Healthy Skepticism Library item: 2172

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

Dippenaar J.
The Pharmaceutical Invasion
Meridian Healthcare 2001 Jul 9

Full text:

The issue of pharmaceutical advertising and its influence on service provider behaviour and member demand is very topical at present.
Dr Johan Dippenaar* speaks his mind in this short article.

A General Practitioner prescribes three antibiotics for an ambulatory case of gastro-enteritis and defends his action as “hitting these cases hard” and thereby curing the patient and avoiding future costs.

A dispensing dermatologist dispenses a systemic antifungal for a case of athletes’ foot. The cost of the prescription comes to in excess of US$ 250. After completing a month’s course, the patient’s acute medication benefit is exhausted but the athlete’s foot no better.

He visits his pharmacist, who gives him a tube of Whitfield’s ointment, which clears the condition completely. When I approached the dermatologist, I received a reply from the medical director of the pharmaceutical company that manufactures the antifungal concerned, justifying the dermatologist’s actions! My comment to the medical director was that it is indeed a sad day when a dermatologist, or any other medical specialist, has to get pharmaceutical companies to justify their prescribing habits, as one can hardly find a more biased source. My actions and comments lead to threats from the pharmaceutical company of legal action by ‘corporate lawyers’.

A prominent pulmonologist from a South African coastal city complains to a drug company about their representatives who, according to him, promote quinolones for ‘respiratory infections’. He asks the representative to get the medical director to visit him to correct these illegal and unethical marketing methods. An appointment is set up, but is cancelled 30 minutes before the time by the director from his head office 1000 km away. He clearly had no intention of keeping the appointment.

Every day millions of prescriptions for antibiotics are dispensed, for conditions where antibiotics are of doubtful value, such as gastro-enteritis and upper respiratory infections.

Why do incidents such as the above occur?

In the book ‘From Promise to Performance’ (1), which deals with the phenomenal successes of a huge pharmaceutical company, the author, an ex CEO of the company, explains that the ratio of money spent on researching new drugs to the marketing of these drugs was 5 to 8. So for every $5 spent on research and development, $8 was spent on marketing. In similar vein, Michael Borland, a well known figure in managed care circles, mentioned at the 16th WONCA conference in Durban, South Africa that the average pharmaceutical company in the USA spends 37% of its budget on marketing and only 14% on research and development of new products.

This strategy appears to be worthwhile (at least in the short-term): one analyst estimates that Schering-Plough generated $3,50 in extra Clarityne sales for every one dollar spent on advertising. (2)

As a result of the increase in the cost and prescribing of drugs, more than 30c in every dollar that medical schemes (health insurers) in South Africa pay out now goes towards medicines, while payouts to General Practitioners have dropped from 10c to 7c of that same dollar. (3)

It seems that we are not listening to our professors or our academic colleagues, but to the medical representative with the shortest skirt! Or as Samuel Shem puts it in his book ‘The House Of God’ (a tongue in cheek look at medicine): ’The main source of illness in this world is the doctor’s own illness; his compulsion to try and cure and his fraudulent belief that he can. It ain’t so easy these days to do nothing now that society is telling everyone that the body is fundamentally flawed and about to self destruct’. (4)

We all know that the medical scheme / health insurance industry is in trouble. All too frequently we read about medical schemes being liquidated, contributions increasing and membership becoming unaffordable. Whilst we as doctors are not committed to becoming aware of the cost implications of our actions, medical schemes and insurers, like us as a profession, are doomed.

What can and should we as a profession do about this?

We as doctors have a moral and ethical duty to understand what is happening to us. Pharmaceutical companies are some of the best marketers in the world and they are unlikely to change their marketing methods. Doctors are at the receiving end of the most sophisticated marketing techniques known to mankind. They need to know this and understand the effect it has on their actions. It is our duty as doctors not to believe everything we are told. Irwig et al, in their book ‘Smart Health Choices’ state: ‘just because it sounds scientific doesn’t mean that it is valid and do not assume that individuals or groups with vested interests will be objective’. Furthermore, they state ‘as compelling as it may sound, anecdotal information can be unreliable as a basis for predicting an outcome. Ask to see the evidence of randomized controlled trials’ [my italics].

Generics can be a cost effective way of prescribing. Sadly, in the USA, only 10% of prescriptions are for generics. In South Africa, the figure varies from 15-20%. We as doctors can make a difference here and the saving could help to make our patients’ health care rands or dollars last longer, thus making medical insurance more affordable. In the end these outcomes benefit us too.

One of Steven Covey’s seven habits is to seek first to understand (5) – a sound principle in medical practice. So many people have told me how they go to a doctor to be heard, to be reassured and to be informed, but instead they walk away with a prescription of $40. We are taught at medical school about ‘systemic interrogation’, how to put our agenda on the table and to work according to that, but I believe that in the process we often fail many patients as we ignore their needs.

Use evidence based guidelines and protocols. Don’t prescribe expensive branded products when the accepted guidelines state differently. In community acquired pneumonia, for example, the guideline suggests treatment be started with amoxycillin, and if no response, one of the macrolides. Why is it then that so many cases of respiratory infections are treated with a third generation cephalosporin or quinolones? (6)

Credit the body’s recuperative powers and try to avoid treating self-limiting illness. Many conditions seen daily are self-limiting and require no treatment other than symptomatic relief. Yet every day thousand of cases of colds and coughs and diarrhoea are treated with expensive semi-placebos and even antibiotics. Would these people not have been better off with advice, reassurance and simple analgesics or antipyretics?

In the turbulent times healthcare finds itself in, I believe every prescribing doctor can make a difference.

In conclusion, I find the words of Samuel Shem very appropriate: ‘The delivery of Medical Care is to do as much nothing as possible’.

References:

(1) Bauman, RP [1997] From Promise to Performance, Harvard Business School Press
(2) The Economist 19 April 2001
(3) These figures are a mixture of the Annual reports of the South African Registrar of Medical Schemes and figures obtained from Managed Healthcare Systems, as well as my own observations at a number of Medical Schemes.
(4) Samuel Shem, [1998], The House of God, Black Swan Books
(5) Covey S, [1989] The Seven Habits of Highly Effective People, Simon and Schuster, London
(6) South African Medical Association guidelines. The African Health Synergies website has good guidelines for the majority of common ailments.

• Dr Johan Dippenaar (MBChB, MFGP [SA] M Prax Med MBA) is the managing member of Johan Dippenaar and Associates , a managed healthcare consultancy in Port Elizabeth, South Africa.