Pharm Free:

More Doctors and Medical Centers Are Going "Pharm-Free"

Choosing Ethics over Drug-Company Enticements.  Medical Students a Force.  Will Others Follow?

by Jay S. Cohen, M.D
www.MedicationSense.com

Revulsion is the natural response to excess.  At Yale, Penn, and Stanford, enough officials apparently succumbed to the revulsion of seeing their doctors and students looking like walking billboards for the drug industry.  For years, patients have felt the same queasiness at the image of their doctors toting pens, pads, and tools emblazoned with drug company logos.  When patients enter doctors' offices wallpapered with drug-company posters, they know they will not be hearing much about natural therapies.  And yet doctors complain when they are called pill-pushers.

Other universities are also going "pharm-free."  At the University of California, Davis, a ban on drug-company gifts takes effect this summer.  UCLA is expected to follow.

"These are reputable, world-class universities," said Dr. Casey KirkHart, who has refused drug company giveaways since early in medical school.  "There's a real culture change happening.  We're going to wean ourselves off drug money.¹"

And what a load of money it is!  Approximately 90 percent of the drug industry's marketing budget -- $21 billion -- goes to doctors.  It is a big investment, and it has paid off handsomely.  Studies have proven again and again that drug company gifts influence doctors' decisions when prescribing medications.

Even small gifts and modest meals have influence.  A study published in 2003 demonstrated that the more doctors interacted with drug marketers, the more often they prescribed expensive drugs even though low-cost generics would do.²  One of the authors, Dr. Arthur Caplan, director of the University of Pennsylvania's Center for Bioethics, commented, "It was indisputable that small gifts had tremendous power in influencing favorable attitudes toward products.¹"

A small gift can affect a doctor's decision-making as much as an all-expenses paid trip.  "With a big gift, you're on guard right away," Dr. Caplan explained.  "The very act of giving a small gift creates a cultural sense of obligation.  Yet it is subtle.  Your guard isn't up."

Less subtle are the young, attractive drug company sales representatives, who do not frequent doctors' offices to simply adorn the waiting rooms.  Their goal is get doctors to push more product, and higher sales equal bonuses for many reps.  Yet their methods are subtle.  There is no hard sell.  Reps know that they only need to sew a friendly, collegial relationship, and by bringing studies, drug samples, or pizza for lunch, a sense of reciprocity will develop.

Students Make a Difference
Medical students have provided much needed impetus for the pharm-free movement.  In 2002, the American Medical Student Assn, an independent organization, launched an ongoing pharm-free campaign.  Members agreed to refuse money, gifts, and information from the drug industry.  Instead, they agreed to seek unbiased scientific information on their own.  The group also provided medical students with "No Free Lunch" pens in exchange for their drug-company logo pens.

Will Other Medical Institutions Go Pharm-Free?
The pharm-free movement hasn't grown without opposition.  Some doctors insist it is their right to accept drug company gifts, and they can do so without being influenced by the drug industry.  Others argue that free drug samples are helpful for starting people on new medications, especially those without insurance.

The downside is that free samples inevitably lead to the use of expensive medications when older, less expensive, better-known drugs might do.  And instead of drug samples, medical institutions can provide discount pharmacy coupons for low-income patients.³

Some medical schools have resisted imposing restrictions on drug company gifting because of concerns about retaliation by the drug industry.  Dr. David Rothman, an author of a 2006 article on conflicts of interest between doctors and the drug industry, does not believe the industry will retaliate.  "Did the drug companies stop giving Penn research money?  I don't for a minute believe that is going to happen.⁴"

Overall, there are few cogent arguments against adopting a pharm-free stance.  The only question is whether enough doctors and officials feel strongly enough to go pharm-free at their institutions.  We will learn a lot about the current ethics of the medical community when the final tally of pharm-free vs. pharm-friendly institutions is taken.

Is Being Pharm-Free Enough?
The pharmaceutical industry is resourceful.  It has many ways of influencing doctors, controlling the information they receive, and motivating doctors to push their products.

Today, the pharmaceutical industry exerts tremendous influence over the content of doctors' continuing education.  The drug industry's presence at some medical conferences is so pervasive, sometimes it is hard to tell whether the conferences are medical meetings or pharmaceutical industry advertising conventions.

The pharm-free movement will not prevent a drug company from sending doctors to lavish resorts.  There, doctors will hear from experts that are hand picked for their willing promotion of the company's medications.

Most worrisome, drug companies will continue to use the medical journals as conduits for pushing products and obtaining free coverage in the media.  The medical journals were once the repository of scientific thought and research.  Now, the medical journals are having difficulty ensuring the accuracy and objectivity of many drug company studies that are published.  Medical journals have few tools to prevent the manipulation of data.  They have no way of preventing the omission of negative results.  Efforts to ensure full disclosure by authors have been disappointing.  The science of medicine relies on the integrity of information published in medical journals.  But for drug companies, the medical journals serve another purpose: extolling the virtues while minimizing the risks of their drugs.  As an example, please see my recent articles on maximum-dose Lipitor.

Pharm-free or not, all of these excesses will continue.

You can help.  If your doctor uses drug company giveaways, bring a stack of writing pads and inexpensive pens to your next office visit.  If your doctor asks why you are giving these to him, smile and say, "It just looks better."  Your doctor will get the point.  Be nice about it.  It's tough for anyone to turn down a freebie.  Doctors are no different.  At the same time, doctors' first allegiance is supposed to be to their patients.  A word from a patient can have a lot of influence.

References
1.  Engel M.  A pox on drug maker freebies, say some doctors.  Los Angeles Times, Feb. 4, 2007:A1.
2.  Katz D, Caplan AL, Merz JF.  All gifts large and small: toward an understanding of the ethics of the pharmaceutical industry gift-giving.  American Journal of Bioethics 2003;3(3):39-46.
3.  Brennan TA, Rothman DJ, et al.  Health industry practices that create conflicts of interest: a policy proposal for academic medical centers.  JAMA 2006;295(4):429-433.
4.  Saul S.  Doctors and drug makers: a move to end cozy ties.  New York Times, Feb. 12, 2007:www.nytimes.com.

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Copyright 2008, Jay S. Cohen, M.D. All rights reserved. Readers have permission to copy and disseminate all or part of these articles if it is clearly identified as the work of: Jay S. Cohen, M.D., the MedicationSense E-Newsletter, www.MedicationSense.com. You may not use this work for commercial purposes.

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