Sunday, March 31, 2013

Drug Reps and Doctors

     Several non-physician readers have asked me questions about the relationship between drug reps and doctors, and between drug companies and doctors, so I thought I would set the record straight.

     Firstly, the major cost decision is when the doctor decides that the patient needs a new drug, e.g. a statin to lower cholesterol. The variation in price between two brands (or two generics) is generally less than 10%. The major cost comes from the doctor's deciding to prescribe the drug, and the drug rep has little or no control over that. Whether the doctor prescribes Lipitor, or Crestor, or simvastatin depends on many facts, mostly upon what the doctor has read. If he/she feels there is no difference among the statins on the market, then the decision is almost a random one. The point here is that the best a drug rep can hope for is to get the doctor to prescribe a particular brand of a statin, and the price difference between brand A and brand B is as I have said, not large. Again, let me emphasize that the medical decision that the patient needs a certain class of drugs is the major decision influencing the cost to the patient. For instance, if the patient has atrial fibrillation, then anticoagulation to reduce the risk of a stroke is usually mandatory.

     The drug reps are strictly limited by the FDA as to what information can be told to or given to the doctors. The rules are so strict that if a drug rep has highlighted a sentence in a journal article, then he/she can only hold the article up for me to read. It is forbidden to give me the article with highlighting because the FDA fears that drawing my attention to the highlighted sentence might unduly influence me. Another rule is that the drug company can only give as a  gift an an article that a non-doctor has no use for. They can give me reflex hammers or tuning forks or pocket eye charts, but no coffee cups or ballpoint pens(!). And if I have a question about the side effects, etc. of a drug, every company has a doctor's hotline whereby I can request information from the company directly. Alternatively, I can file a request for more information with the drug rep.

     The drug reps can invite the doctors to a dinner where another doctor is lecturing on the drug rep's drug. The slides are supplied by the drug company and the company's lawyers restrict the words the doctor can use. The doctor who gives the talk is paid for his/her speech but the other doctors are paid nothing, but the dinner is free.And doctors can no longer bring along their wives to the dinner, unless the wife also works in the office as an office manager, etc.

     There is a service that sells to the drug companies a list of all the doctors in a given area along with the number of prescriptions of the company's product a doctor prescribes in one or three months. The speakers at the dinner are chosen from doctors who are the heaviest prescribers of the medicine on which they are asked to speak, so paying them for the talk is  a post hoc decision, and does not induce the doctor to prescribe a drug that he/she  already heavily prescribes. The drug company only hopes the lecture will influence other doctors to prescribe more of the drug. After the talk, the doctors are free to ask questions to the speaker.

     Doctors who write published articles must post a disclaimer at the end of the article, listing all the drug companies for which they have given speeches, or been a consultant for, or received any remuneration from, so that readers are immediately made aware of any possible conflict of interest.

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