Healthy Skepticism Library item: 12551

Warning: This library includes all items relevant to health product marketing that we are aware of regardless of quality. Often we do not agree with all or part of the contents.

Publication type: news

Tice L.
Doughnuts and Prozac
The Sun Journal 2008 Jan 20
http://www.sunjournal.com/story/248297-3/MaineNews/Doughnuts_and_Prozac/

Full text:

Not so long ago, free lunches at Franklin Memorial Hospital were as close as the nearest drug rep.

Piping hot pizza. Fresh doughnuts. Gourmet chocolates.

Pharmaceutical salespeople brought it all.

Needed office supplies? They offered those, too.

Free drug samples? You got it.

“If you saw a drug rep in a hospital parking lot, invariably they’re on their third trip back to their car to bring their samples in, their bags in, their boxes of Dunkin’ Donuts,” said Richard Batt, president of the Farmington hospital.

Money ran aplenty, too. Want to bring an expert speaker in? Go to a seminar? Host an educational program? Ask a drug company and ye shall receive – sometimes thousands of dollars.

Until last summer.

That’s when Franklin Memorial Hospital instituted one of the most stringent policies in the state limiting the relationship between doctors and sales
representatives: No food. No gifts. No money earmarked for the education of a specific doctor.

“You want the doctor ordering the drug or device because he likes the drug or device, not the rep,” Batt said.

Nationally, in years past, it wasn’t unheard of for drug and medical equipment reps to treat doctors and their spouses to wildly expensive meals and lavish trips in an attempt to curry favor with the keepers of the prescription pad. Local doctors recall catered meals and gifts of alcohol.

That’s lessened dramatically over the last 10 years as pressure from patient advocates and watchdog groups has prompted medical and pharmaceutical organizations to come out with guidelines that limit the freebies that reps can give out and that doctors can take. Now, for doctors employed by some hospitals, a stethoscope is OK but a trip to Hawaii is not. Doughnuts are fine, but a filet mignon lunch is not.

Still, the pharmaceutical industry spent nearly $30 billion on marketing in 2005, over $18 billion of that on drug samples and $6.7 billion on gifts and food, according to The Prescription Project, a national group working to get hospitals and doctors to tighten their conflict-of-interest policies.

“That was to tame the wild, wild west. Now they just have the Wild West,”
said Robert Restuccia, executive director of The Prescription Project.

Franklin Memorial is one of the hospitals taking the lead in Maine. Others, including Maine Medical Center in Portland and Eastern Maine Medical Center in Bangor, are following suit.

Some, like Central Maine Medical Center in Lewiston, have decided to wait and see.

“Ban everything?” said Marc Perlman, a neonatologist and chairman of CMMC’s Ethics Committee. “It’s hard to do and it might not be the best thing to do.”

A matter of influence

Recent research has added significant pressure to sever the ties between doctors and drug reps:

. In 2006, a Journal of Medical Ethics article found that 33 percent of surveyed obstetrician-gynecologists thought accepting a drug sample would influence their prescription decisions.

. That same year, an article in the Journal of the American Medical Association urged medical schools and their hospitals to ban all gifts, free meals, drug samples and direct-to-physician educational support, citing research that showed even small gifts can make it difficult for people to remain objective. It said the rate of prescriptions “substantially increases” after doctors meet with sales reps, attend company meetings or accept drug samples.

But for Franklin Memorial and many other hospitals across the country, the tipping point came last spring when an article published in the New England Journal of Medicine found that nearly every doctor surveyed – 94 percent – had some kind of relationship with the pharmaceutical industry.
Eighty-three percent received free food, while 78 percent received free drug samples, 35 percent received reimbursements for the costs of attending professional meetings or educational programs and 28 percent received money for consulting, giving lectures or enrolling patients in drug trials.

“It’s always been a situation we’ve always been slightly uncomfortable about,” Batt said. “We read that article and said we should give some serious attention to this.”

Soon after, the Franklin Memorial president got some firsthand experience with the issue. He took his parents to their doctor’s appointment.

The doctor’s notepad advertised one drug company, his pen advertised another. The wall calendar was from a drug company. Their drug samples were from another.

“Just go into any doctor’s office and start looking around carefully. It’s just loaded. It’s stuffed with stuff with logos and names. And they (drug
companies) are all doing it not to be nice, but to get a leg up, marketing,” Batt said.

His parents’ doctor worked in a practice owned by Franklin Memorial.

FMH officials explored the policies of other medical centers, including Stanford University School of Medicine in California and Yale University School of Medicine in Connecticut, which had recently tightened their conflict-of-interest rules to ban gifts from drug reps. By summer, the small, rural Maine hospital had come up with a policy whose strictness rivaled those of big-city teaching hospitals. The new rules prohibited every freebie from pizza to pens, and allowed drug companies to pay for educational events only as long as the funding source was fully disclosed and as long as the speaker, not the drug company, chose the content. To Batt’s surprise, he found doctors were largely in favor of the change.

“I actually thought it was going to be more controversial than it was,” he said.

The most contentious part of the new policy turned out to be not what the doctors received, but what patients were receiving from the doctors: drug samples.

“There are pros and cons to that, and we debated that,” Batt said.
Ultimately, the decision came down to one thing. “Free samples are very, very helpful to people who don’t have financial means.”
‘Patient safety’

Right now, both Maine Medical Center and Eastern Maine Medical Center – the two largest hospitals in the state – are considering stricter policies.

“Even a pad of paper, a box of donuts can have an impact on people. We don’t even know it. It’s a subconscious influence. Most of us don’t want to admit it, but it’s there,” said James Raczek, vice president and chief medical officer for Eastern Maine Medical and a member of NoFreeLunch.org, a national nonprofit group advocating distance between doctors and the pharmaceutical industry.

If approved, his hospital’s new policy would be similar to Franklin Memorial’s. But if he had his way, Raczek, who describes himself as “zealot” on the issue, would also ban free samples, which be believes drive up the cost of all medications and gets poor patients tied to the newest, most expensive drugs because that’s what they’re given as samples.

He’d also refuse all drug company money for education.

“I would argue physicians are compensated enough to pay for their own conference,” he said.

Maine Medical and Eastern Maine Medical aren’t alone in considering policy changes. The Maine Hospital Association said conflict-of-interest discussions have heated up in recent years and all of the state’s 39 hospitals are paying attention to the issue.

St. Mary’s Regional Medical Center expects to discuss its policy in the next year.

“We have docs who want us to tighten up,” said Dale Morrell, the hospital’s education director and organizational integrity coordinator.

Its current policy mirrors AMA guidelines and is pretty standard among hospitals. (See the individual hospital standards at right.) St. Mary’s puts restrictions on gifts, meals and money for educational events.

The policy still allows St. Mary’s to bring guest lecturers to campus once every six weeks or so, giving doctors access to experts who can talk about everything from schizophrenia to migraine headaches. Drug companies pay for just over half the speakers’ cost, writing checks for fees that can range from $3,000 to $5,000 a day. Without that money, Morrell said, doctors for the nonprofit hospital wouldn’t be able to stay on the cutting edge of medicine.

“It really is a way to advance the care of the patient in areas where they wouldn’t have access to it,” Morrell said.

Aside from those kinds are arguments, however, it’s hard these days to find someone on the medical side of the equation who supports the doctor/rep relationship of the not-too-distance past.

Ira Shapiro, a psychiatrist with St. Mary’s, used to accept drug companies’
free lunches. He stopped a few years ago because he felt unethical taking something from a company that wanted him to prescribe its drug.

While he’s OK with drug samples, he’d like the free food to go. He’d like to see doctors write prescriptions for generic drugs only, ignoring the sales pitch of drug reps, who only tout drugs by their company brand name.

“Any doctor who tells you they give me the food and the pens but it doesn’t affect what I’m doing, they’re fools,” he said. “Because the bottom line is, if the drug companies didn’t have evidence that it did affect what you’re doing, they wouldn’t spend their money to do it.”

Pharmaceutical Research and Manufacturers of America, or PhRMA, disagrees.

In defending its members, PhRMA chooses to focus less on conflict-of-interest and more on the good that drug companies do. While The Prescription Project rails against the money spent on advertising, PhRMA said its members spent $43 billion in 2006 to develop new medicines and, on average, reinvest a greater percentage of their sales in research and development than do other U.S. industries, including electronics, communications and aerospace.

When asked specifically about the conflict-of-interest issue, Marjorie Powell, senior assistant general counsel at PhRMA, said drug companies play a critical role in medicine by creating new, life-saving medications. Drug reps, she said, are an important part of that because they tell doctors about the new drugs, educate them about drug side effects and keep them up to date on labeling changes. She calls American hospitals’ slow elimination of the doctor/drug rep relationship “a troubling trend.”

“I frankly think that’s a concern for patient safety,” she said.
Shades of gray

In many ways, Maine has been at the front of that trend.

Maine is one of only a few states that require drug companies to disclose the money and gifts they give to doctors and hospitals. The first report on those gifts in Maine is due out at the end of this month.

A recently enacted Maine law also now allows doctors to keep their prescribing practices private from marketers, but the law has been challenged by three groups that buy prescribing information and sell it to drug companies. A federal district court judge in Bangor has issued a preliminary injunction, effectively halting the law’s implementation until the case can be resolved.

For now, some individual hospitals are holding off on any policy changes of their own. Rumford Hospital has no policy, letting individual doctors draw that conflict-of-interest line for themselves. Stephens Memorial Hospital in Norway prohibits staff from accepting vendor gifts “which may be construed as an attempt to influence purchasing decisions.”

Neither hospital plans to change.

Central Maine Medical Center allows samples, small gifts and drug company money for educational events. It had considered a rule that would have banned all gifts large and small, but the change didn’t make it into its conflict-of-interest policy and “there’s no plan on the table now to do that,” said Perlman, head of the Ethics Committee there.

He sees both good and bad in the hospital’s policy. Drug company money helps the hospital get A-list speakers it otherwise couldn’t afford, he said, but there’s evidence that such sponsorships can influence people.
Free samples are given to poor patients who might not otherwise afford them, he said, but those drugs can cost patients more in the long run when they’re no longer free.

“Like everything else, it’s not entirely black or white,” he said. “It’s multiple shades of gray.”

CMMC is happy with its current conflict-of-interest policy. But policies, Perlman added, have a way of evolving.

“This is going to be an ongoing one,” he said.

Back at Franklin Memorial Hospital, Batt is happy his hospital made the change. He figures his hospital and doctors’ offices used to see sales reps multiple times a week, all of them armed with food or goodies. Now they come without the stuff.

“We welcome their visits,” he said. “They just don’t need to bring pizza anymore.”