Just the words “pharmaceutical industry” are likely to elicit some sort of reaction from you whether it is positive or negative. But what is behind this reaction and how and in what ways do our interactions influence us?
A story as old as the industry itself.
Back in the 1950s Senator Kefauver, as chairman of the united states senate’s anti-trust and monopoly subcommittee started to question the practices of the pharmaceutical industry.(1) He charged the industry with excessive margins and prices, these same costs being increased due to expensive marketing. He also claimed that most of the industry’s new products were no more effective than established drugs on the market.(2) Fast forward to 1973 and the US Senate were hearing from Senator Kennedy that “the irrational prescribing of drugs is a serious and increasing problem in this country, a problem that is being paid for by thousands of Americans with their health and sometimes with their lives”.(3) Antibiotic resistance was already on the table and so much of this hearing, including the methods used to influence prescribers could have been written yesterday.
There ain’t no such thing as a free lunch … or pen.
Ex-employees of Pfizer and Merck among others testified to the use of pens to get access to the doctors they wanted to influence. It wasn’t all free fridge freezers, which has since fallen out of favour. They talk of the unique aspect of selling a medication, you have to sell it and unsell it. That is, to sell it you also have to speak of the product’s disadvantages, or side-effects as we physicians would speak of it.(3) Of course, if you hear of a product’s disadvantages, on one level it gives a level of credibility to the advantages…
These ex-employees also spoke of the ubiquity of their role. A bit like the Beatles’ love ballard, the drug reps are here, there and everywhere. For the physician is the final step in a ladder which starts with the receptionist who opens the door. A receptionist who can be engaged in conversation about a busy physician’s tastes and timetable. The ladder involves stepping over the nurse who knows the prescribing habit of the physician they work with. You as the physician are not the only person writing with a free pen.
It’s not all bad.
Of course, not all pharmaceutical interaction is negative and many physicians are able to attend conferences thanks to a drugs rep. And when it comes to generic medication, the recommendation to prescribe any generic. Although you might question the alphabetical laboratory listing in your EHR or electronic health record. Are you really going to scroll down to pick the one from the company starting with Z? There is also an argument that without the pharmaceutical industry there would be no research and development. There have been claims that for every dollar spent on R&D, 2 dollars are spent on marketing. These allegations made the headlines but the industry themselves have defended themselves time and time again, most recently in September 2020 saying that this is not the true vision.(4) You can watch their statements for yourself on YouTube.
When Ben Goldacre’s book “Bad Pharma: How Drug Companies Mislead Doctors and Harm Patients” came out in 2013, it topped the best seller charts and changed practise.(5) If you haven’t read it, do. It covers many topics including the non-publication of trials with what could be seen as negative results. The alltrials project pushes for all trials to be registered and published with a full report of their methods and summary results.
Speaking of which, how do you keep up to date? Is it through, maybe only partially, studies and reports which your local drug reps present you? It is incredible hard to keep on top of all the research being published. Indeed, IBM Watson Health have an entire AI program based on this, where the computer scans all the research publications which appear every day and gives you a summary based on your professional interests. However, it is unlikely that the local drug rep will be offering you the most unbiased view, even with the selling and unselling mentioned before. Subscribing to library updates such as the KnowledgeShare service means you will be alerted to the latest research in your area of interest and you can then look at it critically yourself. Later in the series we will be looking at easy methods for critically appraising research to make it less of a task at the end of a busy day.
Another space you may have thought of as “clean” is CPD or continuing professional development. Yet, if it is free to access you should be looking at who is providing the access and why. Even when accessing the CPD of established institutions you should look carefully at conflict of interests of those writing the CPD module. You might be surprised not only at who the author has been financed by, but also the extent to which they rely on their own research. As an audit of your own practise you can look at how you would have to answer a competing interests policy, such as that of the BMJ. As my own competing interest declaration I should mention that I also work freelance for the British Medical Journal as digital copy editor and also quality audit the Spanish Best Practise translations.
Being aware of who is providing funding is also relevant to online resources for rare conditions. Often these resources for patients and clinicians are financed by companies offering therapeutics of all types, not just pharmacological, in that area. Expert patients offer valuable insight into helping them manage their conditions but in order to make informed decisions everyone has to be aware of who the information is coming from, especially if their SEO or search engine optimisation means that they are coming out top in a google search.
Danone have come under particular fire for their recommendations about safe distances during COVID which makes breastfeeding impossible and goes against WHO recommendations. This was on their affiliated website.
It’s not all work.
Finally, as members of society and consumers ourselves, we may find ourselves consuming products and information which affects our practise. If you have children, you may be exposed to marketing of baby milk products or foods in your home, for example on social media despite this breaking the international codes of conduct about breastfeeding. Nestle is the most well known to have a long-time boycott against its products, it was started in 1977, but Danone again has been flagged for invading our Facebook feeds even if it is not us who signed up to their information sites.
Over to you.
So how do you know if are being influenced in your prescribing? And if you think that you’re not, then, according to the drug reps themselves, you are the most interesting candidates to work on.
The first and easy option is to look around you and on you. What are you writing with, and on? Is it a free writing pad? It doesn’t really matter if it was given to you directly or you picked it up in a conference bag, or even if the pen has been recycled to your children’s pencil case, it’s still present in your mind. You can use this realisation as a prompt to think why you prescribe this medication. It’s not a critique but rather a stimulus to get you thinking about if your practise is still up to date. Do you have the phone number of any drug reps in your contacts?
On the IFMiL website where this podcast is hosted, you will find a couple of exercises to work through in order to get your CPD, but this is a quick one you can do here and now. Off the top of your head, that is without careful thought, write down the first ten medications which come to mind. Now ask yourself why do I use them? Have I checked recent trust or hospital guidelines to make sure I am still current. Then have a chat with a colleague working in a similar environment and see what they use. If it’s different (and even if it’s the same) are you able to say why? Working in different countries and different hospitals has opened my eyes and made me question certain prescriptions. But I never did review my practise in a routine way.
If you’d like to know more about this subject, IFMiL runs an online course on working with the pharmaceutical industry which goes in to more detail about how your interaction as a clinician is regulated both in Catalonia and further afield.
1. Greene JA, Podolsky SH. Reform, Regulation, and Pharmaceuticals — The Kefauver–Harris Amendments at 50. N Engl J Med [Internet]. 2012 Oct 18 [cited 2020 Nov 27];367(16):1481–3. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4101807/
2. Kefauver E. In a Few Hands: Monopoly Power in America. Pelican; 1966.
3. Committee on Labor and Public Welfare, United States Senate, Ninety-third Congress F and SS. Examination of the Pharmaceutical Industry, 1973-74: Hearings Before the … – United States. Congress. Senate. Committee on Labor and Public Welfare. Subcommittee on Health – Google Books [Internet]. United States. Congress. Senate. Committee on Labor and Public Welfare; 1974 [cited 2020 Nov 26]. Available from: https://books.google.es/books?id=jBzQY0IuGhoC&num=100
4. U.S. House of Representatives Oversight and Reform Committee. Pharma executives testify at House hearing on drug pricing — 9/30/2020 – YouTube [Internet]. CNBC Television. 2020 [cited 2020 Nov 27]. Available from: https://www.youtube.com/watch?v=FkI4_xHGkAQ
5. Goldacre B. Bad Pharma: How Drug Companies Mislead Doctors and Harm Patients. In 2013.