I spend 1/2 hr with almost all my pts. I treat them as I would my own folks. I am on call 24/7/365. I make house calls. I spend the time. I write detailed detailed notes. I study every day. Sorry abt the I I I but most of my peers are just like me. We balk at pharma. No one provides monetary kickbacks to me or others and I don’t know of any docs that get $ from pharma (except the specialists who write the articles or give the speeches). The only folks who provide kickbacks are like MD Helm mentioned, the insurance companies and its a bit hard to dodge them. They remove the doc or practitioner from their list if too many referrals are made, or drugs used that are not on their formulary or too many labs and imaging done (ie the pencil pushers make the medical decisions who may be 2000 miles away). My bottom line is my pts. Their bottom line is the board of directors and the shareholders. And I have an independent practice as an FNP so the buck stops here.

As far as neuro meds, they are very very tricky. You cannot prescribe a generic in some cases just to save money, because the bioavailabilty is affected by the manufacturing process and the delivery process and the fillers. Actually in all meds, but switch one in a CNS patient and you may have trouble instantly.

Now for pharma: they push the drugs. They push hard. They bring big articles and statistics and everyone knows that any statistic can be skewed by anyone smart enough to do it. And the pharms (PFIZER in particular) provide money to the FDA to do research. Now that is unethical, esp when the FDA is supposed to be the watchdog of pharma!! So Pfizer whining about the kickbacks, thats called spin.

That being said, most of the drug reps I have ever come across have been nothing but courteous and I welcome their insight because most of them really want to understand the disease process. I am not against pharma. I dislike those who are paid handsomely to shave pennies off a medication so that the big shareholders (by the way if you have a mutual fund, you likely benefit from any one of the big pharmas)make another million. I am quite sure that the reps are better paid than me. They have company cars, the most awesome computers I have seen, and the best clothes on the face of the earth. If they would dress down a bit, be less offensively - rich - esp in my rural area, that would be better. Jeans, bring em on. If pharma would stop advertising on TV, if they would REALLY care abt patient care and the moral dilemmas, they wouldn’t charge pts going thru chemotherapy $4000/month or more, or 5 dollars a pill or more for CNS patients, or change formulations (the mechanics of putting the chemical content together) without regard or notice to docs, pharmacies or patients, then big pharma would gain some ground. At this point they are the least respected by the health care industry because of the $$$$$$$$$$ paid to the CEO’s, and same goes for insurance companies that won’t pay for cancer treatment for a child but gives the CEO a $4 billion in stock options.

The biggest ethical issue I see with pharma right now is the advertising. Five commercials in a row have to do with pharmaceuticals. Whats that cost? Who do you think that influences? The patient who wants that drug and they want it now.

ok off the platform now,
Family Nurse Practitioner

So, in the primary care setting, which is the only place you will find a rep such as you describe, the meds are primarily competitors within well-characterized classes of drugs: anti-hypertensives, anti-diabetics, anti-dyslipidemics, cholinesterase inhibitors, anti-infectives, anti-depressants, analgesics like pregabalin and the NSAIDs. Not exactly life-threatening medicine.

In the specialty arena, I can tell you there ain’t any 23 year-old former cell phone sales reps. And the training is grueling and on-going. In fact, the specialty reps in my company are currently undergoing a re-testing phase that requires detailed knowledge of disease states and clinicals; and several reps that I know of personally have been terminated in this process.

And again, I will point out that a doctor is not reimbursed for spending the time with a patient and caregiver to go through all the options and non-Rx treatments. That, more than a drug rep’s influence, is responsible for the mish-mash of drugs the elderly are on. And family members who just want behavioral problems to “go away” or nurses in LTC who just want patients quiet and out of their hair.

My point is that you make it sound like reps are omnipotent, with some sort of voodoo control over docs. That simply isn’t true. A rep may influence a doc to choose a particular brand of a class of meds, but rarely even has the opportunity to sell a new class of med. And most docs are not early-adopters (trust me, we see the numbers on that kind of thing). A rep may influence a doc to choose meds instead of non-Rx alternatives, but again, there a multitude of factors in that decision: an elder with Alzheimer’s sundowning and hallucinating and being abusive will respond to a dose of risperidone or quetiapine OR massage, soothing talk and other non-Rx therapies. Which is easier and cheaper? Is it only the rep pushing the anti-psychotic who is in control, or is it a system that reimburses for a nurse to give a misbehaving patient a pill, but not time-intensive alternatives?

It is just FAR more complicated than you paint it to be. Yes, doctors are influenced by the relationship they have with reps. But there are so many other factors in the prescribing decision that I believe are just as, if not more, influential. Believe me, I wish it were as easy as you make it out to be, because I have a med that requires a lot of nuance and trial and error–a kind of commitment to get to know it that most docs aren’t willing to make. But I have great relationships with them!!

Justice,
I would argue that patients aren’t informed of all their treatment alternatives because the doctor only spends 4 minutes in the room with them. I have seen myself when I go to my PC–I’m in the room 15 minutes, doc comes in and checks me out, and he’s gone. And I know the guy-he and my parents are friends (so 45 sec of my 4 minutes is spent talking about my mother). Same is true in specialists’ offices–neuros spend 30 minutes with a new patient–and most of that is diagnosing. Then they write a scrip for the drug they always use for that condition, talk about the three most common side effects, and move on to the next patient. They just aren’t reimbursed for spending time with a patient discussing alternatives.

What I see happening is that physicians prescribe what they learned to use in residency. Out in practice, that’s great for the rep whose drug he learned to use; other reps have to persuade him that it is worth the time and effort to learn to use a different drug. This is more true for CNS drugs than anti-hypertensives, I would say, but still–a doc learns how to dose one ARB and deal with it’s side effects…he’s going to use the same one over and over. Formulary issues are huge–if a doc has a critical mass of patients in one plan and that plan restricts a drug, the doc won’t use that drug very frequently in ANY of his patients, because he doesn’t have time to figure out which plan they have. Then it is a rep’s job to convince him that the benefits of the drug outweigh the pain-in-the-ass factor of the insurance process.

The issue that seems to arouse the most ire is the generic vs branded one, and I think that is more complicated than a rep selling the doc on the branded drug. I have many docs who have had negative experiences with generics in the CNS arena–and patients have had negative experience, too. And some docs just bristle at being told my a high-school graduate how they can treat their patients.

The other hot button seems to be that people think doctors are only prescribing drugs because reps are pushing them to, especially for mental illness. I think this is due much more to the current material reductionist view of the brain and consciousness than drug reps. Docs are taught that emotions, thoughts, behaviors, beliefs are nothing more than chemical and electrical signalling–in that context, using other chemicals to change the signalling process makes perfect sense.

HC - no one is saying that marketing pharmaceuticals is unethical. We are suggesting that pharmaceuticals should be managed less like consumer goods. I’ve said this time and time again, patients do not have a choice, they do not pick their disease nor do they pick their treatments. They are beholden to treatment decisions being made by their health care team. We owe it to them as well as ourselves to ensure that we are not interfering with the patients right to access fully informed consent and be involved in the decision making process.

Surely you see as we all do, that it happens at times that patients may not be fully informed about treatment alternatives and that this can be linked to physician prejudices and biases that have been influenced over time by the relationship with a particular pharmaceutical company.

Dr. Helm said it right, “he who has the most gold makes the rules”. When one company can capture so much market share based on highly over priced drugs marketed in a strategic segment, they can effectively shut out other competition and over influence the “rules of that disease segment”. That is very dangerous for the patient and for the physicians. I am suggesting that this is entirely the crux of the matter here.

Do I think more power should reside with insurers? No, I do not think they have shown that they can effectively put the patient first before the issue of cost. It is a squeeze play, on the one hand we have profits before patients, on the other hand we have cost reduction first, treatment options second. No matter how innovative we are with treatment approaches, we need to figure out how to make sure it reaches the patients in a timely and cost effective manner that doesn’t override the “un-biased” (hopefully) decision making of the physician.

When you stand back and look at all the pieces of this puzzle, it is amazing that patients finally do access treatment.

Much work is needed.

Everyone is starting from the premise that somehow marketing pharmaceuticals is unethical. I disagree. We live in a regulated free-market, capitalist society. Sales and marketing within legal guidelines is part of that.

I’ve been on all sides of this issue. I think the answers are not to be found in the tradtional approaches. Nor can all the players continue to play the same (type-cast)roles…

Self-insured and government sponsored plans need to be smarter (or hire smarter consultants) to focus on the desirable health outcomes, not just focus on the costs. Yes, in the past, “managed-care” often meant finding ways to manage to not pay for care. It offends me that the focus in managed care pharmacy these days is more about “specialty” (code for expensive) medications. I’ve found that if you manage the common/frequently used medications well (ie towards the ones with good outcomes and away from those with unknown/unproven benefits), there is a lot more money left for covering those kinds of expensive treatments (assuming that the expensive meds actually provide some value - see the story on Dr. Vagelos’ recent talk).

I might disagree with you on the idea that CNS conditions are less ammenable to treatment with older, generic medications. Many examples abound… But, I don’t want to lose the point of the thread here.

If the employers and people who ultimately have to deal with the consequences of short-sighted financial cost-focused “management” work toward actually improving health outcomes, this will lead to different-looking benefit plans. These plans can move everyone toward a goal of better health/more productivity/more efficient use of resources. At the same time this can also result in significant overall cost savings and efficiency.

However, the idea that an insurance company or other intermediary should adopt the tactics (current or historic - honorable or discredited) of a “competing” interest is NOT the answer to more efficient use of limited resources. It would result in yet more money (which could be directed to patient care) wasted on gimmickery. Why does Pfizer think there is a need to spend a large amount of their money (lost profits for their shareholders) in lobbying efforts for a law to prevent a stupid use of already scarce healthcare resources when there are simpler, more effective means to change prescriber behavior?

Much of the “insidious” salescatship which I do is not against generics–it is to influence a physician to choose my branded med over other branded meds. I am lucky bec CNS conditions are less amenable to generic prescribing than say hypertension or dyslipidemia.