples play an essential role in bridging the gap until the free medications arrive. Although it may be argued that delays in starting medications for chronic diseases are of little clinical consequence, this can make clinic visits inefficient in terms of following up the effectiveness of new medications. Also, in certain symptomatic chronic diseases such as asthma delays in initiating therapy may lead to detrimental outcomes.
When patient assistance programs are unavailable to indigent patients, samples are often useful to test the effectiveness of a medication before it is purchased. If the medication is found to not be beneficial, then the patient can often save a considerable amount of money by not buying it.
Finally, the cost of a “reasonably priced” antibiotic such as sulfamethoxazole-trimethoprim (approximately $10) may still be unaffordable to many indigent patients, and a prescription would therefore not be filled. In those situations, clinical outcomes may be improved by providing a full course of antibiotics as a drug sample.
Although the use of drug samples have the potential to be detrimental to patient care, for medically indigent patients it can be an essential part of the care. I hope that most providers who care for indigent patients are aware of the pitfalls of samples and are able to use them responsibly for the benefit of this group of patients.
Bennett Parnes, MD
Denver, Colorado
Dr Parnes suggests that samples are very helpful in caring for medically indigent patients. He gives several examples, including bridging the gap between prescribing medication and receiving medications from pharmaceutical patient assistance programs and testing the efficacy of medications before paying for them. Providing medication to medically indigent patients is a valuable and important step in meeting their health care needs. It is unclear whether samples are truly the best method for this. Samples are often newer and more expensive medications that might be no more effective than older more established medications. Another method for providing medications to medically indigent patients might be to have a formulary of basic medications that are purchased by the office and dispensed as needed. I am familiar with many community health centers that provide basic medications to their patients with this method.
Dr Messmer suggests that we train our physicians to be more discerning in what they believe, rather than limit advertising to physicians through drug samples and pharmaceutical representatives. This is a great idea and one that we model in our residency. However, the impact is difficult to assess. If this method is successful we will likely find out from the pharmaceutical companies when they stop providing direct visits, meals, and entertainment. Dr Messmer also poses the question whether advertising speech for pharmaceuticals is different than advertising for other products, such as beer. The answer is an emphatic yes! Medical providers are afforded an incredible amount of trust by our patients. Patients understand that beer companies make money for selling beer; they understand that drug companies make money for selling drugs. Patients do not expect physicians to profit from the pharmaceutical industry.
John M. Westfall, MD, MPH
University of Colorado Health Science Center
Denver
