Wednesday, May 02, 2007

Fool Me Once, Shame on You, Fool Me Twice, Shame on Me: Drug Reps' Gifts and Fake Friendships

An important article in PLoS Medicine on how drug representatives "detail" doctors has already gotten a lot of attention. [Fugh-Berman A, Ahari S. Following the script: how drug reps make friends and influence doctors. PLoS Med 4(4): e150 doi:10.1371/journal.pmed.0040150] Note that one of the authors (Ahari) is described as "a former pharmaceutical sales representative for Eli Lilly, and the primary findings of this paper summarize points he made in testimony as a paid expert witness on the defendant's side in litigation against a New Hampshire law prohibiting the sale of prescription data."

The most important points in this very interesting article are:

The Detailing Relationship is Built on False Friendship - The key, deliberate tactic is for the drug representive to convince the individual physician that the rep is the physician's friend. Thus the relationship can be inherently dishonest. To quote the article,

Reps may be genuinely friendly, but they are not genuine friends. Drug reps are selected for their presentability and outgoing natures, and are trained to be observant, personable, and helpful. They are also trained to assess physicians' personalities, practice styles, and preferences, and to relay this information back to the company. Personal information may be more important than prescribing preferences. Reps ask for and remember details about a physician's family life, professional interests, and recreational pursuits. A photo on a desk presents an opportunity to inquire about family members and memorize whatever tidbits are offered (including names, birthdays, and interests); these are usually typed into a database after the encounter. Reps scour a doctor's office for objects—a tennis racquet, Russian novels, seventies rock music, fashion magazines, travel mementos, or cultural or religious symbols—that can be used to establish a personal connection with the doctor.

Good details are dynamic; the best reps tailor their messages constantly according to their client's reaction. A friendly physician makes the rep's job easy, because the rep can use the “friendship” to request favors, in the form of prescriptions.

And the article concludes,

Physicians are susceptible to corporate influence because they are overworked, overwhelmed with information and paperwork, and feel underappreciated. Cheerful and charming, bearing food and gifts, drug reps provide respite and sympathy; they appreciate how hard doctor's lives are, and seem only to want to ease their burdens. But, as SA's New Hampshire testimony reflects, every word, every courtesy, every gift, and every piece of information provided is carefully crafted, not to assist doctors or patients, but to increase market share for targeted drugs.... In the interests of patients, physicians must reject the false friendship provided by reps.

Drug Reps Try to Buy Physicians' Friendship - The article emphasizes that giving gifts to physicians is meant to buy friendship and make the physician feel obligated.

Gifts create both expectation and obligation. 'The importance of developing loyalty through gifting cannot be overstated,' writes Michael Oldani, an anthropologist and former drug rep. Pharmaceutical gifting, however, involves carefully calibrated generosity. Many prescribers receive pens, notepads, and coffee mugs, all items kept close at hand, ensuring that a targeted drug's name stays uppermost in a physician's subconscious mind. High prescribers receive higher-end presents, for example, silk ties or golf bags. As Oldani states, 'The essence of pharmaceutical gifting‥is ‘bribes that aren't considered bribes’'.

There are those who belittle the article as merely showing that pharmaceutical companies employ aggressive marketing tactics. Aggressive marketing is prevalent in the developed world, so why should physicians moan about being subject to it? For example, see these comments by the anonymous "Industry Veteran" in the Health Care Blog, (whether the Veteran is real or a constructed persona playing devil's advocate is not clear).

What the hell, are physicians such delicate flowers that they must not be subjected to the lures of salesmanship?

The fact remains that drugs are discovered and distributed everywhere in the world through a competitive market system. Personal sales serves as one of the main spokes of that marketing wheel. Why do some people buy into the chauvinistic ideology of physicians that they must never serve as targets for marketing?

This might be fairer criticism if the marketing was only meant to persuade physicians to purchase products themselves.

But the ethical issue here is that the physicians are making decisions about what drugs their patients will receive. Patients cannot purchase prescription drugs without a prescription. Physicians (and other health professionals with prescribing authority, who are also detailed by drug reps) are the only ones who can write prescriptions.

So if physicians let these decisions be influenced by the phony friendship of drug reps and the gifts they provide, they are compromising their primary duty to the welfare of their patient. This duty would only be fulfilled if the physicians were to make prescribing decisions based on balancing the possible benefits and harms of the treatment, and their value to the patient.

As others have argued, it may be psychologically very difficult for physicians to prevent themselves from being influenced by gifts given them to market drugs. Thus, there is an argument to ban such gifts. (See our post here on this argument made by Brennan et al.) And before such a ban becomes policy, for physicians to fulfull their obligation to put the welfare of individual patients first, they ought not to accept such gifts.

It probably is just as difficult for physicians to prevent themselves from being influenced by drug reps' feigned "friendship." What to do about this on a policy level is not so clear. But physicians ought to consider simply avoiding drug reps. This may seem harsh, but remember, it is likely that one's apparent drug rep "friends" were only programmed to act that way.

Shame on physicians, though, (myself included) for falling for this. We may be overworked, distracted, and tired, but we should not have been so gullible, or so eager for gifts and new "friends."

Finally, more shame on the pharmaceutical companies for trying to influence physicians' decisions for patients with gifts and fake friendships. Just because many physicians have been too gullible and eager for more gifts and new "friends" to resist these practics does not make them ethical.

One wonders how many drug reps feel contempt for the physicians who really believe the reps are their "friends?" But how do the drug reps feel about themselves for fooling the gullible physicans?


Anonymous said...

The May 1st WSJ had two articles that touched on this subject. The first was that Lilly was going to disclose funding to nonprofits. This amounted to $11.8M in the first quarter. These are the very groups that set the protocols, for care and treatment, of the very diseases, Lilly sells drugs to treat.

The second article outlined the growing student loan debacle and how university staff ranked vendors on the quantify and quality of food and other perks as they sought their business. This reflects my wife's and my experience in our own doctor's offices.

Thirty plus years ago I remember setting in an all male psych class and the instructor took great pains to explain ritualistic feeding. Sharing a meal creates one level of bonding. Buying a meal creates a deeper level. Sharing food from the same plate creates a very deep bond.

Drug companies review sales weekly by physician. They measure the impact of the meals they are purchasing and the reps who are involved. Doctors need to be aware that there is a very real design to the attractive drug rep bringing a plate of food with a bite already cut ready to be eaten.

They call drug reps detail people not just for their knowledge of advertising material, but every move they make in the office is planned and orchestrated to maximize their sales.

Steve Lucas

Anonymous said...

But the ethical issue here is that the physicians are making decisions about what drugs their patients will receive. Patients cannot purchase prescription drugs without a prescription. Physicians (and other health professionals with prescribing authority, who are also detailed by drug reps) are the only ones who can write prescriptions.

With the current public sentiment regarding Big Pharma, many consider Big Pharma as the only source of evil. After all, Big Pharma advocates "aggressive" marketing where everything goes--at least until they get caught. Big Pharma is on the hook for deceiving FDA, with studies that present skewed data, incomplete or inconsequential information, etc. Big Pharma overwhelms our airways with DTC ads. Big Pharma markets dangerous/deadly products--always putting their own bottom line above patient welfare. Naughty, naughty Big Pharma.

But not a single (prescription-only) Big Pharma product can enter the marketplace WITHOUT the aid of a compliant physician. Doctors want to know why the esteem in which they were once held has become so tarnished. Big Pharma, right? Wrong--they need look no further than their mirror. Until physicians grab hold of their own integrity and ponder the tenets of the Hippocratic oath, they will continue to experience a decline in public perception. Many now consider them as little more than "legal" drug pushers.

Just like the legal profession that has sought to form the only interface between the individual and the justice system, doctors will continue to thrive only because they represent the only interface between patients and pharmaceutical treatment. I would contend that "self-policing" is at best ineffectual. Entitlement of the elite is accepted while entitlement for the poor is the bane of the profession. Doctors use their membership in the powerful AMA, and their "brotherhood" of physicians to both protect themselves and intimidate both patients and whistleblowers. Pointing a finger at Big Pharma does not relieve doctors of their own complicit role in the burgeoning healthcare travesty.


Roy M. Poses MD said...

Big pharma is hardly the source of all evil. Big pharma is the source of lots of useful drugs that make it possible for us physicians to do a lot of good, when used judiciously.

On the other hand, in many cases, the practices used by big pharma to market these drugs are not in the best interests of patients, and, as I noted above, basically make chumps out of doctors.

I did indicate that there is plenty of blame to go around. Doctors are to blame for falling for deceptive marketing practices, especially in cases in which greed for pharma hand-outs is a factor.

On the other hand, when pharma deliberately deceives doctors in the course of its marketing, it deserves plenty of blame too.

I made both those points above.

However, putting the onus just on doctors is unfair, IMHO. And believe me, it is time for the meme of the all-powerful AMA to be retired. For better or worse, the AMA's influence has greatly waned since the passage of Medicare in 1965.

Anonymous said...


I suppose I go a bit over the top, blaming doctors. Truly, I recognize there are lots of good doctors--it's just easier when I attack the keyboard, to limit my attacks.

I also recognize BigPharma has brought us some useful and/or important medical treatments. Painting everyone with the broad brush of "evilness" IS contrived. While I was on my soapbox, though, I wanted medical professionals to recognize that they, too, are a big part of our problem. With their education and training, the excuses of "overwork" and "mountainous paperwork" don't excuse lazy behavior and dependence on BigPharma detail-people for "education."

If I had to order the culprits, I would place Big Pharma at the top of the heap. Their greed and single-mindednes in fulfilling their fiduciary responsibility to shareholders keeps them at the top of my list. Profits above patient welfare is unacceptable.

BUT, doctors form the interface; likewise, they have power. Whether they use that power to influence inappropriate/criminal corporate behavior or to intimidate and/or dictate to patients determines THEIR character. Perhaps, I am in a unique locale--but I haven't personally witnessed any significant acts by my local docs that reveal the integrity and character I hope for and expect from medical professionals.


Med-Source said...

At my institution [insert large academic medical center here] the powers that be have completely banned drug reps from the floors of the hospitals and from providing any samples or gifts both in the hospital and in the outpatient setting. In the hospital this is not necessarily a bad thing. Reps provided great lunches, but their samples and gifts did not affect whether or not patients got treated. In the hospital, a drug rep's spiel may have affected which drug was administered (though it shouldn't), but the hospital's pharmaceutical inventory was unaffected, and the physician was always able to chose from the full formulary.

In contrast, at the outpatient offices, many physicians depended on a sample inventory to provide under-insured patients with short courses of treatment (i.e. 3-6 months of Plavix (clopridogrel) status post stent placement). Many physicians now find that they pick their drug of choice for a patient based not on the latest protocol and most highly regarded randomized controlled studies (aka evidence based medicine) but rather on a patients' insurance. The drugs that are approved on formulary with lesser insurance are not the best drugs, they are the older, cheaper drugs.

During my clinical rotations I rotated through 2 outpatient primary care offices and 1 outpatient oncology office. 2 of these offices were affiliated with my academic center and therefore had no samples. I saw chemo patients who had to take Compazine (prochlorperazine) when Zofran (ondansetron hydrochloride) was undoubtedly the drug of choice, and I saw well controlled clinically depressed patients switched from Wellbutrin (bupropion) to generic Prozac (fluoxetine) because they could no longer afford to pay for their medication. In the unaffiliated office physicians I occasionally saw physicians prescribe drugs because there were samples in stock, but the drug was always appropriate and in many cases equivalent to other drugs in the same class. A free 10 day course of antibiotics guaranteed treatment.

Academic institutions need to strike a balance and trust physicians to do their job. I agreed that gifts cross the line, but a free lunch accompanied by a mini lecture on efficacy and same samples provides more benefit than harm. I have heard through the grapevine that re-allowing drug rep lunches, at least at outpatient sites is being reconsidered, we'll have to wait and see.