FEATURE ARTICLE
The Devil’s in the Details
By Ian Hoffman, MD, MPH
It’s 8 a.m. in a typical medical practice, and the aroma of piping-hot cappuccinos lingers in the air at the start of a busy day. As the morning winds down, the smell of fresh-baked lasagna distracts attention from the hectic shuffle of charts. We are eating better and better in medicine these days. Roasted vegetable sandwiches on focaccia bread, gourmet pizzas, fresh salads with gorgonzola and dried currants: you name it, we can get it delivered to our offices in exchange for what is often no more than a handshake, a stack of brochures and free samples, and a few moments with a pharmaceutical representative, commonly known as a “detailer.”
The drug lunch is an accepted part of medical culture. We are accustomed to food being supplied during residency, where the schedule is packed morning, noon and night with lectures and food provided by detailers. It’s joked that one could survive all of residency on “pharm food.” For many it’s no joke. Even after residency, the food provided by the pharmaceutical industry just keeps piling on. In 2007, 83% of U.S. physicians received food or beverages in their workplace courtesy of a pharmaceutical detailer.[1]
Detailing has come a long way since the days before FDA regulation. Back then slick “snake-oil” salesmen would sell medicines out of a trunk in the town square, to doctors and patients alike. Now, over 100,000 detailers—young, well dressed and highly armed—make their way into medical practices daily on behalf of the 13,000 FDA-approved prescription drugs on the market.
Detailers provide doctors and their staff with what the detailers claim is the most up-to-date information on their companies’ products in an ever-changing environment, a complex maze of new drugs and new information. While doing so, detailers also claim to ease the busy lives of practitioners by providing small gifts of nourishment, reading materials, and whatever tchotchkes they can bestow with their product or company logo.
Based on current estimates, the pharmaceutical industry spends just over $22,000 per physician per year on physician detailing—$6.8 billion in all.[2] That isn’t all cappuccinos, or even five-star dining and box seats. Despite limits placed on them by ethical standards, the pharmaceutical industry (or Big Pharma, as it’s known) has continued to find ways to spend its marketing dollars on physicians. The breakdown is somewhat surprising. Direct-to-consumer advertising amounted to only $4.2 billion, mostly for print and TV media. The glossy spreads in medical journals, advertising the newest wonder drugs opposite the newest medical research, only amounted to $450 million. Most was spent on other areas.[2]
Much of the physician detailing money is spent on Continuing Medical Education (CME) series, seminars and weekends, some at nice beaches, ski areas or other resorts. By recent estimates, nearly 90% of CME is now provided for by pharmaceutical dollars.[3] With few exceptions, professional medical associations are highly funded by Big Pharma dollars as well.[4] National conferences are all but run on the millions of dollars Big Pharma pays for booths, advertisements and sponsored dinners.
But the real money of the Big Pharma marketing dollar goes to what are affectionately known as “free samples,” which are not counted as “physician detailing.” More than half of the $30 billion spent annually by Big Pharma’s advertising sector, $18.5 billion, goes to samples of medications that fill the cabinets of physicians’ offices, clinics and hospitals across the country.[2]
Dr. Bob Goodman—an internist at Columbia University and founder of No Free Lunch (www.nofreelunch.org)—tours the country talking with other doctors about the pitfalls of free samples. He often starts his talks with a “CAGE” questionnaire for drug company dependence:
- Have you ever prescribed Celebrex?
- Do you ever get Annoyed by others who complain about drug company gifts?
- Is there a medication loGo on the pen you are using right now?
- Do you ever drink your morning Eye-opener out of a Lipitor mug?
Goodman goes on to describe the “not me” phenomenon whereby most physicians accept that the billions spent by Big Pharma must affect some physicians but deny any effect on their own prescribing habits.
Dr. Marcia Angell, former editor of the New England Journal of Medicine, catalogued in a recent book her disbelief at the bias that pervades the drug industry, which she believes has corrupted our medical knowledge and research.[5] Based on her many years as editor at the journal, she states that the pharmaceutical industry, “instead of being an engine of innovation is a marketing machine.”
Institutional reform has also mount–ed. Harvard University, long hallowed as the pinnacle of U.S. medical knowledge, has started to reform its relationship with Big Pharma. In the February 2008 American Journal of Public Health, Harvard researchers published a detailed account of the real impact of “free sample” marketing.[6] The authors found that, “Poor and uninsured Americans are less likely than wealthy or insured Americans to receive free drug samples. Our findings suggest that free drug samples serve as a marketing tool, not as a safety net.”
The Harvard finding makes sense, considering that free samples fall under the marketing division of companies, not the charity or research divisions. Free samples are distributed—along with lunches and promotional materials—from the trunks of detailers’ cars. Many studies have shown that free samples greatly affect the prescribing practices of physicians and trainees.7 Why else would Big Pharma spend $18 billion on the practice each year?
Free samples also tend to be the most expensive drugs. When the samples are gone, patients get prescriptions for the expensive brand-name sample drug, rather than the equally effective generic. This practice, known as “upselling,” is described at length in many advertising manuals.[8] Upselling can more than make up for the $18 billion of free-sample marketing each year. Patients are moved to expensive, heavily marketed drugs in the long term at the cost of a few months of free samples in the short term.
Understanding upselling as a marketing ploy, rather than distribution of science, explains why the practice is so heavily relied upon by the drug industry. To guard against this marketing, Harvard, Yale, the University of Pennsylvania, and the University of California have all passed dictums limiting the interactions of doctors with the pharmaceutical industry. Many of these not only limit pens, mugs and lunches, but also free samples.
Resistance to drug companies has also emerged from a small handful of national medical organizations. The American Medical Student Association—with over 68,000 members in medical schools, premedical studies and postgraduate training—has pioneered a “Pharm-Free” campaign (www.amsa.org), and the National Physicians Alliance (www.npalliance.org) has decided to forgo Big Pharma funding altogether. Instead, NPA is taking on the industry with its “Protecting Prescription Privacy” campaign. NPA is calling for a ban on the practice by which Big Pharma buys physician license numbers from the AMA and then uses those numbers to compile sophisticated databases with information on every prescription written by each licensed physician. This information is very handy when the detailer dropping off free samples (with food and brochures) knows the doctor’s office is mostly prescribing the generic competition, not the expensive brand name.
More than 75% of physicians in the United States gave out free samples in 2005.[1] Even more received free breakfast, lunch or dinner from detailers. The long-ingrained and widely accepted practices of interacting with pharmaceutical representatives will be a hard habit to break. As physicians, the question we must answer now is whether conditions are right for us to move away from the “free lunch” on our own, or do we need regulatory laws to break us of the habit?
References
- Campbell EG, et al, “A national survey of physician-industry relationships,” N Engl J Med, 356:1742-50 (2007).
- Donohue JM, et al, “A decade of direct-to-consumer advertising of prescription drugs,” N Engl J Med, 357:673-681 (2007).
- Accreditation Council for Continuing Medical Education, ACCME Annual Report Data 2003, ACCME (2003).
- Levit K, et al, “Health spending rebound continues in 2002,” Health Aff, 23;1:147-159 (2004).
- Angell M, The Truth About the Drug Companies, Random House (2004).
- Cutrona SL, et al, “Characteristics of recipients of free prescription drug samples,” Am J Public Health, 98:284-289 (2008).
- Wazana A, “Physicians and the pharmaceutical industry: Is a gift ever just a gift?” JAMA, 283:373-380 (2000).
- Schiffman S, Upselling Techniques, Adams Media Corporation (2005).
Dr. Hoffman, formerly on the executive board of trustees of the American Medical Student Association, is a family physician at the Santa Rosa Family Medicine Residency.
