Monday, May 07, 2007


Hey, man, wanna try some drugs?

The New York Times tells us that some hospitals and some physicians are eschewing drug samples because of concerns that they improperly bias patient care, sometimes resulting in patients not getting the best drugs for their situations.

To be sure, there is a danger that doctors will use the most heavily promoted drugs, rather than the “best ones”. But this was the most interesting part of the article to me:

And many physicians say they like using samples because the marketing representatives are an important source of medical education, helping to keep the doctors up to date on the latest therapies.

“Doctors who are shutting the door to sales reps are cutting themselves off from a lot of valuable information,” said Scott Lassman, senior assistant general counsel for the Pharmaceutical Research and Manufacturers of America, a trade association. “Sales reps can explain when it’s right to use a drug, when it’s not right to use the drug, which patients might benefit and which patients it might not work for.”

Some doctors are skeptical. “The sales reps are nice people, and they try to do a really good job,” said Dr. Judith Chamberlain, medical director of the Bowdoin Medical Group, a practice near Portland, Me., that banned samples this year. “But their job is to get you to use their product.”

A 1995 study in The Journal of the American Medical Association found that 11 percent of the statements drug company representatives made during presentations were inaccurate, and all of the inaccuracies were skewed in favor of their products.

What I find interesting about that is the assumption of unfounded credulity on the part of the physicians, the idea that they're being sucked in by the self-serving inaccuracies that the marketing reps are feeding them.

Surely some are. But maybe most are checking out what they hear, and not blindly believing everything the reps are saying. And if 11% of what they say is inaccurate, that means that 89% is accurate, and much of that might be useful information to doctors who are trying to keep track of the new drugs that are coming on the market.

Consider that all of the pharmaceutical companies — not just one or two — send out marketing reps, and are giving out sample product along with the pens, post-its, mouse pads, and plush-stuffed anthropomorphic pills. If there are competing products for, say, allergy relief, the allergist's office will be filled will samples of all of them, not just those of one manufacturer. The cardiologist's office will have samples of all the options for reducing cholesterol and keeping blood pressure down.

All the name-brands, that is; we'll get to that.

Consider that now that prescription drugs are advertized on television and in magazines (I truly hate that!), the patients themselves have become sales reps for the drug companies. “Ask your doctor if Floobazol is right for you.” You know what? If they get enough patients to ask their doctors about Floobazol, the doctors will start using it, in preference to other, similar remedies, just to make their patients happy.

And now consider the benefits of having free samples, as pointed out in the article: they allow patients to get started on their medications sooner, they allow doctors to try different options to see what works best for the patient, and they allow poorer patients to use medication, at least in the short term, that they might not be able to afford otherwise.

What I see as the most significant counter-argument is the issue of generics vs brand names. If an older drug that's now available as a far-cheaper generic formulation would serve the patient well, but there's a new, brand-name, expensive drug for the same purpose... the argument is that the physician will use samples of the brand-name drug, getting the patient started on a far more expensive regimen unnecessarily. They don't get samples of the generics; there are no sales reps promoting them.

That may be so, but there are other factors pushing that outcome as well. Whether or not there are free samples, the company reps are still promoting the brand-name drugs. The TV ads are still encouraging patients to ask their doctors for them. There are still claims — biased ones, possibly among the 11% of false ones — of improved efficacy and safety, of fewer side effects.

It also strikes me that a medical practice that chooses to limit or ban free samples has already taken the first and most important step here — they've acknowledged that there are issues to consider. They're now properly equipped to monitor the situation and to make sure that they're prescribing medications properly, and not getting sucked into the free-sample vortex. That they've thought about eliminating the samples means that they probably don't have to.

1 comment:

Maggie said...

I think doctors need to find a new way to get educated. If pharmaceutical companies want to give free samples, they should, but the doctors shouldn't be getting "educated" by them because it's not unbiased or necessarily accurate information. Even if the doctor is aware of that, how's s/he supposed to know what information is accurate and what isn't?

I know doctors are busy people, but I also know what pharmaceutical reps do to schmooze them. There is the prinicpal of reciprocation at work. Pharm. reps take doctors out to very expensive dinners. Even if a doctor is aware of the reciprocation effect, it still could bias him/her toward the product. That's natural. And naturally, if it didn't work, pharmaceutical reps wouldn't operate that way.

My dad is a writer, and he had a very strong ethic. He never accepted anything free that he was writing about, because he knew it could bias his opinion of the product. We have some cost/value analysis mechanisms built in. There are even other primates and other species with this ability.

Human behavior changes when a gift is involved.

And why wouldn't a doctor try something that's free? Especially if it's not a life-threatening situation. I don't believe doctors really care if you suffer for a few extra days, if they can make you go away with a sample in your hand. It also gives them a feeling for whether the product actually works. There's no cost to the doctor, and some benefit.

OTOH, if doctors paid for the samples, then you can bet you'd be getting the cheapest appropriate sample. Their values aren't aligned with yours if they have an expensive, free product that they can hand you, rather than writing you a prescription for a generic.

Just an anecdote, but my allergist once held a zpac in front of my face and explained to me that the medicine stays in your body after you've taken it for seven days -- he could've been on TV. It was almost word-for-word what was printed on the packaging. It was insulting and I couldn't help laughing at his ridiculous, brain-washed behavior. I have no idea if the medicine was appropriate for my sinus infection -- I needed a second antibiotic after the zpac was done because it had no effect. But I couldn't shake off the feeling that I was being prescribed medicine by a pharmaceutical company.