Tuesday, October 2, 2007

The AMA, Pharma Gifts, and the Power of 8

This Thursday I will be joining several colleagues in testifying at the Massachusetts State House in support of a bill to tame the cost of medical care in the state (read a fact sheet from Health Care For All here). One portion of the bill will ban most drug company gifts to doctors. The thinking here is that when we receive gifts from reps, such as textbooks or free dinners or lunches, we inevitably feel that we owe the rep something in return. That's just human nature.

What we give the rep in return varies widely. Sometimes, it's just increased access--more frequent visits with us, an extra few minutes of shmoozing, etc.... This works for the rep, since more access equals more time to sell their product.

More insidiously, the pay-back is choosing to prescribe their product over an alternative drug that may be much cheaper. This happens to us all, even to an industry skeptic such as myself. For example, not too long ago, my Ambien CR rep gave me a pamphlet with a selection of free books, and against my better judgment I took her up on it. It was a book on the brain by John Ratey.

Several days after her visit, one of my patients came in complaining of insomnia which had not responded to several hypnotics. He had tried Ambien, Sonata, and Benadryl, but was unable to sleep through the night. Usually, in these situations, I would offer trazodone, which has a long enough half life to last most patients all night long. But something in me made me think about my Ambien CR rep, who had left the office saying, "I hope you'll give Ambien CR a try." I prescribed Ambien CR. As it turned out, this worked no better than regular Ambien, and he ended up on trazodone.

The fact is that pharmaceutical gifting is an effective marketing technique, as much as physicians deny that their medical opinions can be swayed by such small dispensations.

Our increasingly embarrassing American Medical Association (AMA) touts its policy on the ethics of accepting pharmaceutical gifts. Recently, they accepted over $600,000 in pharmaceutical money in order to help advertise their guidelines to doctors. In a nutshell, the policy is: no gift over $100 in value, and any gift must be related to medical care or medical education. Here, as in most of AMA's policies, the emphasis is on making no waves and maintaining the status quo, since this allows docs to get their textbooks, stethoscopes, and nice dinner programs, as long as the dinners are modest. (By the way, the AMA defines "modest" dinners as those meals that physicians would ordinarily pay for themselves, which leaves plenty of room for largesse).

The AMA guidelines become farcical at times. For example, not only is it acceptable to accept a nice dinner out by industry, but it is also acceptable to be offered an array of $100 gifts as an inducement to attend the dinner. But here's where AMA draws the line: physicians can be offered no more than eight different gifts to choose from. Here, verbatim, is the relevant section:

"(i) May companies invite physicians to a dinner with a speaker and offer them a large number of gifts from which to choose one?
In general, the greater the freedom of choice given to the physician, the more the offer seems like cash. A large number of gifts presented to physicians who attend a dinner would therefore be inappropriate.
There is no precise way of deciding an appropriate upper limit on the amount of choice that is acceptable. However, it is important that a specific limit be chosen to ensure clarity in the guidelines. A limit of eight has been chosen because it permits flexibility but prevents undue freedom of choice. Each of the choices must have a value to the physicians of no more than $100."

We don't need gifts from drug reps, nor do we need the biased "education" they provide during their visits. Let's stop pretending that gifts are anything other than influence-peddling.


soulful sepulcher said...

I appreciate your honesty here. My psychiatrist told me he didn't think he was directly influenced by the reps either, until I asked him that question, and he sat back and realized he did often rx the med the rep had just dropped off.

Interestly, the psych ward that my daughter is currently inpatient has a big notice up "Lunch and Learn". I wish I could go to it and see how they work. I never heard the phrase until you wrote about it here. Now I know exactly what a "Lunch and Learn" really is, and I appreciate you writing it here. Thanks for the information, from a patient and mother.
PS- Trazodone at 100mg. kept me awake and caused night sweats. I use Benadryl 50mg. now.

Anonymous said...

This is an interesting post. Do you think there is also unconscious pressure to prescribe drugs in general over other types of treatment?