drug rep vs program paying for lunches, etc

[Hurricane]

For years, our resident's organization had a weekly lunch for the residents that was sponsored by a drug rep, during which we had various faculty members or representatives from outside sites come and meet with the residents. The resident organization also organized a couple parties during the year, and we had drug rep's provide the food for that as well. Our other money came mostly from the sale of our annual christmas party skit DVDs.

Well, now the university is trying to get rid of drug reps, and the drug companies themselves have stricter rules about what they can and can't sponsor. So if we want to continue doing these events, we are going to need our department to give our residents organization a budget.

Before we go and ask them, I was wondering if anyone here could tell me what it's like at other programs - does your dept provide lunches on a regular basis, do they give financial support for resident social events, etc?

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[toby jones]

You guys crack me up.

We don't get lunches, no. Students do get subsidised for dinners, though. We have a couple of seminars a week (which involves drinking then dinner then drinking) and typically those with jobs subsidise those without jobs so it is (fairly kinda sorta) feasible for those without jobs to go.

Um... Sometimes we have biscuits during one of the seminars... And of course we do have catering etc for special lectures... But then... No health funding for us ;-)

 

[NewmansOwn]

You guys crack me up.

We don't get lunches, no. Students do get subsidised for dinners, though. We have a couple of seminars a week (which involves drinking then dinner then drinking) and typically those with jobs subsidise those without jobs so it is (fairly kinda sorta) feasible for those without jobs to go.

Um... Sometimes we have biscuits during one of the seminars... And of course we do have catering etc for special lectures... But then... No health funding for us ;-)

What?

 

[Faebinder]

There are much better ways to stop the drug companies influence than to stop those dinners..... they could for example work on the stupid copyright issue or switch to universal buyer plan for the US like Canada.

 

[Chimed]

Our hospital does not allow drug reps to sponsor any events. I'm not even sure if they're allowed on hospital grounds...

We have a weekly "residents lunch" that is sponsored by the department, that includes a catered meal. We also have about 4 departmental dinners throughout the year.

What ends up happening, however, is that the residents organize off-site drug rep dinners. It really ends up being a sneaky way to have a social event under the guise of a "drug rep dinner." Residents may go to the dinner, but end up not paying attention to the "talk" that is required by the drug reps to justify buying dinner for the residents. This is just happens, I'm not going to make any comments about morality of doing this....

 

[Anasazi23]

For years, our resident's organization had a weekly lunch for the residents that was sponsored by a drug rep, during which we had various faculty members or representatives from outside sites come and meet with the residents. The resident organization also organized a couple parties during the year, and we had drug rep's provide the food for that as well. Our other money came mostly from the sale of our annual christmas party skit DVDs.

Well, now the university is trying to get rid of drug reps, and the drug companies themselves have stricter rules about what they can and can't sponsor. So if we want to continue doing these events, we are going to need our department to give our residents organization a budget.

Before we go and ask them, I was wondering if anyone here could tell me what it's like at other programs - does your dept provide lunches on a regular basis, do they give financial support for resident social events, etc?

Our program has a two-weekly sponsored lunches. Typically, there is some material left or vouchers given for the resident's lounge which resident's can use in the outpatient clinic. A 5 minute schpeal is usually given as well.

The department also sponsors occassional classes or special seminars which may or may not be after work hours.

The most likely scenario in your case is that you'll basically lose free lunch. They won't subsidize you the difference, and they'll say something like, "we should have done this a long time ago and nobody else has it either so stop complaining."

 

[sunlioness]

We have more cafeteria meal tickets than I've ever been able to use in the month. So that's what I use for lunch.

From what I understand all residency programs are going to have to be making these changes soon.

http://www.aamc.org/newsroom/pressrel/2008/080619.htm

 

[toby jones]

> What?

I'm a PhD candidate. We don't get fully funded lunches. The absence of health funding? I don't think the medical researchers get lunch either...

 

[blabbyblab]

I am immune to bribery so I do not feel guilty about accepting bribes.

 

[toby jones]

Hmmm... I'm not at all sure that that is psychologically plausible.

Why would pharma companies spend so much money on advertising if they didn't make that money back (and then some) on the sales? I'm sure they do their market research. One might be tempted to think that psychiatrists are more sophisticated than the general consumer of advertisements but then the problem becomes:

Why would pharma companies spend so much money on lunches and pens and so on for psychiatrists (and other medical peoples as well, of course) if they didn't make that money back (and then some) on the sales? I'm sure they do their market research.

There is a lot of evidence in the psychology literature to show that the things we are exposed to have a lot more impact than we might want to think. We are influenced by the color / race of a job candidate *even when* we are making a conscious effort not to. We are influenced by exposure effects *even when* we are making a conscious effort not to be. One might think that one can simply block up ones ears and snooze or sleep through a little pharma speel... Unfortunately that doesn't seem to help undermine the impact either...

Not quite sure the phrase 'selling ones soul' and the phrase 'there is no such thing as a free lunch' spring to mind ;-)

That being said, you might be able to get some funds out of the department. That would be cool. I wonder if the handsoap people or the handtowel dispensor people would be willing to fund something?????

;-)

 

[Faebinder]

Hmmm... I'm not at all sure that that is psychologically plausible.

Why would pharma companies spend so much money on advertising if they didn't make that money back (and then some) on the sales? I'm sure they do their market research. One might be tempted to think that psychiatrists are more sophisticated than the general consumer of advertisements but then the problem becomes:

Why would pharma companies spend so much money on lunches and pens and so on for psychiatrists (and other medical peoples as well, of course) if they didn't make that money back (and then some) on the sales? I'm sure they do their market research.

There is a lot of evidence in the psychology literature to show that the things we are exposed to have a lot more impact than we might want to think. We are influenced by the color / race of a job candidate *even when* we are making a conscious effort not to. We are influenced by exposure effects *even when* we are making a conscious effort not to be. One might think that one can simply block up ones ears and snooze or sleep through a little pharma speel... Unfortunately that doesn't seem to help undermine the impact either...

Not quite sure the phrase 'selling ones soul' and the phrase 'there is no such thing as a free lunch' spring to mind ;-)

That being said, you might be able to get some funds out of the department. That would be cool. I wonder if the handsoap people or the handtowel dispensor people would be willing to fund something?????

;-)

then why not go back to the origin of the main problem.... Is advertising drugs ethical? (Whether on TV or through drug reps or even brochures). If the answer is yes it's ethical then you know dinners are okay... if the answer is no it's unethical then you are going to kill every single new drug being made whether its perfect for the disease or pure crap. It will take many years for it to be spread in the US and it would have to be one of those gifts from God drugs that clearly works better than placebo to the point that you dont need a study for it.

I wish people would stop being idealistic ALL the time and act like we all have 100% knowledge of every single drug out there and every drug that just got approved.

Don't get me wrong, I dont think Big Pharm are innocent. They do things that I shake my head at and think should be blocked. E.g. Getting access to which doctor prescribed what... that way they know the physician that is prescribing the competing generic or company and work on kicking him out or making his practice difficult. This has been reported to the AMA and so far little success in resisting it has been reported.

 

[Chimed]

One might be tempted to think that psychiatrists are more sophisticated than the general consumer of advertisements but then the problem becomes:

Why would pharma companies spend so much money on lunches and pens and so on for psychiatrists (and other medical peoples as well, of course) if they didn't make that money back (and then some) on the sales? I'm sure they do their market research.

I don't remember where I read this, but actually psychiatrist are the worst offenders in taking drug rep "gifts." So, you might be right that we think we're too sophisticated for them. But I'm not sure I believe they'd keep spending the money if they didn't think it was working....

I personally don't think pharm companies are evil, but I am weary about their tactics and the free gifts. I have been known to go to one (literally) dinner and felt like a ***** afterwards...(Not a judgment on others, just my own thing). I'm still deciding whether or not I'll go to another one.

 

[sunlioness]

It took me several tries, but currently I haven't eaten food purchased by a drug rep for over 3 months. Including at my own drug-rep sponsored graduation. We'll have to see if I manage to continue when I start at a private practice next month, where there are lunches all the time, but I intend to continue with it. So it's definitely possible.

And yes, I understand that my not eating their food or writing with their pens does nothing to hurt them. Few people even notice it as I don't try to turn it into some big statement; its just a personal behavioral choice. But it's still seems to me to be the right thing to do.

 

[blabbyblab]

It took me several tries, but currently I haven't eaten food purchased by a drug rep for over 3 months. Including at my own drug-rep sponsored graduation. We'll have to see if I manage to continue when I start at a private practice next month, where there are lunches all the time, but I intend to continue with it. So it's definitely possible.

And yes, I understand that my not eating their food or writing with their pens does nothing to hurt them. Few people even notice it as I don't try to turn it into some big statement; its just a personal behavioral choice. But it's still seems to me to be the right thing to do.

I think this is a good attitude. I stopped eating drug food last year and have had a fair number of people ask me why. It is a subtle way to open up discussion.

 

[BabyPsychDoc]

I think this is a good attitude. I stopped eating drug food last year and have had a fair number of people ask me why. It is a subtle way to open up discussion.

I thought, you were "immune to bribery and do not feel guilty about accepting bribes"?

I have no problem eating food provided by reps. I know that my personal prescribing is not influenced by their presentations, and my conscience is clean. I frequently just switch off when it comes to the presentations. I do not attack them or engage in any discussions, especially since sometimes they do not know what they are talking about.

On the other hand, I am aware that the practice of rep-sponsored events is seen increasingly negatively, and puts a blemish on my whole profession. Given that, I think rep-sponsored events will become less common (though I have little doubt that Big Pharma will still find a way to offer "support" to programs and departments).

 

[MBK2003]

With regard to the OP, in my adult training program, we moved away from drug-sponsored lunch budget for the weekly meeting two years before I started. In it's place we did resident dues ($100-120/year) and department pitching in funds (about 50/50 split) for food.

In my current fellowship, the department has a budget for food, has not accepted drug company money in many years, and the residents/fellows are considering resident dues to upgrade the quality and quantity of food.

Personally, I don't do drug rep dinners and at the med-psych conferences I'm required to attend once a month that are catered by the drug companies (almost exclusively psych meds) I bring my own food. Is my practice influenced by exposure to drug reps? I don't know as I don't actually have to interact with them (not allowed in the building), and plan to continue this practice after I leave. I feel like my time and moral comfort with myself are valued higher than the price of a lunch. However, I'm pretty careful not to force my opinions and practices onto others.

 

[Anasazi23]

In all this talk, I just can't believe that people actually don't seem to mind the fact that the government is actually about to regulate our morality. You can "cover" it in science...but this is what's happening.

Guess it's just an inherent difference between conservative vs. liberal thought, or something like that.

 

[sunlioness]

Well, I don't really see government regulation of morality as anything new. It's just when the regulations agree with one's own personal morality, it's harder to notice I think.

 

[toby jones]

If the institution of law isn't about the government enforcing morality on its citizens then what is it? Why do you think we have punishments for rape and murder and breaking of contracts etc etc etc.

Did you know bestiality is 'still legal' in Florida? Perhaps that is a good thing as we wouldn't want the goverment to enforce a moral code...

I think it depends significantly on what moral code the goverment is trying to enforce.

> I have no problem eating food provided by reps. I know that my personal prescribing is not influenced by their presentations...

Of course... Never mind the research... *YOU* are the exception.

I'm fairly sure drug companies make enough money to do good market research. How many billions do they spend on advertising each year?

What would happen if pharma advertising was banned????? Why, doctors would have to rely on RESEARCH instead of ADVERTISING. I can't help but see that as a good thing. Peer reviewed literature reviews. Science communication would take off. Would result in a lot more good than the current 'misinformation' that passes as advertising these days, I'd bet.

Actually... I'm finding this whole conversation strangely reassuring. That individuals / programs are trying to take steps to distance themselves from the whole pharma investment thing. Maybe times are changing... And maybe the norms on undisclosed financial backing for research will become more appropriately harsh over time too (thus resulting in better quality research).

 

[Chimed]

What would happen if pharma advertising was banned????? Why, doctors would have to rely on RESEARCH instead of ADVERTISING. I can't help but see that as a good thing. Peer reviewed literature reviews. Science communication would take off. Would result in a lot more good than the current 'misinformation' that passes as advertising these days, I'd bet.

I completely agree with this. Overall, I think this would be a great thing to see.

Actually... I'm finding this whole conversation strangely reassuring. That individuals / programs are trying to take steps to distance themselves from the whole pharma investment thing. Maybe times are changing... And maybe the norms on undisclosed financial backing for research will become more appropriately harsh over time too (thus resulting in better quality research).

Yes, things are changing. As I mentioed above, I'm at a major university hospital that has banned all drug reps from the hospital. Overall, I think it is a good thing.

 

[blabbyblab]

I thought, you were "immune to bribery and do not feel guilty about accepting bribes"?

Oh just a little sarcasm. Though I've heard people actually say the same thing in more words.

 

[Anasazi23]

If the institution of law isn't about the government enforcing morality on its citizens then what is it? Why do you think we have punishments for rape and murder and breaking of contracts etc etc etc.

So now drug rep lunches are like rape?

Nice....

There's a difference between crime and capitalism, and I'd almost always err on the side of hands-off than its opposite.

 

[toby jones]

I didn't mean to claim (or imply) that drug rep lunches were like rape.

The point of an argument from analogy is to say 'x and y are alike in respects a and b and c, we think t about x so we might well think t about y'.

The analogy is only as good as the similarities between x and y being sufficient to ground the conclusion y.

Everything is of course similar to everything else in *some* respects. That doesn't establish that they are alike in *relevant* respects for the argument to go through, however.

I thought that you were claiming that it was a bad thing for the government to regulate morality. I was just pointing out that the government does indeed regulate morality by way of the institution of law. Some people think that the government also regulates morality by way of the institution of psychiatry (but I'll save that for another day).

We tend to think that some regulation of morality is indeed in order. So... Are drug rep lunches the *kind* of thing that it would be appropriate for a government to regulate?

I think it can be argued that advertising is inappropriate in medicine.

Advertising attempts to persuade people to buy a product on the grounds of 'non-rational' or 'a-rational' factors such as people are more likely to buy what they are frequently exposed to, people are more likely to buy products associated with puppies and happy attractive people and so on and so forth.

We might think that we are 'above' such a-rational or non-rational attempts at persuasion. I can guarantee that pharma WOULD NOT spend billions of dollars on advertising each year if that advertising didn't pay off with respect to sales, however. This shows us that people are in fact persuaded by non-rational or a-rational factors.

This might not matter so much when it comes to choosing a brand of spaghetti sauce or diaper.

Health is more important than that, however.

Pharma advertisements are presented as 'informational' and yet their use of statistics etc is problematic. If we know that '9 out of 10 doctors prescribe brand x for condition z' then we might be persuaded to request brand x. Trouble is that the only reason that 9 out of 10 doctors prescribe brand x is because they are well disposed to brand x for funding their lunches. If there is no difference between brand x and brand z then what is the harm? How much difference does there need to be before that strategy is unacceptable?

Again, I think there are good reasons for the abolution of advertising for medical treatments. How come? Because health really MATTERS and treatment decisions (both by consumers and by health professionals) should be based on RATIONAL REASONS rather than a-rational or non-rational emotive appeal.

 

[toby jones]

Here is a thought...

'I have the right to defend myself and my property by being allowed to carry a gun'.

But here is another thought...

'When I am behaving lawfully I have the right to not be shot by people with guns'.

How many innocent people are harmed by guns because of permissive gun laws?

How many innocent people need to be harmed by guns before government intervention (in the form of restricting gun ownership) is justified?

We might disagree on the number required - but the thought is that there are very few people who think that 'anything goes' with respect to the government having a 'hands off' approach to the welfare of its citizens.

There are of course different views of the role of government and different views of how much that role is one of custodial care / guardianship or not (whether such things as health and welfare and education etc are considered a 'right' or a 'privilege' in a given society, for example).

I guess how sympathetic one is to how much power the government should have to restrict the accepted conduct of its citizens depends quite significantly on how much one accepts the morality / ethics of the government. E.g., I'd be unhappy with increased taxes (where taxation is a form of government control) given the current government of the USA, but I'd be happy with an increase in taxes if that money went to fund universal healthcare instead of an ongoing war...

 

[Anasazi23]

Everything is of course similar to everything else in *some* respects. That doesn't establish that they are alike in *relevant* respects for the argument to go through, however.

This nears Godwin's law.

I thought that you were claiming that it was a bad thing for the government to regulate morality. I was just pointing out that the government does indeed regulate morality by way of the institution of law. Some people think that the government also regulates morality by way of the institution of psychiatry (but I'll save that for another day).

Yes, let's.

We tend to think that some regulation of morality is indeed in order. So... Are drug rep lunches the *kind* of thing that it would be appropriate for a government to regulate?

Here's a better idea. Let's leave our choices to ourselves when the line is blurred, and not have governmental laws dictate how we should think. I look forward to more science showing that doctors now flee to medical journals to look up which drugs to use instead of drug dinners. Won't happen.

I think it can be argued that advertising is inappropriate in medicine.

Advertising attempts to persuade people to buy a product on the grounds of 'non-rational' or 'a-rational' factors such as people are more likely to buy what they are frequently exposed to, people are more likely to buy products associated with puppies and happy attractive people and so on and so forth.

This is an opinion. There are many equally compelling counter-arguments as to why advertising builds a better mousetrap - particulary with medical device companies.

We might think that we are 'above' such a-rational or non-rational attempts at persuasion. I can guarantee that pharma WOULD NOT spend billions of dollars on advertising each year if that advertising didn't pay off with respect to sales, however. This shows us that people are in fact persuaded by non-rational or a-rational factors.

Advertising does not imply an a-rational decision. Better products generally sell more. i.e. Honda
People watch more successful sports teams. i.e. Yankees always sell more merchandise than the Orioles.

This might not matter so much when it comes to choosing a brand of spaghetti sauce or diaper.

Health is more important than that, however.

Not saying I disagree, but this is an opinion.

Pharma advertisements are presented as 'informational' and yet their use of statistics etc is problematic. If we know that '9 out of 10 doctors prescribe brand x for condition z' then we might be persuaded to request brand x. Trouble is that the only reason that 9 out of 10 doctors prescribe brand x is because they are well disposed to brand x for funding their lunches. If there is no difference between brand x and brand z then what is the harm? How much difference does there need to be before that strategy is unacceptable?

People like to use these simplified arguments. The truth is that there is often a difference. It might not be to the level they are advertising, but the FDA doesn't even generally approve identical medications.

i.e. is pristiq the same as effexor? If you know your neuroscience, you know the answer is "no." Does that mean it's better? That remains to be seen. I know that Geodon is NOT the biggest offender of qtc prolongation. I know this due to my observations of drug company battles in their advertising and counter advertising. In this case, the "reseach" was wrong based on longer range studies and experience.

Again, I think there are good reasons for the abolution of advertising for medical treatments. How come? Because health really MATTERS and treatment decisions (both by consumers and by health professionals) should be based on RATIONAL REASONS rather than a-rational or non-rational emotive appeal.

I'm a big research-reader. I don't disagree that decisions should be based (most of the time) in science. However, there is no research (ironically) that demonstrates that the government regulating an industry based on their perceived ethics results in better patient outcome, decreased adverse events, or cost-savings.

 

[Faebinder]

I didn't mean to claim (or imply) that drug rep lunches were like rape.

The point of an argument from analogy is to say 'x and y are alike in respects a and b and c, we think t about x so we might well think t about y'.

The analogy is only as good as the similarities between x and y being sufficient to ground the conclusion y.

Everything is of course similar to everything else in *some* respects. That doesn't establish that they are alike in *relevant* respects for the argument to go through, however.

I thought that you were claiming that it was a bad thing for the government to regulate morality. I was just pointing out that the government does indeed regulate morality by way of the institution of law. Some people think that the government also regulates morality by way of the institution of psychiatry (but I'll save that for another day).

The government might regulate SOME morality but it does not regulate ALL morality.. otherwise our current government would be in a theocratic fundamentalism. So it's up to us to decide what morality should and should not be regulated... why is this more important that regulating meals a person eats? After all, it is clearly harmful to eat too much or too little and it impacts our medical system way more than the drug reps do. Shall we give people meal diaries to check if they are eating right?

Too much government is a bad thing just like little government is.

 

[toby jones]

I'm not sure that the line is blurry...

> I look forward to more science showing that doctors now flee to medical journals to look up which drugs to use instead of drug dinners. Won't happen.

I look forward to the day that the major scientific findings are presented to doctors and consumers alike in a way that is comprehensive and accessible.

I'm greatly concerned about the impact of advertising on medical decisions. If it were the case that the best products sold more then I wouldn't have a problem with that. What concerns me is that the medical advertising doesn't make scientifically reputable claims about their products. They willfully mislead because they are more focused on making sales than patient welfare. They are a business primarily.

> Advertising does not imply an a-rational decision.

In 'critical reasoning' courses it is common to distinguish between rational means of persuasion (e.g., based on evidence and arguments) and a-rational or irrational means of persuasion (e.g., rhetorical devises, appeals to emotion, fallacies in reasoning (appeal to illegitimate authority like models singers and actresses, base rate fallacy etc etc etc).

There is a science behind advertising (psychologists get paid a bomb to find out how to make products sell) and the most effective means of persuasion aren't the rational ones. People are often surprised to find that product placement has a significant impact on peoples purchasing decisions in supermarkets. People are often surprised to find that they are purchasing a product in bulk (with 20% extra free!!!) when it is actually cheaper (on occasion) to buy 2 boxes of the smaller which is equivalent in the amount of product. People are often surprised to find how much they are susceptible to 'exposure effects' of a brand name being more familiar so that people feel more psychologically comfortable with that brand. Not all of these apply... But maybe there is no such thing as a free pen ;-)

As such it is important to counter the effects of advertising (one would have thought) to both lend better credibility to psychiatry and to medicine (so prescribing practices actually are based in evidence based medicine rather than on sampling errors, base rate fallacies, who sponsors lunches etc) Also to ensure the best possible standard of health care.

New Zealand (or possibly Australia - I forget) trialled doing without direct to consumer advertising (clinicians still weren't spared advertising, however). There were interesting findings - more people would go to the doctor for minor ailments if there was an advertising campaign to the consumer (might be that we are picking up on more cases which is good, might be that the ailments weren't anywhere near as problematic as the side effects some experienced from the medication which was bad, might be that the conditions became overdiagnosed as patients weren't happy unless they were prescribed the brand they asked for).

New Zealand (I think) changed. For political reasons.

I guess there could be two options:

1) Have stricter laws about false advertising and raise the standard of the claims that the advertisements are allowed to make. That won't help the consumer much with respect to willfully misleading statistics, however. This also won't help with familiarity effects and positive associations of drug x and puppies happy beautiful people and sunny meadows.
2) Restrict (or ban) advertising altogether.

> I'm a big research-reader. I don't disagree that decisions should be based (most of the time) in science. However, there is no research (ironically) that demonstrates that the government regulating an industry based on their perceived ethics results in better patient outcome, decreased adverse events, or cost-savings.

The research done in New Zealand might be a place to start. That was just a ban on DTC advertising and not pharma advertising across the board, however.

Who do you think are going to fund those studies? Pharma? That is another problem with science in medicine / psychiatry... While pharma sponsors the studies / provides the samples to approved investigations / hires the people to conduct the trials etc... We simply don't have access to the same quality (relatively objective) scientific studies as other fields such as physics and (non-medical) chemistry and biology...

 

[Doc Samson]

I know that Geodon is NOT the biggest offender of qtc prolongation.

Really? The last meta-analysis of published and unpublished data that I saw had it at ~40ms per comparable dose unit (as opposed to Haldol coming in at ~4ms and Zyprexa at ~10). If you have more info, I'm eager to hear.

 

[1viking]

If we eliminate advertising, and, worse yet, eliminate copyrights (there is a thing called democracy, and it's central dogma is rule of law, meaning, if I invent something, you can't steal it), then I fear we will dramatically reduce our R&D in pharmaceuticals.

Did you know that this year the number three export in the US in dollars is pharmaceuticals? Number 1 is civilian aircraft and number 2 is industrial machines. We are supplying the world with life-saving medications, and in return, we are receiving the rewards of our R&D. Sources can be found here: and the actual tables can be found here (this is the bureau of economic analysis of the US Government). So, restricting our third largest export is sticky business. Anytime we impose regulations, consumers are hurt. Look, for instance, at your cell phone. Ever wonder why Japan has superfast cell networks and we are just now getting broadband speeds on our phones?

Also, I'm so happy that we have medications like plavix, vanc, metro, metformin, etc...these drugs were developed by pharmaceutical companies with one goal, fill a need to make a profit. We, the people of the world, are greatly benefiting from their selfishness. So, I say, "pharma, continue being selfish". My patients will greatly benefit from your selfishness in the future.

I think we are getting very close to biting the hand that feeds us. Patients visit us because we can reduce symptoms. We can reduce symptoms in part because of pharmaceuticals. I wonder how many patients would visit us if we didn't have SSRIs...

 

[sunlioness]

Also, I'm so happy that we have medications like plavix, vanc, metro, metformin, etc...these drugs were developed by pharmaceutical companies with one goal, fill a need to make a profit. We, the people of the world, are greatly benefiting from their selfishness. So, I say, "pharma, continue being selfish". My patients will greatly benefit from your selfishness in the future.

I am glad we have those medications too. But we also have Lexapro, Lyrica, Invega, Vyvanse, etc. that are very expensive almost-copies of already developed medications on the market. They're not bad drugs and I don't mean to knock them, but how much does their existence really add to the overall state of health?

That Pharma is going to continue to be selfish is a given. And maybe regulation from above isn't the answer. But I am not hearing a lot of answers here either given that the same people who are saying "Down with government regulation!" are the same people who are saying "Advertising has no effect on me!" which is a bit concerning.

 

[Anasazi23]

Really? The last meta-analysis of published and unpublished data that I saw had it at ~40ms per comparable dose unit (as opposed to Haldol coming in at ~4ms and Zyprexa at ~10). If you have more info, I'm eager to hear.

You talking about the ZODIAC study? That's interesting, but the confounds are very large to make reasonable conclusions, I think. Though I do like the real-world applicibility. I was basing my comments on CATIE and a couple of subsequent smaller studies.

Which brings up a relevent point. What evidence do we have of the prolonged qtc causing any clinically significant negative effects? This clearly goes back to marketing, and anti-marketing, which was very prominent prior to Geodon's launch, and persisted for years. Competing pharmaceutical companies laid heavy into doctors, telling them that Geodon was unprescribable due to the risk of sudden cardiac death. We were getting EKGs on everyone. Now we don't, and there's usually no reason to.

By banning drug reps completely, I take my finger off the pulse of the industry. Not all that we need to be aware of, in my opinion, comes from journal articles, and our science does not exist in a vacuum. By artifically divorcing myself from the realities of clinical practice, market forces, and the like, I feel as though I have that much less information to integrate into my psychiatry gestalt.

 

[Anasazi23]

I am glad we have those medications too. But we also have Lexapro, Lyrica, Invega, Vyvanse, etc. that are very expensive almost-copies of already developed medications on the market. They're not bad drugs and I don't mean to knock them, but how much does their existence really add to the overall state of health?

That Pharma is going to continue to be selfish is a given. And maybe regulation from above isn't the answer. But I am not hearing a lot of answers here either given that the same people who are saying "Down with government regulation!" are the same people who are saying "Advertising has no effect on me!" which is a bit concerning.

It's the physician's responsibility to use whatever tools are most appropriate for the patinet. I don't get upset about the fact that lexapro is similar to celexa. I have plenty of patients that can tolerate or respond to one, and not the other. Not to mention having more options during poop-out.

Toby criticises psychiatry for developing no new real treatments for schizophrenia in 50 years. In a way, Toby is right. By eliminating pharmaceutical industry's ability to make money, however, (which comes from advertising, marketing, etc), you can expect even further delays. People (public) demand instant generics for poor old people who can't afford meds. Few also realize that there is almost invariably methods throught those same companies that provide assistance in receiving those meds. Producing early generics, for example, will cripple R & D in the pharmaceutical industry - which means less innovation and treatment options for us. I'd rather have too many options and let market forces sort it out than have big government and election-year senators decide for me what I'm allowed to do and not do as a doctor.

Again, I'm not making the argument that DTC advertising, or clinical decisions based solely on drug-rep influence is proper. Those that know me know I despise doctors that don't keep up with the literature. However, I'll take less regulation over the opposite any day.

 

[toby jones]

I think it is a sad day indeed when having contact with drug reps is regarded to be 'having ones finger on the pulse of the industry'. Sure pharma is working hard trying to develop new drugs, but there are people working hard in academic settings trying to develop new drugs too. Working for pharma compared to working in a university research environment is typically considered 'selling ones soul'. You get paid considerably more for working for pharma, of course, but with that comes the knowledge that if you make a breakthrough the medication will only be accessible to the wealthy and it won't be until the patent runs out that the medication will be accessible to the people who most need it. And there is also the knowledge that one is paid to develop new medications - whether they ultimately are better than previous versions or not. They must still be marketed as 'better than' or you simply aren't earning your keep.

I don't grant the assumption that we wouldn't make medical advances if pharma wasn't allowed to advertise their product. In order for pharma to make money without advertising the peer reviewed scientific studies would need to show that their product really was better than previous versions. I don't grant the assumption that we wouldn't make medical advances if there were greater restrictions on pharma investment in research studies. People are making medical advances in university research environments *without* pharma investment. It might be that *less* new drugs are developed, to be sure, but the trouble is that the *quality* of much of the recent drugs comes under severe critique several years down the road (especially as the patent is due to expire) - and what tends to be found was that there was that that was obvious from a proper (e.g., peer reviewed) analysis of the data all along.

I think one should be extremely careful about saying that it is 'undemocratic' to consider restricting pharma advertising. As I said, DTC advertising was banned for a time in either Australia or New Zealand and those countries are democratic countries. I don't think the US has a trademark on the term 'democracy'.

I think it is indeed the physicians responsibility to use whatever tools are appropriate to the patient. I don't think that pharma advertising does anything in the way of helping doctors or patients be better informed, however. It would be like if I wanted to buy a car and there were certain things that were important to me like safety, good mileage, not many breakdowns, good handling. If there were a few brands on the market then would I be a better informed consumer if I watched the TV ads? I think not. If one wants to be informed one would be best to seek out an independent agencies (comparatively) objective assessment of comparisons of cars on those dimensions. By watching the TV ads I'm more likely (studies have shown) to give up on several dimensions that were 'rationally' most important to me and pick the one that gave me the warmest fuzziest feeling on the commercial. I don't see how pharma does anything different - except that their techniques are more sophisticated. Psychologists, too, can sell their souls earning a great deal of money showing companies how to better promote their product. There is a lot more money in that than in helping people make decisions that are the most rational for them given their interests.

> I wonder how many patients would visit us if we didn't have SSRIs...

I think that is a shocking reason to support pharma. My history of psychiatry could be off but my understanding is that MAOI's are actually more effective than SSRI's - it is just that SSRI's have less dietary restrictions etc etc etc. A great deal of the efficacy of SSRI's is placebo. Not sure they have done a study on generic medication putting some in 'brand name' boxes to see how much brand specificity effects are placebo. But then again why would pharma assess this? If one really thinks that psychiatry is based on this kind of thing... Then that undermines psychiatry's status as a branch within medical science (and the chemical and biological sciences, rather). How is that so very different from faith healing? Oh yeah... the US economy depends upon it...

 

[Anasazi23]

I garner information based on taking in information from every source: drug reps, original research, my own research (when I used to do it), and clinical experience. These different sources offer different types and qualities of information. Some correct, some incorrect, and all in between. I can synthesize it. If you can't, I'm not losing sleep over it.

I scoff at the notion that ivory-tower academics produce unbiased research. I was on that end. They are arguably much more corrupt than that of private companies. Shall we discuss the travesty that is archeological/anthropological research scandals in history?

You keep bringing up new zealand and australia. What world market share do they have in drug development?

I don't like dumbing down to the lowest common denominator. But, this is what is happening in health-care. Everyone should be a doctor, everyone should prescribe and nobody should have their feelings hurt. I suppose I shouldn't be surprised that now people are ok with the government is regulating what we're allowed to do and not do as physicians and how we make clinical decisions. It follows the trend of removing any and all autonomy from physicians and the field of medicine.

 

[masterofnone]

My biggest problems with academia banning pharma is it's not preparing their resident's (us!) for the future. I've been told that about 80% of us will work in a private practice setting (though maybe someone can correct me with the appropriate references ). I don't know every psychiatrist in town, but of all the psychiatrists I've been aquainted with none ban pharma from their office.

Rather than ban the same pharm companies that will be bombarding us after residency, why not educate us as to how best recognize fallacious arguments and biased research? Best of all, maybe they could have
Ortho-McNeil-Janssen sponser the "critical thinking" class and provide me with a big 'ol steak while I learn

 

[toby jones]

> I garner information based on taking in information from every source: drug reps, original research, my own research (when I used to do it), and clinical experience. These different sources offer different types and qualities of information. Some correct, some incorrect, and all in between. I can synthesize it. If you can't, I'm not losing sleep over it.

I'm questioning how much advertising is in the business of providing "information". The purpose of advertising isn't to inform / educate, it is to make sales. If you think that a-rational or ir-rational sales techniques simply don't have an impact on the prescribing / buying practices of medical professionals and consumers then I'd suggest that you are sorely mistaken. The impact of advertising is well known in psychology and in critical reasoning classes in philosophy.

> I scoff at the notion that ivory-tower academics produce unbiased research.

The notion was that academics are COMPARATIVELY more unbiased than pharma. There is a difficulty with pharma investment creeping its way into academia. That is why the academic studies on medications aren't as rigorous as the academic studies on physical, chemical, and biological phenomena when people don't have (often undisclosed) financial investments.

> You keep bringing up new zealand and australia. What world market share do they have in drug development?

New Zealand is often used as a test case to see whether it is worth employing a certain market campaign in Australia, the UK, Canada, and the US. The way that New Zealanders respond to advertising is fairly representative of how other countries will respond to advertising. It is preferable to companies to use New Zealand as a test case for advertising campaigns as the population of New Zealand is much smaller that those other countries. As such it costs considerably less to fund a nationwide multi-media advertising campaign in New Zealand than in those other countries. The effects of the advertising on sales is taken to be representative of how comperable advertising is likely to impact on sales in other countries.

As such it isn't a surprise that a temporary ban on DTC advertising would be conducted in New Zealand where 1) The relative lack of pharma investment in the country makes it more of an option and where 2) New Zealand is often used as a test market because generalizations about the impact of advertising (or the lack thereof) has been shown to be fairly accurate.

> I suppose I shouldn't be surprised that now people are ok with the government is regulating what we're allowed to do and not do as physicians and how we make clinical decisions. It follows the trend of removing any and all autonomy from physicians and the field of medicine.

?

Yeah... So many restrictions... You can't lock up homosexuals anymore, you can't screw patients, you can't recruit patients to buy shares in your company... Terrible.

I don't think anyone (even you) is really opposed to the government (and other authorative bodies such as the APA) placing regulations and restrictions on the conduct of health professionals. Firstly, because it is a way of enusuring that the field has standards of professional conduct which is surely a good thing. Secondly, because medicine is supposed to be about helping the patient. Evidence based medicine is supposed to be a good thing. Advertising... Is typically NOT interested in a (comparatively) objective and fair dissemation of (comparatively) objective findings, however. Advertising is about making money. Surely one can see that the aims of pharma come apart from the aims of a reputable health profession? Doesn't one want to distance ones profession from pharma in order to embrace the scientific?

And people think that psychiatry isn't political or normative / ethical at all... Those same people who seem most willing for it to be largely driven by political considerations... I'm very surprised.

Most people don't have trouble saying 'no thankyou' to the door knocking Mormons or Jehova's Witnesses... How hard is it to do the same to pharma?????

I'm not terribly thrilled with the majority of philosophers being interested in psychiatry from the point of view of bio-ethics. I think that there is much more that is interesting than that. Instead of philosophers focusing on teaching bio-ethics to training doctors I'd like to see them teaching critical thinking skills (in particular advertising techniques of pharma compared with evidence / argument provided in *quality* peer reviewed articles). Also in more metaphysical (what is the nature of disorder?) and epistemological (how do we find out about it?) issues...

 

[sunlioness]

Most people don't have trouble saying 'no thankyou' to the door knocking Mormons or Jehova's Witnesses... How hard is it to do the same to pharma?????

Well, the Mormons and Jehovah's Witnesses would probably start getting a lot more converts if they went door to door with juicy steak dinners instead of tracts of literature.

 

[billypilgrim37]

Well, the Mormons and Jehovah's Witnesses would probably start getting a lot more converts if they went door to door with juicy steak dinners instead of tracts of literature.

That's already made my day.

 

[toby jones]

Yeah, that cracked me up. Maybe I'd be more persuasive if I came bearing steak or a free pen?



I think that one can tease apart the issues of the stance one takes on ones involvement with pharma (e.g., a decision to go to pharma sponsored events or to boycott them as much as possible) and the issue of what (if any) restrictions governing bodies such as the government of a country or the APA should place on clinicians involvement with pharma. For example, I could make a personal decision to not expose myself to pharma advertising as much as possible while also maintaining that neither the government nor the APA should attempt to restrict pharma's advertising activities. There doesn't seem to be a contradiction in that.

I think... That Australia has contributed quite significantly to psychiatric medication development with respect to a clinical researcher (not supported by pharma) discovering that lithium was effective for some people with bi-polar. Pharma was not happy with him as there were problems with attempting to patent a naturally occurring substance...

 

[TheWowEffect]

 

[i61164]

WRT the original question: I'm not a resident yet, but the program at Wake doesn't provide lunches for residents on a regular basis. I think they have lunch ocassionally, but I don't know if the department pays or not. Drug reps do come to the department weekly to restock the med cabinet. Our residents also get invited to drug rep dinners ocassionally.

Interestingly, as I rotated through third year I noticed:

Family medicine had drug rep lunches about twice a week.
Surgery had them once a week.
Internal medicine had them every single day.
Neurology had them every single day.

Residents do get free meals when they are on call, but I have heard that they are trying to inforce a limit on how much you can spend.

I think this is an interesting issue that is worth talking about because as a resident you are a hospital employee and free meals are a "benefit." Some employers are giving better benefits than others (either via drug companies or out of their own pockets). It's also interesting that it varies so much between departments within the same hospital. I'm sure people will say that these types of "perks" do not really influence how they rank programs and that the "quality of the training" is much more important. I worked for a few different companies before going to med school and these perks can really feel like a big deal (especially things like vacation time and health insurance premiums).

 

[BabyPsychDoc]

The government might regulate SOME morality but it does not regulate ALL morality.. otherwise our current government would be in a theocratic fundamentalism. So it's up to us to decide what morality should and should not be regulated... why is this more important that regulating meals a person eats? After all, it is clearly harmful to eat too much or too little and it impacts our medical system way more than the drug reps do. Shall we give people meal diaries to check if they are eating right?

Too much government is a bad thing just like little government is.

I wish the UK government understood that simple truth. The rumour has it, the UK government are thinking about rolling out a system that would allow them to monitor citizens' grocery shopping habits, especially those of parents with young children - theoretically, to ensure appropriate fruit&veg intake by the youngsters. Of course, knowing the UK's record of rolling out big IT projects, it is destined to never happen, but the very fact that the government thinks such intrusion into your personal space is justified disturbs me a great deal.

 

[BabyPsychDoc]

Well, the Mormons and Jehovah's Witnesses would probably start getting a lot more converts if they went door to door with juicy steak dinners instead of tracts of literature.

Only if they do it in silence.

 

[MBK2003]

I don't know every psychiatrist in town, but of all the psychiatrists I've been aquainted with none ban pharma from their office.

Sorry to beat the proverbial dead horse here, but not every psychiatrist in private practice has drug reps visiting their office. I know at least a few who have told the drug reps, "I don't accept visits, literature, samples or treats. Please don't call or darken my doorstep." They will occasionally have to be mean about it, but one joked "Think of it like the telemarketers, it's okay to hang up."

Rather than ban the same pharm companies that will be bombarding us after residency, why not educate us as to how best recognize fallacious arguments and biased research?

Isn't your residency already teaching you this as part of didactics on dissecting the literature?

 

[HCE]

I suppose I shouldn't be surprised that now people are ok with the government is regulating what we're allowed to do and not do as physicians and how we make clinical decisions. It follows the trend of removing any and all autonomy from physicians and the field of medicine.

I'm certainly not surprised, given how doctors have watched Big Insurance and Big Pharma take over the practice of medicine in this country with hardly a peep...

 

[HCE]

I wish the UK government understood that simple truth. The rumour has it, the UK government are thinking about rolling out a system that would allow them to monitor citizens' grocery shopping habits, especially those of parents with young children - theoretically, to ensure appropriate fruit&veg intake by the youngsters. Of course, knowing the UK's record of rolling out big IT projects, it is destined to never happen, but the very fact that the government thinks such intrusion into your personal space is justified disturbs me a great deal.

Do you have a similar problem with private companies doing the same kind of shopping habit monitoring, particularly online, or is your distaste for such intrusion limited to that of the government? Just curious, and more a rhetorical question...I mean no disrespect with the question.

 

[BabyPsychDoc]

Do you have a similar problem with private companies doing the same kind of shopping habit monitoring, particularly online, or is your distaste for such intrusion limited to that of the government? Just curious, and more a rhetorical question...I mean no disrespect with the question.

Monitoring of my shopping habits by private companies could benefit both parties (eg, I get cut-price coupons for items I buy most often - that is fine by me!) - and they do not paternalise me (because they do not want to piss me off!). When the Big Brother thinks he knows best and he should know all about you "to protect you" - thank you very much, I had enough of this crap in the USSR.

 

[billypilgrim37]

thank you very much, I had enough of this crap in the USSR.

BabyPsychDoc = Ayn Rand?

 

[OldPsychDoc]

I have multiple thoughts on this thread, so in no particular order:
1) Monitoring of shopping/prescribing habits--Pharma's already doing this. They know, based on your DEA#, what you have prescribed--all the better to customize their marketing toward your patterns.
2) In the interests of full disclosure, I consumed my share of lunches in the day. They weren't "free", anymore than my watching a favorite TV show is "free". They were paid for from a marketing budget of the manufacturer, which was supported ultimately by the consumers of the products being marketed. We can pretend it didn't influence us, but we can't pretend it was altruistic on the part of industry. There may not be an explicit "quid pro quo", but they wouldn't be buying our attention if they didn't think it was worth it!
3) I 'm glad that my organization no longer allows reps. I hate sales talks, I hate feeling like they're lurking in my waiting room for "just a moment of your time". Sometimes I miss the lunches, but if I drink a diet shake I can make through the afternoon and save myself 20-30 minutes and at least 500 kcal.
4) I don't expect research or "educational presentations" provided by a drug company to be unbiased, any more than I expect that drinking a Coors Light will instantaneously refrigerate my office or that buying a Chrysler Town & Country will restore peace and harmony between my children.
5) The real issue, as I raised in these previous threads, is not freedom from regulation, but the appearance of an ethical conflict of interests. The patient who sees the neatly attired salesman entering the office with the fragrant pile of pizzas may rightly wonder if I am prescribing their medication based on their best interests or because I liked the lunch. It gets even stickier as the stakes get higher--stipends for "advisory boards", "speakers' bureaus", "key opinion leaders"*** etc. In my state, payments from industry must be disclosed. This has made some doctors look really, REALLY bad. There's just no way to present it without it looking like we're "on the take" to the public. It's similar to legislators needing to disclose the golf trips paid for by their friends the lobbyists. One can argue that the only difference between the pizza at lunch, the fancy dinner at the trendy restaurant, and the golf junket to Bermuda is the price our "customer" (Pharma) is willing to pay for our "services".
6) Medicine is a profession--which means we are to self-regulate according to accepted ethical standards of our profession. If we were doing an adequate job of this, no one would be arguing that the government needs to step in and "do something".
7) Finally, I have to ask myself, why do I, making a six-figure salary, "deserve" to have someone buy a spendy meal for me that I could afford on my own? I don't believe that turning down this meal "artifically divorc(es) myself from the realities of clinical practice, market forces, and the like" (per Sazi). All I have to do is listen to the struggles my patients have making ends meet, and listen to NPR on my drive home to stay quite well abreast of these.

Well that's more than enough to chew on, I'm sure.

***Seriously, READ THIS ARTICLE!

 

[Anasazi23]

I'll make a couple closing comments too.

I don't really disagree with too much of what OPD says. I don't eat that many lunches, and I think OPD brings up a great point. You dont EXPECT a drug lunch to be unbiased. Just like I don't HAVE to believe that mighty putty welds metal and any other two earthly substances together, or that Debbie Myers garden bags prevent your bananas from rotting. Contrary to what Toby presents, data is presented at conferences, and speakers do not exclusively talk to drug brands and pitch. The data may be their own, but it's still data. It's our job to synthesize this. Drug companies are required to produce research (3 separate trials to assert efficacy). It's natural for them to present their results, as biased or unbiased as they may be.

I get nervous when I see the assertion that the govenment is "stepping in" because we can't regulate ourselves. The government's "stepping in" has resulted in third party payor disaster, doctors running commando without insurance, the bankruptcy of Medicare, and ginormous profits for HMOs run by lawyers.

The public's opinion basically doesn't matter.

The public is unqualified to judge how physicians should practice, what damage awards should be in the case of negligence, and certainly not in internal codes of behavior. To exemplify, this is why malpractice reform is underway in some states. The nonsensical and clear money-making scam called step II CS was borne out of public opinion. On the website when CS was borne, it was declared that [paraphrase] 'a public poll via the telephone was conducted which showed that 80% of respondents surveyed supported increased oversight and testing to ensure physician competence upon completing medical school." This is nonsense. Black/white polls of an uninformed population will always err on the side of "good." If I were to conduct a poll asking the average Joe, "Do you think it would be a good idea to extend physician training by 10 years in order to ensure greater competence and lowered incidence of medical mistakes?" The answer would be a resounding 80%ish yes. So why don't we do this? We've lost autonomy as a profession and nobody seems to mind.

We run around hiding microwaves from JCAHO, we get reimbursed 16$ for a pediatric follow-up visit in primary care, and we discharge patients early because we don't have the time to hassle with a bachelor's level snot nose kid on the phone with a psychology degree from Hell's Pass HMO. Things are bad, getting worse, and I simply don't feel that government bills introduced by bridge-driving drunkards or high-class hooker toting governers attempting to further regulate our profession is something we need.