Drug representatives and residents: dangerous liaison?
By Christine Wiebe
William Arnold, FACP, remembers walking into a noon conference where a "tall, striking brunette was handing out hot beef sandwiches and fries to housestaff," along with hats bearing the name of a drug she was promoting. The sales rep was thanking residents for their support as they filed by, while the conference speaker was kept waiting during the "feeding frenzy," Dr. Arnold recalls with disgust.
The incident alerted Dr. Arnold to the possibility that the relationships drug sales reps build with residents may influence which drugs are chosen for the hospital's formulary. Dr. Arnold, program director for internal medicine at Lutheran General Hospital in Park Ridge, Ill., says he was even more appalled when he learned that the hospital had been using the drug touted by the sales rep--partly at the urging of residents--even though it was more expensive and no more effective than its counterparts.
Dr. Arnold responded soon afterward by instituting a new policy limiting drug reps' contact with residents in his program.
No free lunches
That was four years ago. Today, a number of residency programs are moving in the same direction. (The movement has been slow in part because opinion on the issue is so divided.) However, because residents' relationships with drug companies vary widely in scope, and because some contend reps fill an "information void" for residents, experts disagree on where to draw the line. Many residency programs allow drug companies to hand out small "freebies" like penlights and calendars, for example, or to cater noon conferences. Others accept free drug samples and pass them on to indigent patients. At the far end of the spectrum, some use drug company funding to pay for research or educational programs.
The problem with accepting even small gifts, some educators believe, is that it encourages residents to develop relationships with drug sales reps and therefore be more likely to use the drugs those reps promote. "Gift-giving is not done without an expectation of something in return," says Dr. Arnold. "There is no such thing as a free lunch."
In fact, sales reps rarely give gifts or offer sponsorships to "bribe" residents, but rather to get a foot in the door to make a sales pitch, says Norm Fost, MD, director of the program in medical ethics at the University of Wisconsin in Madison. Offering a free baseball ticket, for example, may just be the first step in a subtle yet seductive process, he says. Physicians who accept a gift are more inclined to grant the giver a few minutes of their time, he argues, and studies have shown that physicians who develop relationships with sales reps are more likely to prescribe their drugs.
The most powerful way to teach residents about the dangers of such relationships is to limit drug companies' access to them, Dr. Fost argues. In fact, his hospital has done just that by banning sales reps from patient wards. "It sends a message that we think there's something wrong with them roaming the halls," he says. Salespeople may still contact physicians in the lobbies and other public areas.
Do residents need protection?
Some residents appreciate being shielded from the "nuisance" of dealing with drug reps. At Providence Medical Center in Portland, Ore., residents encounter drug reps only during their ambulatory care rotations away from the hospital, says Douglas Romney, ACP Member, who recently completed a stint there as chief resident. The program director forbids sales contacts at the hospital, he says.
"The trinkets and things that they bring by, I didn't miss that one bit," says Dr. Romney, who now practices in Salt Lake City, Utah. Neither did he miss the sales pitches. "A lot of [reps] use data that is biased, and sometimes they don't have a clear understanding of the whole picture," he says.
Other residents, however, resent the notion that they have to be protected from drug companies. Instead, they want to learn how to handle sales pitches in training, so they will know what to do in private practice.
"It's unrealistic to think that you're going to do away with these marketing capabilities," says Rodolfo Aldir, ACP Member, a cardiology fellow at Case Western Reserve Metro Health Center and Mount Sinai Medical Center in Cleveland. Given that residents can expect to encounter drug salespersons in practice, they need to learn how to sift through that information and make decisions on their own, he says. "If part of our job lies in prescribing medications, then we should know about those medications," he says.
Dr. Aldir rejects testimonials affirming that free lunches or gifts induce physicians to prescribe one drug over another. He and several other physicians recently completed a three-county survey of residents and practicing physicians, and he concludes that such marketing practices have "no significant degree of influence" on physicians' prescribing patterns.
Drug companies, of course, balk at the idea of limiting their access to residents. "Most physicians would be insulted by the idea" that they need to be shielded, says Steve Berchem, assistant vice president for communications for the Pharmaceutical Research and Manufacturers of America.
His association has developed ethical guidelines that prohibit sales reps from directly compensating physicians-- paying cash--for altering their prescribing practices. Still acceptable, however, are such practices as providing food at conferences, offering speaker's fees or funding research.
Drug companies nationwide are regulated by the FDA, Mr. Berchem says, and they have a high level of compliance with FDA rules. Individual sales reps also are subject to sanctions if they violate accepted practices, he says. Of course, he adds, "physicians have to be the ultimate judge of who they're going to trust."
Many drug reps provide a valuable educational component in residents' education, Mr. Berchem argues. "It's very easy to criticize pharmaceutical companies for their promotional activities," he says, "but the reality is, who knows the medication better than the company that developed it?" Drug reps try to fill the information void for residents who are exposed only to medications prescribed by their attendings, he says.
Competing without pizza
It's just that strategy, however, that frustrates educators such as Theodore Goodfriend, MD, professor of medicine and pharmacology at the University of Wisconsin. Although considered an expert in treating hypertension, he often feels he is competing with drug reps when advising residents about drugs to use. The experts say they often can't compete with professional campaigns; attractive, friendly salespeople; and the overall allure of advertising. Attendings who are experts in their fields "are the only ones giving a balanced view, and we don't give free pizza," he says.
Residents are attracted to drugs touted as "new and improved"--drugs that are usually more expensive without being proven to be more effective, Dr. Goodfriend says. Residents fail to recognize that "pharmaceutical representatives have only one goal: to increase the sales of expensive drugs," he says.
For instance, Dr. Goodfriend relies heavily on diuretics to treat hypertension. Residents, however, "almost always gravitate toward the newer drugs," he says. When he asks them to defend their choices, they often repeat the advantages cited by the drug salesperson. Dr. Goodfriend then points out aspects the salesperson failed to address, such as cautions for concomitant use with other drugs. The bottom line, he says, is that many new medications may have slight benefits, but they are more expensive and not proven to have significant advantages.
Dr. Goodfriend says he has never heard a sales rep make a false claim, but he frequently hears sales pitches that provide only partial information. Like Dr. Romney, he believes that drug reps often know volumes about the particular drug they are promoting, but may not have a broad perspective. "Sales reps are wonderful to talk to because they're so likeable," he concludes. "But I would never ask one which drug to use for a specific case."
Residents who say they need contact with drug reps to get current pharmaceutical information should instead rely on attendings who are acknowledged experts in their fields, Dr. Goodfriend suggests. Even he talks to salespersons about hypertension medications, he says, but only because that is the sole area where he feels knowledgeable enough to evaluate their information.
Program directors who decide to limit residents' access to drug company reps may encounter resistance, says Dr. Arnold of Lutheran General. Housestaff already feel underpaid and unappreciated, he says, so eliminating a "perk" of the job could be unpopular. However, he adds, his policy on limiting drug rep-resident contact has not hurt his ability to recruit residents.
Another problem is that attendings often set a bad example by accepting gifts themselves, says Dr. Arnold. For example, he recalls physicians who vacationed in Hawaii, compliments of a pacemaker manufacturer, for meeting a quota. In general, however, such practices have declined since 1991, when Congress investigated the issue and both the ACP and the AMA adopted guidelines for appropriate relations between physicians and drug companies.
Still, drawing the line for housestaff may be uncomfortable for program directors, Dr. Arnold says. When he decided to take a stand in his residency program, he had to make sure he wasn't violating his own standards and portraying himself as "holier than thou," he says. Reluctance to expose their own practices may deter some educators from pursuing this issue, he suggests.
Christine Wiebe, of Providence, Utah, writes frequently on issues related to medical residency.
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