Transcript Detailing Drugs to Docs

Duke Internal Medicine Residency Curriculum
The Doc, The Drug Rep
and The Ward Rounds
Or everything you wanted to know about
pharmaceutical marketing but was afraid to ask.
By: Amer K. Ardati, MD
Editor: Amy Shaheen, MD, Assistant Professor
of Clinical Medicine
Duke University Medical Center
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Them Introductions
• Pharmaceuticals as a business
• Detailing Drugs to Docs
–
–
–
–
Costs of detailing to docs
Influence of detailing on docs
Perception of physicians and patients about drug detailing
What the academy and industry has to say about drug
detailing.
• Conclusions and Questions
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The Business of Drugs
• Pharmaceutical companies are for profit entities with a
fiduciary responsibility to obtain profits for their
shareholders.
• The drug industry is highly profitable when compared to
others.
• The drug industry invests more in marketing than in
research and development.
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The Business of Drugs
Source: Public Citizen 2002: http://www.citizen.org/documents/Pharma_Report.pdf accessed 9/1/05
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The Business of Drugs
Source: Public Citizen 2002: http://www.citizen.org/documents/Pharma_Report.pdf accessed 9/1/05
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The Business of Drugs
Source: Public Citizen 2002: http://www.citizen.org/documents/Pharma_Report.pdf accessed 9/1/05
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The Business of Drugs
Role of Pharmceutical Industry Employees
2%
11%
Administration
26%
Marketing
R&D
39%
22%
Production,
Quality Control
Distribution,
Other
Source: PhRMA, Industry Profile 2001. Calculations by Sager and Socolar
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Detailing Drugs to Docs
• More than $11 billion is spent each year by
pharmaceutical companies in promotion and marketing,
$5 billion of which goes to sales representatives. It has
been estimated that $8000 to $13,000 is spent per year
on each physician.
• The money is well spent and does influence prescribing
patterns.
JAMA 2000: 283;373
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Detailing Drugs to Docs
• Unlike advertising, gifts and hospitality promote a sense
of obligation towards the gift giver and encourages
reciprocation of the gesture. This creates a conflict of
interest.
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Detailing Drugs to Docs
• Physicians recognize that gifts influence other doctors but
not themselves.
• Patients perceive drug gifts as a form of bribe against
their interests regardless of whether or not the bribe is
effective.
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Detailing Drugs to Docs
• From a review of 29 studies evaluating physician-industry
interactions:
– Most physicians meet with drugs reps 4 times a month.
– Most physicians believe that drug representatives provide
accurate information.
JAMA 2000: 283;373
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Detailing Drugs to Docs
• From a review of 29 studies evaluating physician-industry
interactions:
– Most physicians deny that interactions influence their
behavior.
JAMA 2000: 283;373
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Detailing Drugs to Docs
In a survey of 102 medical residents,
most respondents felt that they were
immune to drug representative
marketing, while their colleagues were
vulnerable.
Am J Med: 2001: 110; 551
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Detailing Drugs to Docs
Am J Med: 2001: 110; 551
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Detailing Drugs to Docs
In a case control study of physicians
requesting formulary additions at an
academic hospital, physicians who met
with pharmaceutical representatives
were more likely to have requested
addition of drugs made by those
companies OR=4.9, 95%CI, 3.2 - 7.4
JAMA 1994;271:684
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Detailing Drugs to Docs
In a survey of 468 physicians (both
academic and community) a significant
positive correlation was found between
physician cost of prescribing and
perceived credibility, availability,
applicability, and use of information
provided by pharmaceutical
representatives.
Arch Fam Med 1996: 5;201
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Detailing Drugs to Docs
• In a survey of 196 patients and 268 physicians
at two tertiary care centers, 54% of patients
were aware that doctors received gifts from
drug representatives, but only 27% thought
that their doctors received gifts.
• Patients were more likely than physicians to feel
that gifts influenced medical practice.
JGIM 1998; 13:151
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Detailing Drugs to Docs
Percentage of Respondents that Thought
Gifts Were Not Appropriate
80
60
Patients
Physicians
40
20
0
Pen
Mug
Lunch Dinner
Trip
JGIM 1998; 13:151
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Detailing Drugs to Docs
Percentage that Thought Gifts Were
Influential
60
50
40
30
Patients
Physicians
20
10
0
Pen
Lunch
Trip
JGIM 1998; 13:151
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Detailing Drugs to Docs
Drug detailing is an orchestrated
endeavor. Here is an example of a drug
detailing training manual from Merck that
was obtained by the House Committee
on Government Reform hearing on
Rofecoxib (Vioxx):
Harper’s 2005; 311: 16
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Detailing Drugs to Docs
• The Merck Manual:
– “Health Education Learning [HEL] Situation:
• Physician Says: What a great football game yesterday. Did you
see how effective Drew Bledsoe was in the fourth quarter? That
guy is amazing.
• Possible rep response: Bledsoe is effective on so many levels.
He’s a leader, you feel safe with him carrying the ball, and he’s a
proven winner. You know who else he sounds like? Zocor, a
market leader with an eight-year safety record, proven to save
lives of your patients…”
Harper’s 2005; 311: 16
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Detailing Drugs to Docs
Policy Recommendations
and Guidelines
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Detailing Drugs to Docs
• The AMA Position:
– “Any gifts accepted by physicians individually should
primarily entail a benefit to patients and should not be of
substantial value.”
– “Subsidies from industry should not be accepted directly or
indirectly to pay for the costs of travel, lodging, or personal
expenses of the physicians who are attending the
conferences and meetings . . .”
– “No gifts should be accepted if there are strings attached.”
JAMA 1991: 261;501
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Detailing Drugs to Docs
• The ACP position:
– The acceptance of individual gifts, hospitality, trips,
and subsidies of all types from industry by an
individual physician is strongly discouraged.
– Physicians should not accept gifts, hospitality,
services, and subsides form industry if acceptance
might diminish or appear to others to diminish the
objectivity of professional judgment.
Annals 2002: 136; 396
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Detailing Drugs to Docs
• The ACP position:
– Acceptable Industry Gifts:
• Inexpensive gifts for office use (pens and
calendars).
• Low cost gifts of an educational or patient-care
nature (such as textbooks).
• Modest refreshment.
Annals 2002: 136; 396
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Detailing Drugs to Docs
• AMSA’s Position:
– BELIEVES that practicing physicians should maintain
an independent financial posture vis-a-vis the
pharmaceutical industry to avoid the potential of
conflict of interests in prescribing for and treating their
patients
– URGES all physicians, residents and medical students
not to accept as end recipients any promotional gifts
from the pharmaceutical industry.
– URGES all hospitals and residency programs to
discontinue the practice of pharmaceutical companyfunded lectures and lunches.
http://www.amsa.org/about/ppp/pharm.cfm, accessed 8/31/05
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Detailing Drugs to Docs
• AMSA’s Position:
– URGES all physicians not to accept honoraria on behalf
of pharmaceutical companies for speaking at
educational conferences and not to accept
compensation for token consulting or advising.
– SUPPORTS including curricula in medical school
education concerning the ethics of physician-industry
interactions, particularly in relation to pharmaceutical
research and marketing.
http://www.amsa.org/about/ppp/pharm.cfm, accessed 8/31/05
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Detailing Drugs to Docs
• PhRMA’s (The pharmaceutical industry)
Position:
– Items primarily for the benefit of patients may be
offered to healthcare professionals if they are not of
substantial value ($100 or less).
– Items of minimal value may be offered if they are
primarily associated with a healthcare professional’s
practice.
– Items intended for the personal benefit of healthcare
professionals (CDs, tickets to a sporting event) should
not be offered.
http://www.phrma.org/publications/policy//2004-01-19.391.pdf, accessed 8/31/05.
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Detailing Drugs to Docs
• The Duke Position:
– Representatives may sponsor or attend
educational conferences with Duke faculty,
trainees… upon prior approval by the
program director, clinic director or conference
organizer.
– Promotional materials (e.g. all branded office
supplies, personal items such as coffee mugs,
bags, calendars, note pads) and other
devices will not be distributed within Duke
Hospital, Duke Clinics or the PDC clinics.
http://pharmacy.mc.duke.edu/pt/index.htm, accessed 8/31/05.
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Detailing Drugs to Docs
• The Duke Position:
– No advertisements should be posted on walls,
doors, windows, and cabinets or placed in
reception area(s).
– Financial support directly to housestaff,
fellows and students is prohibited.
http://pharmacy.mc.duke.edu/pt/index.htm, accessed 8/31/05.
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Conclusions
• The pharmaceutical industry is in the
business of selling drugs to make money.
• Drug marketing influences the way we
treat our patients.
• Our patients know that drug marketing
exists and that it affects the way we care
for them.
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Conclusions
• Academic societies have recognized this
conflict of interest and have made
varying attempts to manage this conflict.
• As a group we need to be more
cognizant of the power of marketing to
cloud our judgment.
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Question 1
Congrats! You have been elected chief
medical resident and have to manage
noon conference lunches for the next
year. During last year as a GI fellow you
got to know the Astra Zeneca Drug Rep
while at the AGA meeting. She calls and
asks if she could sponsor a talk in Peptic
Ulcer Disease to your residents. She
offers to bring lunch, pens, mugs, and a
stack of tickets to go see Justin
Timberlake at the RBC Center in Raleigh.
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Question 1 (cont.)
Based on what you know about Duke’s Rules
you decide to tell her:
A) Sure come on down, the interns are hungry, my ACR
stole all my pens, and Justin is dreamy.
B) Thanks, but I can’t have you do the talk or pass out
gifts. If you want to buy us lunch we may be able to
work things out with my boss.
C) No way! After Janet Jackson’s wardrobe malfunction, I
wouldn’t feel Justified. Besides, couldn’t you use that
money to pay for Malaria drugs in Africa?
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Answer 1
The answer is B.
According to Duke rules, the drug rep
cannot bring gifts. She may sponsor
lunch, if the program director and chair
agree. Wouldn’t it be nice if the $11
billion spent by drug companies to
advertise to us were spent on saving
lives?
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Question 2
Your have just graduated from your Allergy and
Immunology fellowship and finally have to work
for a living. You move to Columbus, OH where
the Buckeye Allergens are high enough to
support your career in treating allergic rhinitis.
The Schering representative drops by your
office and notices that your golf clubs are
looking kind of ratty. He offers to hook you up
with a new set of clubs and a membership at
the Country Club in exchange for your advice on
the advantages of Clarinex.
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Question 2 (cont.)
Based on what you know about the ACP and
PhRMA’s guidelines on drug marketing you tell
him:
A) Could you please arrange for a 3PM tee time MondayFriday I like to get a game in after a hard day in the
office.
B) My golf game is kind of weak, could you throw in a
couple of lessons.
C) Sorry I can’t take your bribe, ahem, gift.
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Answer 2
The answer is C.
Gifts should be of an educational nature
and should benefit patient care. PhRMA’s
voluntary guidelines recommend that the
value of gifts not exceed $100. The ACP
says that docs “should not accept gifts,
hospitality, services, and subsides form
industry if acceptance might diminish or
appear to others to diminish the
objectivity of professional judgment.”
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Questions 3, 4, and 5 background
You’ve just finished Gen Med Duke
as an intern and have CAD and
9090 to look forward to. As you try
to figure out how much of your well
earned paycheck to invest in
PfizerMerckSchering and Co, you try
to remember how these companies
spend their money.
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Questions 3, 4, and 5
Match the following numbers with the
correct description:
$11bn
Amount of total revenue spent on
Research and Development
14%
Amount of total revenue
that is diverted to profits
17%
Amount of total revenue
spent on advertising drugs
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Answers 3, 4, and 5 Answers
• $11Bn is spent on marketing
drugs each year
• 14% of drug company revenue
is spent on research and
development
• 17% is spent on profits
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