Pharmaceutical Rep or Drug Dealer?

According to Burt (2002), patient visits to doctors' offices increased 19% from 1985 to 1999 while "drug mentions" increased 59%. Of the drug mentions, the largest increase regarded psychiatrists with a rate of increase of 82 per 100 visits in 1985 to 178 in 1999. Antidepressants accounted for 13.5%. In patients from ages 15 to 24, the largest increase of 130% in drug mentions were drugs for the central nervous system, which includes drugs such as selective serotonin reuptake inhibitors (SSRIs) and methylphenidate (which was the most frequent drug in 1999). The study contributed factors to this increase to include FDA approvals doubling in the last couple decades with faster approval times, increased health insurance coverage, and direct marketing to the consumers.

However, other studies show that pharmaceutical marketing schemes correlate to the attitudes and behaviors of physicians.

According to Wazana (2000), pharmaceutical companies spend over five billion dollars each year in marketing estimating an average of $10,000 for each physician annually. Wazana found that while the majority of medical students thought it unethical for politicians to accept gifts, only half thought it was unethical for themselves to do the same. The study's results were categorized by interactions between physicians and the industry, attitudes towards the interactions, and effects on behavior. Regarding interactions, they start in medical school averaging four times a month. While certain benefits such as meals and samples decreased as they entered practice, increases in benefits like honoraria, conference travel, and research funding were noted. Regarding attitudes, most physicians were skeptical about the intentions of the sales representatives; however, most also believed the information they received to be accurate and admitted that without the benefits, they were less apt to continue interactions. Most physicians believed in banning pharmaceutical speakers. In addition, samples, continuing education, and travel funding were considered more influential than promotional materials. Regarding behavior, an independent association existed between interactions and "formulary addition requests" for represented drugs (even if they didn't have any advantages over other drugs) and prescribing behavior. Samples were associated with prescription practice and positive attitudes. Sponsored meals and acceptance of symposium funding were associated with "formulary addition requests for any drug." Pharmaceutical speakers inspired an inaccurate view of drugs, and the attendance of pharmaceutical representatives during rounds were associated with "inappropriate treatment decisions."

In a study by Campbell, Gruen, Mountford, Miller, Cleary, & Blumenthal (2007), a new study similar to Wazana (2000) took place in an effort to see if new codes and standards had any effect on the said behaviors. According to the survey that took place from November 2003 to June 2004, most physicians received gifts and samples. Over a third received reimbursed costs for meetings and continuing education while over a quarter received payments for services such as consulting, speaking, serving on an advisory board, and enrolling patients in clinical trials. Cardiologists were highly likely to receive payments as well as physicians in group practices were highly likely to receive samples, gifts, and payments. Family Practitioners reported the most interactions with the industry with an average of 16 meetings per month (four times of what Wazana, 2000 reported).

According to an article in the New York Times, Psychiatrists were the top receiver of benefits more than any other specialty (Harris, 2007).

In a study by Petroshius, Titus, & Hatch (1995), advertising from pharmaceutical companies to consumers (bi-passing doctors) had an effect on physicians. Surveys were requested from 250 physicians in Ohio, Michigan, and Indiana by their pharmaceutical sales representative, and 148 participated. Physicians practicing 20+ years were less influenced and favorable towards the advertising. The younger physicians in urban settings were more influenced. Attitudes had an impact on prescribing behavior.

Regarding research practices, according to Sharav (2004) the Food and Drug Administration produced two Acts: The Food and Drug Administration Modernization Act of 1997 and an extended version of Better Pharmaceuticals for Children Act of 2002. In these acts, sizable financial incentives and patent extensions were given to companies who performed drug research on children. Specialists in trials earned over a million a year. In addition, regardless of laws and acts stating unethical to do so, physicians still received 2-5 thousand dollars for each child referred to trials. Since these Acts, child research participants grew from 16,000 in 1997 to 45,000 in 2001. It is believed that these increases are also related to the over-usage of risky prescription drugs in life situations.
Do pharmaceutical marketing efforts affect the practice of physicians? According to a pharmaceutical representative, that is exactly the pharmaceutical company's intended goal. Drug representatives are chosen for their sales type personality and are trained to assess the surroundings, read non-verbal cues, and ask many questions retaining information such as birthdays and interests to place in a database. Physicians are generalized into convenient categories with response protocol designed for each type (such as skeptical doctors are treated with educational literature and are "wooed as teachers"). For physicians who refuse to interact with the industry, the staff is then wined and dined. Gifts with drug names on them are designed as a repetitious device to remind doctors of the medication and keep the drugs in their heads. Physicians who prescribe the most drugs from the company are considered "high prescribers," and they are treated better with better gifts and more incentives. After all this, the companies track prescriptions by using companies such as IMS Health who purchase lists from pharmacies. While no identifiable information is given on patients, physicians are often identified by a number, and corresponding names can be purchased for those who are registered with the American Medical Association. Then these named physicians are ranked and treated accordingly. Some new standards were developed regarding tracking prescriptions; however, many loopholes exist making it far too easy for pharmaceutical companies to infiltrate the information. (Fugh-Berman, & Ahari, 2007)

In conclusion, who really is in charge of your health care?

References
Burt, C. W. (2002). National trends in use of medications in office-based practice, 1985-1999. Health Affairs, 21(4), 206-214.
Campbell, E. G., Gruen, R. L., Mountford, J., Miller, L. G., Cleary, P. D., & Blumenthal, D. (2007). A national survey of physician-industry relationships. The New England Journal of Medicine, 356, 1742-1750.
Fugh-Berman, A., & Ahari, S. (2007). Following the script: How drug reps make friends and influence doctors. PLOS Medicine, 4, 621-625.
Harris, G. (2007, June 27). Psychiatrists top list in drug maker gifts. The New York Times. Retrieved August 6, 2007, from http://www.nytimes.com
Petroshius, S. M., Titus, P. A., & Hatch, K. J. (1995). Physician attitudes toward pharmaceutical drug advertising. Journal of Advertising Research, 35(6), 41+.
Sharav, V. H. (2004). Conflicts of interest in biomedical research harm children with and without disabilities. Journal of Disability Policy Studies, 15, 50+.
Wazana, A. (2000). Physicians and the pharmaceutical industry: Is a gift ever just a gift. JAMA, 283(3), 373-380.