Introduction to pharmaceuticology
It's a course we should all take seriously, argues Anthony N Fleg
Medical
students learn much about the art of medicine in their clinical years,
honing diagnostic and therapeutic skills. What you may not realise is the
added, non-credit course that you take in the middle of your
rotations-introduction to pharmaceuticology. Differing from
pharmacology, the study of therapeutic agents and their effects on the
body, pharmaceuticology involves the interaction between doctors and the
industry that manufactures and promotes these agents. Medical schools do
not prepare their students for the onslaught of drug company salespeople
and advertisements that immediately vie for our loyalty. Gone are the days
of the preclinical years, when drugs were known by their hard to pronounce
generic names and complicated mechanism of action. Now the medical student
is expected to speak in the language of brand names, pill colours, and
catchy drug slogans.
Introduction to pharmaceuticology is a reality of our
clinical training, and confronts us with the larger question: what
relationship should doctors have with drug companies? I find that many of
us, busy learning the practice of medicine, never attempt to answer this
question and, by default, conform to the norms of older doctors and the
current environment, which caters to the wishes of the drug industry.
In the first weeks of my third year of medical school,
which for medical students in the United States marks the transition from
classroom to caring for patients, I realised that I could not simply
conform to the status quo on such a critical issue. Therefore, I made a
simple decision: I would not take any free food, pens, or other drug
company propaganda until I had wrestled with the ethical and practical
concerns pertaining to my interactions with the drug industry.
I hope that in sharing what I have learned, colleagues
at various stages of their medical careers will explore the same issues.
Whatever position you then take towards your relationship with drug
companies, it will be based on personal conviction rather than on the
morally unsound "I do what everyone else does."
Can doctors interact with drug company representatives
without compromising their ethical duties to their patients?
This question begs us to consider the foundation of
both disciplines. On one hand, physicians take oaths across the globe in
various languages, all of which have the core principle that doctors are
ethically committed to doing the best for their patients. Patients'
and their wellbeing are to be the focus of a doctor's work. The
pharmaceutical industry, meanwhile, has a simple founding economic
principle-to maximise profits through the sale of prescription drugs.
Dr Brody, a US general practitioner writing on this subject, reminds us
that this goal "includes persuading physicians to prescribe more of
the most expensive drugs."1
Doctors who take gifts and propaganda (including a
lunch lecture on the "newest, biggest drug") from
pharmaceutical salespeople, and who also treat patients, walk an ethical
tightrope. How can we serve our patients' interests and keep company
with those who see our patients in terms of revenue?
Taking this question to the literature, I found that
doctors have raised the ethical problems of this relationship for decades.
Moreover, what struck me in the empirical studies on the influence of
pharmaceutical salespersons on doctors are two consistent themes. Firstly,
doctors prescribe medicines "in ways favorable to the pharmaceutical
industry" in direct proportion to the frequency of contact they have
with the sales representatives. And secondly, medical students and doctors
overwhelmingly think that contact with drug representatives has little or
no potential for influencing their prescribing behaviour.
Regarding the first theme, the simple truth that the
drug industry spends $13bn (£7bn; €10bn) a year on gifts and promotional items,2 that it has
increased its salespeople 50% in the past four years, and that the industry
now spends almost three times more on "marketing and
administration" than on research and development, implying that the
drug industry knows very well that each pen, each lunch, and each
"sample" has considerable influence on doctors.3 A randomised
controlled trial looked at the influence on prescribing behaviours in
residents who either did or did not have access to drug samples. The
authors concluded, "Resident physicians with access to drug samples
were less likely to choose unadvertised drugs [and] less likely to choose
over-the-counter drugs … there was a trend towards less use of
inexpensive drugs."4
Despite the growing body of evidence, doctors continue
to underestimate the influence of drug advertisements on their prescribing
behaviours. A recent study of medical students in JAMA found that 58% believed that
gifts would not affect prescribing behaviour, and 80% felt an entitlement
to gifts. As further evidence of the nonchalant attitude towards drug
company influence, 60% of these students thought that grand rounds lectures
were both "educationally helpful" and "likely to be
biased."5 Interestingly, patients are less convinced, according to a study
that compared doctors' and patients' attitudes. Patients
thought that gifts are more influential but less appropriate than their
doctors think. Also, half of the patients were not aware of such gifts and,
of these, 24% responded that this "knowledge altered their perception
of the medical profession.6"
This paints a utopian picture for the drug industry:
doctors who can be persuaded to forgo their ethical principles (to their
patients) in favour of the economic principles of the drug companies;
moreover, these doctors in a fit of denial and pseudo-oblivion have
convinced themselves that there is no such phenomenon. The available
evidence makes it hard to argue that doctors' ethical duty to serve
the best interests of their patients is not compromised by the current
"bosom buddy" relationship between doctors and pharmaceutical
representatives. Also, as more patients realise the extent of this
relationship, they are likely to have less trust in and respect for their
doctors.
Can doctors stay informed about novel medicines
without the help of pharmaceutical representatives and their materials?
For medical students and younger doctors, drug
representatives are seen as a convenient and even essential source of
information about the overwhelming number of drugs on the market. However,
information provided by these "sources of information" is often
biased towards the sponsor, minimising negative aspects of the drug, and
often uses selling points that do not relate to clinically relevant,
patient oriented data.
Take, as an example the 78 drugs approved by the US
Food and Drug Administration in 2002. Only 17 of these contained new active
ingredients, and the FDA classified seven as improvements to older drugs.
So, most of these 78 drugs had little to offer clinicians or their patients
above and beyond the current drug choices, but the drug companies had to
find "selling points" for all 78 to convince doctors that these
new, expensive medicines had compelling advantages. Junior doctors and
medical students are often quoted erroneous and clinically insignificant,
unsubstantiated claims. Although a pharmacist, whose job it is to know
medicines inside out, might challenge these claims, doctors who do not
bring substantial knowledge of a drug to the discussion are likely to be
misled.
The same problem exists in printed promotional items.
One study sought to ascertain the availability of references and
sponsorship of "original research" using 438 advertisements
from US medical journals, with a comparison group of 400 references from
research articles in these same journals. More than 25% of the adverts had
no references, and 20% of the references given were "data on
file" that is largely unavailable to the public. In addition, 58% of
the original research cited in the adverts had an author affiliated with
the sponsor drug company compared with 8% of the references in the research
articles.
Given these data, it seems that medical students and
doctors would do better to spend their valuable time researching competing
prescription medicines than turning to drug representatives as trusted
sources of information. Ralph Faggotter, a general practitioner affiliated
to Healthy Skepticism says, "Drug reps nearly always present
misleading information in these meetings [with doctors]. If a doctor is up
with the latest medical information, then they will pick up on
this-but then they wouldn't be wasting their time on the rep in
the first place."
Does a doctor lower the cost of medicines for their
patients by taking drug company samples and other promotions?
Many doctors think that drug companies'
"free samples" help them to care for poor patients, for whom
free samples of an expensive medicine may be the only way to get them this
medicine. And, in a sense these doctors are correct. But, let us ask three
further questions. Do these patients always need the high cost, designer
brand medicines they are prescribed? And what happens when this patient
needs a refill of the expensive medicine? And do all of these medicines
make it to the patients in most need?
We must realise that there is no such thing as a free
sample of a prescription drug. Instead, all samples are advertisements for
a certain company's drug, no different from a billboard or magazine
advertisement. No Free Lunch, in a document made to educate patients says,
"‘Free' samples are promotional. The medications in the
‘sample cabinet' are always the newest and most expensive
medications available. Salespeople want very much to get samples into
our closet, because they know that once there, they will be given to
patients."
When I tried to find research proving that drug
samples save patients money, I came up with no studies that show that this
is the reality. What seems to be the more agreed upon consensus is that
patients are given free samples of an expensive medicine and then kept on
this medicine long term, often not offered a similar cheaper (generic)
medicine that might work equally well.
I spoke with a family doctor in the southern US about
her perspective of the benefits of drug company samples, knowing that she
had worked for four years in a clinic with poor patients. I assumed that
she had relied on drug company salespeople to provide medicines to her
patients. "Actually, I never saw drug representatives there,"
she commented. "In fact, there was only one [sales representative]
who came to the clinic regularly." Her statements were all the more
powerful in that her current clinic, a more affluent clinic a few miles
away from the other had large catered lunches and promotional drugs
provided by drug company salespeople every day. Examples such as this
illustrate that drug companies make very calculated economic decisions as
to where their "drug advertisements" are worth the investment.
In a setting of poor patients who will not be able to afford the medicine,
the incentive to send salespeople to give medicines to get them
"hooked" on the newest, most expensive medicine was not there.
Tackling the third question a bit further, there is
another set of reasons that promotional drugs do not reach the neediest
patients. In the example above, the poorest clinic was simply excluded from
the drug companies' radar; however, many other samples are diverted
from needy patients by clinical staff and even the salespeople themselves.
One anonymous survey of all doctors, residents, nursing staff, and office
staff in a family practice residency found that 51 of the 53 (96%)
respondents reported having taken samples in the past year, with four
people admitting to taking 10 or more medicines. Another survey of 27 drug
salespeople found equally startling misuse of samples, with 59% providing
medicines to people other than doctors, 26% had exchanged medicines with
other drug representatives, and 48% reported self medicating or providing
samples to friends or relatives. Although these infractions may seem
slight, the numbers of people in these two samples misusing promotional
drugs suggests that much of the enormous costs of providing
"sample" medicines within a region's or country's
health system is not spent on medicating patients in need, but on
medicating those with the easiest access to the medicines. This, taken with
the larger body of evidence that discounts the justification that samples
lower the cost of drugs for patients, leads us to look for other means to
cut costs for our patients. Generic medicines, programmes to help patients,
and consumer oriented websites that grade medicines by cost and
effectiveness (for example, www.crbestbuydrugs.org/index.html) will do
more to save your patients money than promotional drugs.
In conclusion
I hope that this article prompts you to study
pharmaceuticology further and to make informed, ethical decisions in your
dealings with drug companies and other commercial interests in medicine.
Although the US has unique problems (that is, the massive effect of direct
to consumer marketing), the problems and responsibility to change medicine
is shared among the global community of doctors to be. In light of the
evidence that exists, I urge my colleagues to begin by inverting the
current default-"I'll accept drug company gifts unless I
am convinced otherwise"-to a more honest and ethically sound
position-"I will not take such gifts unless I am convinced that
there is no potential harm to my patients in my doing so." Join with
other medical students to question your school, your mentors, and the
medical system around you about the need to create a doctor-drug company
code of ethics that is evidence based and brings medicine back into accord
with its simple ethical duty: to serve our patients' interests
without bias or conflict of interest.
Anthony N Fleg, medical
student, University of North Carolina at
Chapel Hill, USA
Email: anthony_fleg@med.unc.edu
Competing interests: None declared.
studentBMJ 2007;15:45-88 February ISSN 0966-6494
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- Ziegler MG, Lew P, Singer BC. The accuracy of drug
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- American Medical Student Association. Marketing
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- Adair RF, Holmgren LR. Do drug samples influence
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- Sierles FS, Brodkey AC, Cleary LM, McCurdy FA, Mintz
M, Frank J, et al. Medical students exposure to and attitudes about drug
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