denialism blog

John Oliver, right on drug rep influence

It is amazing how powerful a free lunch is. And the data are real, that people tend to favor those who do nice things for them. That is why, despite new rules about the amount drug companies can give to doctors, or all the rules on disclosure, the pharma reps are always going to push the boundary to try to gain any advantage because it results in real world financial benefits to pharmaceutical companies.

Leave it to John Oliver to nail this. Reps are pervasive. They are influential. Their influence comes not necessarily from the right impulses of science and data, but from attractiveness and free food.

Since I’m a surgical resident, I am mostly immune to this kind of temptation. Not because I’m some kind of special human. Its because I only prescribe a tiny set of medications. In fact only really prescribe one type of drug – pain killers – because I’m a surgeon. I have no business screwing with people’s other meds. At the same time I get invitations to free dinners hosted by these companies designed to tempt even lowly residents like me into changing our prescribing practices. Oliver is right, these things happen.

My joy in this is, if I ever take up one of these offers, all I get is information about drugs I’ll never prescribe and an opportunity to antagonize drug reps, which I usually find entertaining. I have gone to them, gleefully, as I literally prescribe only 1-2 drugs ever, and they can tell me about whatever they want, it is totally irrelevant to me, and hey I get free food! Suckers. As a resident you search out free meals, it’s a matter of survival. If you bring a resident within arm’s reach of a shrimp platter it will be destroyed because we’re hungry and we feel the world owes us for all the other crap we have to endure.

So yes, this is a real. And while the idea there is a quid pro quo relationship is a wild exaggeration, we know, psychologically and because drug companies spend money on this that these tactics work. Money spent on advertising is effective. Money spent on wooing doctors to one prescription vs another will tempt enough to be profitable. I will show up and listen to a drug rep talk about their drug for a candy bar. The difference is, I prescribe almost no medications, so, at least in my case, it’s a losing investment for the reps. For most doctors who have to deal with these influences all the time, I’m sympathetic, it’s easier to listen to an attractive person bearing a free lunch than it is to independently investigate every new drug that is dropped on the market. And to be fair, this isn’t always a bad thing. We need to know about which products are out there and which are most effective for our patients. But a situation in which the drug company with the best reps, or the best market share, or saturation of the market, or whatever, wins, is not necessarily what is best for the patient.

There is a simple solution. Ban the practice of using drug reps and food. It’s not like pharmaceutical companies are selling placebos like herbal supplements. They aren’t devastated by the loss of advertisement. Usually what they’re doing is trying to push equivalent (but usually more expensive) medications, or gain market share for some slight advantage, or advertise some niche they think their drug should enjoy, or some off-label use that some physician should think a lot harder about before they decide it’s appropriate. We’ll still have access to the same meds, but the decisions will be based on things like journal articles, data and research. Instead of diverting money into advertising and drug reps bearing food (I am so jealous I’m not the type of doctor that gets all this free food), maybe they’ll spend the money on the research that bears results that should influence physicians in a legitimate fashion. If the only influence they have to bear is copies of peer-reviewed journal articles you will be sure docs are making these decisions based on the right information.

So let’s ban drug company practices which seek to influence physicians based on meals and perks rather than data. Let’s ban direct to consumer advertising too, because you know who is even easier to influence? The lay public who have little to no access or knowledge to interpret and understand the literature on appropriate treatments for illnesses. The United States is the only country that allows this, because basically every other country figured out long ago it is a terrible idea. Let’s stop all drug advertising period. If a drug company wants doctors to prescribe a drug, they should use the scientific literature to justify its use. Not free food, or stupid advertisements with animated bees, or smiling happy people pushing their kids on swings. Drug reps, if anything, should show up with papers, not sandwiches.

This is a gimme. While people shouldn’t overblow the effect here – most physicians have a great deal of skepticism to claims from reps and are very reluctant to change practice unless they provide good data – there is clearly some influence, and it’s not based on legitimate enticements, which are data, and the interests of our patients.