Undoubtedly, But Patients' Interests Come First
By Gary Goldenberg, M.D.
A recent study in the Journal of Medical Ethics found that 33% of responding obstetrics/gynecology physicians thought that their decision to prescribe a drug would probably be influenced by accepting drug samples.1 These samples were distributed because of patients’ financial need (94%), their convenience (76%), and as a result of knowledge of the efficacy of the sample product (63%). The same group of responders also saw no problems with drug samples (92%), an informational lunch (77%), an anatomical model (75%), or a well-paid consultantship (53%) from pharmaceutical representatives. The study concluded that “the widely accepted practice of receiving and distributing free drug samples needs to be examined more carefully.”1
In my opinion, before any conclusions can be made, we need to consider the following question: Is medicine a business or a benevolent service everyone has a right to? Or is it a little of both?
Pharmaceutical Industry — All Business
There is no doubt that the pharmaceutical industry considers medicine a business. According to Advertising Age and TNS Media Intelligence data, the top 13 drug companies spent nearly $13.8 billion in 2005 on marketing prescription and over-the-counter (OTC) medicaments.2 According to Mukherjee and Topol, in 2000 Merck spent $160.8 million to promote Vioxx, while Budweiser and Pepsi spent $146 and $125 million dollars, respectively, promoting their products the same year.3 These authors also point out that “essentially company propaganda” was published in major medical journals written by “rent-a-docs.”3
Physicians — Balancing Self-Interests and Patient Interests
So what about physicians? I believe, most physicians act in the best interests of their patients from altruistic drive and an interest in their patients’ well-being. But would you invest all those years of training and the expense of a medical education if the average annual salary of a dermatologist wasn’t $232,0004 but $46,7525 as it is for a teacher?
Physicians participate in pharmaceutical industry research, marketing, and development. In fact, even the editor of Journal of the American Medical Association (JAMA) has recently been accused of “carelessness” after several JAMA article authors failed to disclose their relationships with the pharmaceutical industry.6
Mutual Interests — Disseminating Information to Prescribers
But medicine is not just a business, even though the pharmaceutical industry, trial lawyers, insurance companies, and even some physicians view it as such. Direct-to-consumer advertising, advertising to physicians, and even drug samples most certainly influence our prescribing habits. The simple fact that there are new medications influences our prescribing habits. But what’s the alternative? Who can we trust to develop new medications? I certainly wouldn’t want our government bureaucracy getting involved in this process any more than it is already.
Conclusion: Patient Interests Outweigh Pharma Influence
The relationship between physicians and the pharmaceutical industry is a delicate one, but one that needs to be preserved. We simply cannot separate ourselves from the companies that develop and manufacture the very medications we use to treat our patients. I agree with the need for full disclosure, as well as honesty and decency from doctors and drug companies. But in the end, I think as long as we continue to prescribe what is best for our patients, no amount of drug samples, informational lunches, anatomical models, or a well-paid consultantships can influence our desire to provide the best care for our patients.
Response: The Evidence Says “Yes”
By Noah Scheinfeld, M.D., and Zoe Veritas, M.D.
The challenge of modernity is to live without illusions and without becoming disillusioned.
— Antonio Gramsci
Dr. Goldenberg’s statement reflects medicine’s highest spirit. While the desire of physicians to provide patients with the best care remains indisputable, recent studies suggest that unconscious dynamics shape care and that care expense and care quality are not synonymous.
Post-Symposium Prescription Sales
The annual dollar amount of prescriptions written by physicians correlates to the amount of contact they have with pharmaceutical representatives.1
Although many residents think samples are only a boon to patients, residents who possess branded drug samples tend to prescribe highly advertised and detailed drugs rather than less- expensive or OTC alternatives.2
In addition, after attending a pharmaceutical-sponsored symposium, physicians are 4.5 to 10 times more likely to prescribe the pharmaceutical-sponsored drug after, compared to before, the symposium, although they claim not to think meetings change prescribing behavior.3
Maybe We are Not Aware Of The Impact
Among practicing physicians, pharmaceutical promotional activities have been found to directly affect doctors’ prescribing behaviors and the number of requests to add medications to a formulary.4,5 Despite this growing body of evidence, most physicians do not realize they are influenced by the pharmaceutical industry. In fact, many studies have demonstrated that both resident and practicing physicians typically believe they are not being influenced.6,7,8,9,10
Some physicians acknowledge that other providers may be influenced, but feel that they themselves are immune to this type of bias. In one study that polled medicine housestaff, a majority (61%) felt that their prescribing practices were not being influenced by the pharmaceutical industry. Yet, interestingly, they felt that only 16% of other physicians were similarly unaffected.10
While we apparently trust ourselves to make the right decisions for our patients, we appear to have little confidence in our colleagues.
Expense Not Correlated to Product Safety/Efficacy
Expense does not mirror safety or efficacy. The Cochrane Database Systemic Review data showed that while minocycline (Dynacin, Minocin) effectively treats acne, no reliable randomized trial data justifies its continued use as a first-line therapy, given its expense and safety profile.11
A review of etanercept (Enbrel) and efalizumab (Raptiva) found them to be efficacious in patients who are eligible for systemic therapy, but that economic evaluation demonstrates that these biological therapies are likely to be cost-effective only in patients who have poor baseline quality of life and who are at risk of hospitalization.12
Physician, Watch Thyself
Conscious good intentions and unconscious bias can coexist simultaneously. Physicians should cleave to their patients’ interests.
We do not know if full disclosure is a surrogate for a code of conduct or merely a preface to a code of conduct. We do not pretend to possess a truth for how to balance the complexities of the provision of 21st-century medical care.
As to with whom physicians, the patients’ watchmen, should engage in close corporate or personal relationships, we reflect: Sed quis custodiet ipsos custodes? — who will watch the watchmen?
Undoubtedly, But Patients' Interests Come First
By Gary Goldenberg, M.D.
A recent study in the Journal of Medical Ethics found that 33% of responding obstetrics/gynecology physicians thought that their decision to prescribe a drug would probably be influenced by accepting drug samples.1 These samples were distributed because of patients’ financial need (94%), their convenience (76%), and as a result of knowledge of the efficacy of the sample product (63%). The same group of responders also saw no problems with drug samples (92%), an informational lunch (77%), an anatomical model (75%), or a well-paid consultantship (53%) from pharmaceutical representatives. The study concluded that “the widely accepted practice of receiving and distributing free drug samples needs to be examined more carefully.”1
In my opinion, before any conclusions can be made, we need to consider the following question: Is medicine a business or a benevolent service everyone has a right to? Or is it a little of both?
Pharmaceutical Industry — All Business
There is no doubt that the pharmaceutical industry considers medicine a business. According to Advertising Age and TNS Media Intelligence data, the top 13 drug companies spent nearly $13.8 billion in 2005 on marketing prescription and over-the-counter (OTC) medicaments.2 According to Mukherjee and Topol, in 2000 Merck spent $160.8 million to promote Vioxx, while Budweiser and Pepsi spent $146 and $125 million dollars, respectively, promoting their products the same year.3 These authors also point out that “essentially company propaganda” was published in major medical journals written by “rent-a-docs.”3
Physicians — Balancing Self-Interests and Patient Interests
So what about physicians? I believe, most physicians act in the best interests of their patients from altruistic drive and an interest in their patients’ well-being. But would you invest all those years of training and the expense of a medical education if the average annual salary of a dermatologist wasn’t $232,0004 but $46,7525 as it is for a teacher?
Physicians participate in pharmaceutical industry research, marketing, and development. In fact, even the editor of Journal of the American Medical Association (JAMA) has recently been accused of “carelessness” after several JAMA article authors failed to disclose their relationships with the pharmaceutical industry.6
Mutual Interests — Disseminating Information to Prescribers
But medicine is not just a business, even though the pharmaceutical industry, trial lawyers, insurance companies, and even some physicians view it as such. Direct-to-consumer advertising, advertising to physicians, and even drug samples most certainly influence our prescribing habits. The simple fact that there are new medications influences our prescribing habits. But what’s the alternative? Who can we trust to develop new medications? I certainly wouldn’t want our government bureaucracy getting involved in this process any more than it is already.
Conclusion: Patient Interests Outweigh Pharma Influence
The relationship between physicians and the pharmaceutical industry is a delicate one, but one that needs to be preserved. We simply cannot separate ourselves from the companies that develop and manufacture the very medications we use to treat our patients. I agree with the need for full disclosure, as well as honesty and decency from doctors and drug companies. But in the end, I think as long as we continue to prescribe what is best for our patients, no amount of drug samples, informational lunches, anatomical models, or a well-paid consultantships can influence our desire to provide the best care for our patients.
Response: The Evidence Says “Yes”
By Noah Scheinfeld, M.D., and Zoe Veritas, M.D.
The challenge of modernity is to live without illusions and without becoming disillusioned.
— Antonio Gramsci
Dr. Goldenberg’s statement reflects medicine’s highest spirit. While the desire of physicians to provide patients with the best care remains indisputable, recent studies suggest that unconscious dynamics shape care and that care expense and care quality are not synonymous.
Post-Symposium Prescription Sales
The annual dollar amount of prescriptions written by physicians correlates to the amount of contact they have with pharmaceutical representatives.1
Although many residents think samples are only a boon to patients, residents who possess branded drug samples tend to prescribe highly advertised and detailed drugs rather than less- expensive or OTC alternatives.2
In addition, after attending a pharmaceutical-sponsored symposium, physicians are 4.5 to 10 times more likely to prescribe the pharmaceutical-sponsored drug after, compared to before, the symposium, although they claim not to think meetings change prescribing behavior.3
Maybe We are Not Aware Of The Impact
Among practicing physicians, pharmaceutical promotional activities have been found to directly affect doctors’ prescribing behaviors and the number of requests to add medications to a formulary.4,5 Despite this growing body of evidence, most physicians do not realize they are influenced by the pharmaceutical industry. In fact, many studies have demonstrated that both resident and practicing physicians typically believe they are not being influenced.6,7,8,9,10
Some physicians acknowledge that other providers may be influenced, but feel that they themselves are immune to this type of bias. In one study that polled medicine housestaff, a majority (61%) felt that their prescribing practices were not being influenced by the pharmaceutical industry. Yet, interestingly, they felt that only 16% of other physicians were similarly unaffected.10
While we apparently trust ourselves to make the right decisions for our patients, we appear to have little confidence in our colleagues.
Expense Not Correlated to Product Safety/Efficacy
Expense does not mirror safety or efficacy. The Cochrane Database Systemic Review data showed that while minocycline (Dynacin, Minocin) effectively treats acne, no reliable randomized trial data justifies its continued use as a first-line therapy, given its expense and safety profile.11
A review of etanercept (Enbrel) and efalizumab (Raptiva) found them to be efficacious in patients who are eligible for systemic therapy, but that economic evaluation demonstrates that these biological therapies are likely to be cost-effective only in patients who have poor baseline quality of life and who are at risk of hospitalization.12
Physician, Watch Thyself
Conscious good intentions and unconscious bias can coexist simultaneously. Physicians should cleave to their patients’ interests.
We do not know if full disclosure is a surrogate for a code of conduct or merely a preface to a code of conduct. We do not pretend to possess a truth for how to balance the complexities of the provision of 21st-century medical care.
As to with whom physicians, the patients’ watchmen, should engage in close corporate or personal relationships, we reflect: Sed quis custodiet ipsos custodes? — who will watch the watchmen?
Undoubtedly, But Patients' Interests Come First
By Gary Goldenberg, M.D.
A recent study in the Journal of Medical Ethics found that 33% of responding obstetrics/gynecology physicians thought that their decision to prescribe a drug would probably be influenced by accepting drug samples.1 These samples were distributed because of patients’ financial need (94%), their convenience (76%), and as a result of knowledge of the efficacy of the sample product (63%). The same group of responders also saw no problems with drug samples (92%), an informational lunch (77%), an anatomical model (75%), or a well-paid consultantship (53%) from pharmaceutical representatives. The study concluded that “the widely accepted practice of receiving and distributing free drug samples needs to be examined more carefully.”1
In my opinion, before any conclusions can be made, we need to consider the following question: Is medicine a business or a benevolent service everyone has a right to? Or is it a little of both?
Pharmaceutical Industry — All Business
There is no doubt that the pharmaceutical industry considers medicine a business. According to Advertising Age and TNS Media Intelligence data, the top 13 drug companies spent nearly $13.8 billion in 2005 on marketing prescription and over-the-counter (OTC) medicaments.2 According to Mukherjee and Topol, in 2000 Merck spent $160.8 million to promote Vioxx, while Budweiser and Pepsi spent $146 and $125 million dollars, respectively, promoting their products the same year.3 These authors also point out that “essentially company propaganda” was published in major medical journals written by “rent-a-docs.”3
Physicians — Balancing Self-Interests and Patient Interests
So what about physicians? I believe, most physicians act in the best interests of their patients from altruistic drive and an interest in their patients’ well-being. But would you invest all those years of training and the expense of a medical education if the average annual salary of a dermatologist wasn’t $232,0004 but $46,7525 as it is for a teacher?
Physicians participate in pharmaceutical industry research, marketing, and development. In fact, even the editor of Journal of the American Medical Association (JAMA) has recently been accused of “carelessness” after several JAMA article authors failed to disclose their relationships with the pharmaceutical industry.6
Mutual Interests — Disseminating Information to Prescribers
But medicine is not just a business, even though the pharmaceutical industry, trial lawyers, insurance companies, and even some physicians view it as such. Direct-to-consumer advertising, advertising to physicians, and even drug samples most certainly influence our prescribing habits. The simple fact that there are new medications influences our prescribing habits. But what’s the alternative? Who can we trust to develop new medications? I certainly wouldn’t want our government bureaucracy getting involved in this process any more than it is already.
Conclusion: Patient Interests Outweigh Pharma Influence
The relationship between physicians and the pharmaceutical industry is a delicate one, but one that needs to be preserved. We simply cannot separate ourselves from the companies that develop and manufacture the very medications we use to treat our patients. I agree with the need for full disclosure, as well as honesty and decency from doctors and drug companies. But in the end, I think as long as we continue to prescribe what is best for our patients, no amount of drug samples, informational lunches, anatomical models, or a well-paid consultantships can influence our desire to provide the best care for our patients.
Response: The Evidence Says “Yes”
By Noah Scheinfeld, M.D., and Zoe Veritas, M.D.
The challenge of modernity is to live without illusions and without becoming disillusioned.
— Antonio Gramsci
Dr. Goldenberg’s statement reflects medicine’s highest spirit. While the desire of physicians to provide patients with the best care remains indisputable, recent studies suggest that unconscious dynamics shape care and that care expense and care quality are not synonymous.
Post-Symposium Prescription Sales
The annual dollar amount of prescriptions written by physicians correlates to the amount of contact they have with pharmaceutical representatives.1
Although many residents think samples are only a boon to patients, residents who possess branded drug samples tend to prescribe highly advertised and detailed drugs rather than less- expensive or OTC alternatives.2
In addition, after attending a pharmaceutical-sponsored symposium, physicians are 4.5 to 10 times more likely to prescribe the pharmaceutical-sponsored drug after, compared to before, the symposium, although they claim not to think meetings change prescribing behavior.3
Maybe We are Not Aware Of The Impact
Among practicing physicians, pharmaceutical promotional activities have been found to directly affect doctors’ prescribing behaviors and the number of requests to add medications to a formulary.4,5 Despite this growing body of evidence, most physicians do not realize they are influenced by the pharmaceutical industry. In fact, many studies have demonstrated that both resident and practicing physicians typically believe they are not being influenced.6,7,8,9,10
Some physicians acknowledge that other providers may be influenced, but feel that they themselves are immune to this type of bias. In one study that polled medicine housestaff, a majority (61%) felt that their prescribing practices were not being influenced by the pharmaceutical industry. Yet, interestingly, they felt that only 16% of other physicians were similarly unaffected.10
While we apparently trust ourselves to make the right decisions for our patients, we appear to have little confidence in our colleagues.
Expense Not Correlated to Product Safety/Efficacy
Expense does not mirror safety or efficacy. The Cochrane Database Systemic Review data showed that while minocycline (Dynacin, Minocin) effectively treats acne, no reliable randomized trial data justifies its continued use as a first-line therapy, given its expense and safety profile.11
A review of etanercept (Enbrel) and efalizumab (Raptiva) found them to be efficacious in patients who are eligible for systemic therapy, but that economic evaluation demonstrates that these biological therapies are likely to be cost-effective only in patients who have poor baseline quality of life and who are at risk of hospitalization.12
Physician, Watch Thyself
Conscious good intentions and unconscious bias can coexist simultaneously. Physicians should cleave to their patients’ interests.
We do not know if full disclosure is a surrogate for a code of conduct or merely a preface to a code of conduct. We do not pretend to possess a truth for how to balance the complexities of the provision of 21st-century medical care.
As to with whom physicians, the patients’ watchmen, should engage in close corporate or personal relationships, we reflect: Sed quis custodiet ipsos custodes? — who will watch the watchmen?
