Rules, technology leave drug reps out of luck

Have we made progress on the ethics of drug rep interactions with physicians? Some doctors have stopped seeing the sales representatives directly and instead have sought drug information online.

Reply: Asked whether pharmaceutical sales reps provide any value to you or your patients, a physician might reply:

• No, that’s why I stopped seeing them in my office.
• Yes, if I get samples, coupons or vouchers.
• No, I find out all I need about drugs online or through other means (e.g. medical letter, Epocrates).
• No, I can just call an 800 number and order samples, as needed.
• Yes, if I get a good meal.

Drug reps had been a fixture of the American physician’s private practice for years before the turn of the 21st century. In the accepted quid-pro-quo relationship, the physician agreed to talk and listen to the rep’s pitch about the newest wonderful and amazing drug for condition X, Y or Z. In return, the rep provided any and all of the following: medical office paraphernalia, lunch, tickets to an event, invitations to evening educational sessions at a swanky venue and, lastly, drug samples. The drug samples were given to doctors to dole out to patients, providing free advertising about the newest drugs and creating a captive audience for them.

During the heyday of pharma reps, resident physicians — the next-generation prescribers — were fawned over by hospital-based reps. Resident physicians were spoon-fed drug information over elaborate lunches and dinners. To the financially strapped trainees, these reps promoted new drugs as if they were pure gold — better than the previous drug in many ways. Surprisingly, supervising physicians encouraged this interaction. Perhaps there was an educational message to be had in the long run, but the immediate message was clearly “Prescribe more of this drug.”

Receiving drug samples was a rite of passage for physicians as they trained and entered the work force. This seemingly philanthropic maneuver is now known to confer no real benefit to those who need these drug samples the most — the uninsured and underinsured. Changing the drug sample paradigm such that coupons and/or vouchers are now provided has not modified the collective physician stance, i.e. drug reps no longer have a free pass into doctors’ offices. These coupons and vouchers are most often redirected to the local pharmacy for use at the pharmacist’s discretion.

Things are different today for many reasons. First, the push from the managed health care industry to promote nonbrand-name drugs during the final decades of the last century rewarded physicians and physician groups with bonus incentives for generic drug utilization that exceeded preset thresholds and penalized patients by making co-pays higher for brand drugs. The move also lowered physicians’ desire to inquire about new drugs, much less prescribe them.

Then, during the past decade, medical authorities published scientifically sound data documenting that physicians, especially those still in training, were susceptible to pharma’s overt and subtle influences, prescribing more of the costly, cutting-edge drugs when rep interactions occurred in either the office or hospital settings. Many doctors have since eschewed direct interactions and have chosen to seek new drug information online through pharma-sponsored websites, third-party websites or reading evidence-based reviews of these drugs.

Finally, online medical educational resources have proliferated in the past decade. Continuing medical education through the Internet is now commonplace, as are physician community networks where medical information and case presentations are shared. Pharma has joined this shift in medical education by making websites that cater to both physician and patient, as well as not so subtly sponsoring medical software products directed toward the busy physician. By calling 800-“new-drug,” a physician can get the information needed to at least prescribe the latest and greatest drug, as well as obtain drug samples, as needed.

Medical conferences are still rife with drug company booths, providing brief interactions for the physician attendees while affording the opportunity to collect colorful knickknacks. But the move toward online physician interaction/education has made the face-to-face physician-rep scenario in offices and hospitals all but obsolete. Why call or contact a friendly neighborhood drug rep when you can find out all you need through the manufacturer’s website, a third-party entity or a continuing medical education event?

Sponsorship by pharma of these online educational modules is now evident, allowed by medical organizations for the moment. The climate of discouraging receipt of goods of any value in return for time devoted to learning about the newest drug as it pertains to the featured medical condition has made online physician-pharma interaction more acceptable to the professional medical and lay public.

Hospitals now restrict promotional sales calls, keep tabs on when and where reps go and do not allow them unfettered access to trainees. Resident physicians are sequestered, so to speak, learning only about evidence-based science and drug information and unexposed to pharma’s literature and personnel advocating costly, newly minted and brand-name drugs.

As alternative ways of advertising and educating grow and become more sophisticated, drug reps may no longer be used or needed. Physicians have a wide array of educational means by which to learn about medical topics and drugs of interest. Use of handheld devices, laptops and computerized electronic health records is more common and likely to increase in prevalence with the federal government’s mandate to submit all billing and prescriptions electronically by mid-decade.

Samuel Grief, MD, associate professor of clinical family medicine, medical director, campus care, University of Illinois, Chicago