Healthy Skepticism Library item: 6162

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Publication type: Journal Article

Saunders C.
Drug reps can be a useful source of information if used the right way
Australian Doctor 2006 Sep 6;
http://www.australiandoctor.com.au/news/9a/0c043e9a.asp

Full text:

REGISTRARS should take advantage of their training time to learn how to deal with and, if they so choose, make the best use of visits from drug company representatives.

Dr Sean Stevens, chairman of WA General Practice Education and Training’s GP supervisors’ forum, says registrars can learn the skills of dealing with drug reps when on the training program and can bounce ideas off their supervisors.

“It is quite useful to discuss how it went, what you learnt, what to take away and what sort of marketing ploys they may have used,” he says.

Victorian GP Dr Duncan Ledger, who was a drug rep before studying medicine, recommends to GPs and registrars that they should get reps to talk off the cuff about the product rather than allowing them to use product detail aids with “flashy headlines and quotes from specialists”.

Dr Ledger, who completed his GP training last year, also advises registrars to make good use of each company’s medical department.

“If I have a problem with a particular drug, such as an unusual side effect, I ring their department directly because they have got all of the data and if they haven’t, they will find it for you.”

He warns that reps are sometimes more interested in asking questions to “profile” the registrar or GP than in presenting information.

“They are fact-finding,” he says. “So make sure they are telling you about what you want to know rather than getting stuff out of you.”

Dr Ledger admits he is probably a bit harder on drug reps because he knows the tricks, which is why he suggests registrars and GPs can optimise their interactions with them.

He is adamant that if doctors are going to see a drug rep, they should control the timing.

“Don’t just let them come in any time – they come in at a time that suits you so it is not just an irritation and you are not stuck between trying to get your work done and trying to be polite,” is his advice to GP registrars.

He has no compunction about accepting company lunches. “It is quid pro quo, otherwise I am just going to be donating my time for free.”

Nor does he have a problem with small gifts such as pens, which he says don’t alter his prescribing habits.

“I have half a dozen biros on my bench and they’ve all got a name on them but I couldn’t tell you one of them. I don’t look at them, I write with them.

“The truth of the matter is that doctors can’t be persuaded to use a bad product, certainly not more than once.”

He says pharmaceutical companies selectively use information.

To counter this, he advises registrars to ask reps why their competitor’s product isn’t better.

“That way you get a much better idea of the downsides,” Dr Ledger says.

A US study published in the Journal of the American Medical Society in 2000 estimated the industry spends $US8000-$US13,000 ($A10,500-$A17,000) a year per practising doctor on drug promotion.1

In Australia it was estimated in 2004 that the figure was $21,000 per practising doctor.2

Some doctors say point blank they don’t see reps. Others will only see reps during a booked appointment or at a lunchtime meeting at the practice. Some will only see reps between patients.

Advanced WA GP registrar Dr Marnie Rowan believes the attitude of registrars ranges from those “quite happy to take any junket that is going” to those, like herself, who tend to avoid reps.

She was put off seeing them early in her medical student days by a rep who denied a certain drug had any GI side effects. “It was patently untrue,” says Dr Rowan, who was formerly a pharmacist.

Dr Ledger says drug reps learn sales techniques that are similar to those used by most salespeople.

He says there is a trick when selling a car – you don’t ask the customer if they want to buy the car, you ask them what colour they prefer. That way, they are envisaging buying their car, having skipped the step of deciding whether they really want it at all.

A similar strategy is used by pharmaceutical company representatives. “With drug reps, it is more about saying, ‘Wouldn’t you like your patients to be risk-free?’ and the answer to that question is obviously, ‘Yes’,” he says. “But it isn’t quite the same thing as, ‘Wouldn’t you like to use this drug because it is a good choice?’

“So sometimes they are playing on the emotions.”

General Practice Education and Training chairman Associate Professor Simon Willcock says reps are a useful source for finding new information.

“The reality is a lot of new products come onto the market each year and we as GPs … will not normally have an opportunity to sit down and read the clinical literature,” Professor Willcock says. “But we recognise there is a detailing and marketing campaign associated with it.”

His first advice to registrars is to treat everyone, including reps, courteously, but says if registrars feel browbeaten, they should politely stop the conversation.

Professor Willcock says some doctors may be persuaded to try a drug by a pleasant rep, but others may be deterred from using a drug by a rep who gets “up their nose”.

“There was one brand of the flu vaccine which I never prescribed for years before the government made it widely available because I had been quite irritated by the particular rep,” Professor Willcock admits.

“Most of us who are experienced tend to feel [seeing reps] doesn’t hugely influence us.”

However, WA GP Dr Brett Montgomery, who completed his registrar training in March, says it is “hard not to be taken in” by drug reps because the techniques they use are sophisticated.

“I think the most elegant solution to the problem of dealing with drug reps is not to see them at all,” he says. Information provided is often selective, graphs and statistics can be presented to maximise the benefits of a drug and the relative rather than absolute benefits of a drug are usually cited, he says.

He was persuaded by a meta-analysis of 29 studies in JAMA that found most doctors deny gifts from the industry influence their prescribing and the more gifts they receive, the more they believe this.1 More frequent contact with reps is associated with unnecessary prescribing and increased use of new drugs, according to the meta-analysis.

Dr Peter Maguire, a WAGPET medical educator, says he is also partly persuaded by the view that reps are likely to influence prescribing. “They put a lot of money into this and I think they do expect to see some spin-off from it,” he says. “There are better ways, I think, of gaining drug information.”

Sources registrars can use that are considered evidence-based and impartial include Australian Doctor, Australian Medicines Handbook, Therapeutic Guidelines, the National Prescribing Service’s publications (NPS RADAR, NPS News and Prescribing Practice Review), Australian Prescriber, the online clinical program UpToDate, the Cochrane database, unsponsored clinical meetings run by the practice GPs, and local hospital clinical society meetings.

DRAWING THE LINE

MANY doctors attend drug company-sponsored dinner meetings and accept small gifts such as pens, but draw the line at accepting substantial gifts such as expensive equipment for the surgery and company-sponsored trips.

Medicines Australia, which represents drug companies in Australia, has a code of conduct that sets standards for the marketing and promotion of drugs to doctors. The code bans excess in the form of gifts, entertainment and travel.

Sample packs provided by drug reps are generally considered useful for trialling patients on a new drug, such as an antidepressant to check for side effects or getting them started quickly on an antibiotic – as long as the practice has a system to ensure the drugs are in date and a record is kept of who they are given to.

General Practice Registrars Australia chairwoman Dr Rachael Sutherland says drug reps sometimes offer items that registrars might find useful, such as placebo inhalers or pill packs that assist in patient education.

“They often also provide certain resources, either texts or copies of independent guidelines,” Dr Sutherland says.

They may have useful patient literature, such as cookbooks for patients with diabetes or handouts on certain conditions. And they can provide copies of formal trials.

“The registrars will be able to assess each of those individual items as to whether they are objective or promotional,” Dr Sutherland says.

TIPS FOR DEALING WITH REPS

EXPERIENCED GPs and registrars provided the following tips on how to make the most of a drug rep’s visit:

• See reps during a booked time or at practice lunchtime meetings.

• Be courteous.

• Don’t let reps ask you questions about your practice – you ask the questions.

• Be sceptical when they quote specialists singing the praises of a drug – hear it from an independent source.

• Ask about competing products.

• Check the cost-benefit of drugs.

• Use drug companies’ medical departments for information on unusual drug side effects, etc.

• Accepting small gifts such as pens may be okay, but think twice about larger gifts such as equipment for the surgery and trips.

WHO ARE THEY?

PHARMACEUTICAL companies try to recruit people with a health or science background to be reps, with many being former nurses, physiotherapists and pharmacists.

CSL Pharmaceuticals national sales director Richard Ward says his company looks for people who are good communicators, are able to retain and disseminate highly technical information, have a business sense and can be convincing with doctors.

The initial three-week training course includes information on medical issues, marketing and sales, backed up for another 3-4 months into the job.

“The most important aspect of being a successful sales rep is to get an appointment with a doctor,” Mr Ward says. “This is also the hardest thing to achieve in many cases. With this in mind, we try to ensure that all reps treat the doctors with respect and this means we discourage ‘cornering’ doctors between patients. Having said this, some doctors will only talk to reps between patients, as they will not make appointments.”

Reps are encouraged to ask questions of the doctors to find out what is important to them and to build a profile.

“We can also get some information just by looking around the practice, for example, what type of patients are in the waiting room, what posters are on the wall, etc,” Mr Ward says.

When it comes to reps’ behaviour and use of gifts and samples, all pharmaceutical companies in Australia are bound to act in accordance with the Medicines Australia code of conduct and all reps must complete the Medicines Australia education program, run by the University of Queensland.

References

1. JAMA 2000; 283:373-80.

2. Medical Journal of Australia 2004; 180(8):409-10.