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Healthy Skepticism Library item: 4436

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: news

Kron J.
To see or not to see.
Australian Doctor Weekly 2005 Sep 14


Full text:

While most GPs make the time to see pharmaceutical company reps, a large number are turning their backs. Is this a wise decision, or just another form of censorship? by John Kron

DR Peter Mansfield was startled when a fellow GP asked him: “You think that I would betray the trust of my patients just for a pen?”

“I was offended by the accusation,” says Dr Mansfield, a GP in Willunga. “It was a clear misunderstanding of my position that doctors prescribe what they believe are the best drugs, but the evidence shows that unintended bias is common because the more we see drug reps, the worse our prescribing.”

As the founder of Healthy Skepticism, an organisation that describes its aims as improving health by reducing harm from misleading drug promotion, Dr Mansfield is happy to defend his beliefs, which go beyond concerns about accepting gifts. He wants doctors to cut all contact with drug company representatives.

And research conducted last year on behalf of an industry group showed 24% of GPs have done just that, although it did not reveal why.

But talk to Professor Paul Komesaroff, chief author of the Royal Australasian College of Physicians’ policy on “relationships with the pharmaceutical industry”, and you get a different story.

While he has no great love for the pharmaceutical industry, he defends the right of doctors to see reps.

“The first reason is that I am against censorship,” Professor Komesaroff says. “I believe it is important to be open and read widely from a variety of sources, including [material provided by] drug reps.”

He believes refusing to see pharmaceutical reps will not guarantee objectivity because all sources of information are biased, including journals, which can fall victim to publication bias.

“It won’t even make objectivity easier. It is more a gesture to support the principle of objectivity.”

Professor Komesaroff, a Melbourne physician and director of the Monash Centre for the Study of Medicine, Society and Ethics, says the best way to remain objective is to be vigorously critical and sceptical of all information received and remove the bias, whatever the source.

“Doctors do need to get much better at being aware of the aims and impact of having contact with drug reps, and develop their skills of assessing the information received from them,” he says.

“And I have absolute confidence that doctors can apply themselves to the learning and training that is required to do it, and they don’t need to resort to not seeing drug reps.”

However, Dr Mansfield does not agree. “I don’t have the time to do the research to balance out what the drug reps tell me. If I saw drug reps, my patients, on the evidence, would be worse off, therefore I don’t see them.”

And despite 20 years of studying pharmacology, logic, psychology, statistics and semiotics, he says he is “still not skilled enough to avoid being misled by the information put out by drug companies”.

Dr Geoff Spurling, a Brisbane GP, has also chosen not to see any drug reps, questioning the motivation behind the bias found in the information they distribute.

“I feel better off going straight to information sources such as Cochrane reviews because even though there is bias, at least they actively seek to reduce it,” he says.

“In contrast, the drug companies are intentionally biased in order to maximise the chances of doctors prescribing their products.”

Dr Spurling wants to send a message to the drug industry. “I believe doctors can have an impact on the amount of money wasted on promotions of drugs and hopefully also make them give doctors less biased information by refusing to see drug reps,” he says.

However, Mr Paul Chamberlin, Medicines Australia’s senior manager of communications and strategic relations, defends the information provided to GPs by pharmaceutical reps. He says all sources of information can be perceived as biased, including the pharmaceutical industry and the National Prescribing Service, and “we are no more biased than other sources”.

He also defends the motivations of the pharmaceutical industry. “Sure, we have a responsibility to shareholders, but we also have a responsibility to the community, the consumers and the medical profession,” he says.

As proof that profits aren’t the primary goal, Mr Chamberlin cites the pharmaceutical industry’s initiative to instruct pharma representatives to inform GPs of the PBS indications for each medication and, at its own expense, include these indications on all their advertisements.

“GPs have less and less time to see representatives but usually will see those who offer value and who are ethical, even if their general approach is not to see drug reps,” Mr Chamberlin says.

He also says most GPs attend education programs sponsored by drug companies.

Professional medical organisations do not offer any guidance to doctors about seeing pharma representatives. Ethical guidelines produced by the RACGP and AMA do not list refusal to see reps as an option.

Dr Mansfield says force of habit could be one of the reasons doctors rarely consider cutting off contact with reps.

“A significant part of learning to be a doctor involves copying what older doctors do to develop your professional identity,” he says. “That enables us to ask patients to remove their clothes, something the average person doesn’t do.

“But for doctors to end up seeing drug reps via the same process, without properly weighing up the pros and cons, is a failure of informed consent. And once the habit is established, it is too hard to admit that what you’ve been doing all these years is wrong.”

Research demonstrates that visits from pharma representatives do have an impact on the way doctors prescribe.

In a recent article in the Annals of Family Medicine1, Professor Howard Brody, professor of family practice at Michigan State University, US, wrote: “Reps are not evil, but they are time-consuming and serve interests that are often at odds with those of our patients.

“Systematic reviews of the literature [confirm] a direct relationship between the frequency of contact with reps and the likelihood that physicians will behave in ways favourable to the pharmaceutical industry.”

For example, a study published in the Journal of the American Medical Association2 found doctors were 13 times more likely than controls to request that drugs be added to a hospital formulary if they had met with representatives from the drug’s manufacturer.

If the doctors had accepted money from those companies they were 19 times more likely to support the drug.

Professor Brody says there is some evidence that the mechanism underlying the change of prescribing occurs because the doctor feels a sense of debt to the representative and hence the product.

“Yet [studies have found that] physicians influenced by pharmaceutical marketing nonetheless believe that their information is scientific and unbiased,” he wrote.

“We are indeed heavily influenced by reps and … we ourselves are very poor judges of that influence. To the extent that we claim to be scientific practitioners, we would seem obligated to take this evidence into account in deciding upon our proper professional behaviour.”

While some GPs have decided the easiest way to deal with these issues is to refuse to see pharma reps, others believe the best approach is education to acquire the critical and sceptical skills needed to assess the information.

1. Annals of Family Medicine 2005; 3:82-85.

2. JAMA 1994; 271(9):684-89.

THE CASE FOR AND AGAINST SEEING PHARMA REPS

FOR

- Refusing to hear from a source of information is unacceptable censorship.

- The information received from reps needs to be critically assessed like other sources of information, which are all biased to some extent, including medical journals which are biased towards the publication of positive results. Medicines Australia cla ims that information from reps is no more biased than other sources.

- Patients can benefit from free samples provided by reps, for example, expensive medications not covered by the PBS.

- Doctors can attend drug company-sponsored medical conferences that would otherwise by prohibitively expensive for them and can provide knowledge that is beneficial to patients.

AGAINST

- Lack of time and/or education to critically and sceptically assess information provided by reps can lead to bias in clinical decision-making.

- Systematic reviews show a direct relationship between the frequency of contact with pharma reps and the likelihood that doctors will behave favourably towards the drug industry.

- Studies show doctors influenced by marketing falsely believe they are making unbiased decisions.

- Free samples are mostly used by doctors, staff or go to patients who can afford them anyway.

 

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There is no sin in being wrong. The sin is in our unwillingness to examine our own beliefs, and in believing that our authorities cannot be wrong. Far from creating cynics, such a story is likely to foster a healthy and creative skepticism, which is something quite different from cynicism.”
- Neil Postman in The End of Education