Three papers published this week examine ties between industry and doctors in the US. They suggest that drug and other companies invest heavily in grooming doctors to use and recommend their products and that despite recently published ethical guidelines by various professional bodies, many doctors are overstepping the mark when accepting reasonable favours, education and “freebies”, ostensibly in the interests of patients.

One paper, by a former drug rep and a physiology professor who researches drug marketing, looks at how drug reps are trained to influence doctors to buy their drugs and is published in PLoS Medicine. Another paper in the same edition of the journal looks at the impact of sales visits for one drug in particular.

A third paper publishes the results of a national survey on doctor-industry relationships and suggests these are very common and vary according to specialism, type of practice and professional activity. It is published in the New England Journal of Medicine (NEJM).

How Drug Reps Influence Doctors

Shahram Ahari, a former drug rep from Eli Lilly, who is with the School of Pharmacy, University of California San Francisco, and Adriane Fugh-Berman, an Associate Professor in the Department of Physiology and Biophysics, Georgetown University Medical Center, Washington, District of Columbia review the intensive training that drug reps receive to learn how to develop and maintain relationships with doctors.

Their work was supported by a grant from the Attorney General Prescriber and Consumer Education Grant Program. This was set up in 2004 as part of a settlement between a division of the drug company Pfizer (Warner-Lambert) and the Attorneys General of 50 US states and the District of Columbia, who accused the drug company of marketing the drug Neurontin (gabapentin) in violation of state consumer protection laws.

The article describes in great detail the type of training that a drug rep goes through to learn how to change the prescribing behaviour of the doctors in their sales territory.

It includes two tables that list different “physician categories”, or personality types, and the technique to use with each one. Example entries include: “friendly and outgoing”, “aloof and sceptical”, “high-prescribers”, “acquiescent”.

The tactics for how to relate to each doctor depends on the physician category.

For instance with the outgoing and friendly types the emphasis is on friendship development; with the aloof and sceptical, the emphasis is on collecting and presenting journal articles that counter the doctor’s view on the drug.

It describes how reps are trained to “assess physicians’ personalities, practice styles, and preferences, and to relay this information back to the company. Personal information may be more important than prescribing preferences. Reps ask for and remember details about a physician’s family life, professional interests, and recreational pursuits.”

In conclusion, the authors say that:

“Every word, every courtesy, every gift, and every piece of information provided is carefully crafted, not to assist doctors or patients, but to increase market share for targeted drugs.”

And their recommendation to the medical profession is:

“In the interests of patients, physicians must reject the false friendship provided by reps. Physicians must rely on information on drugs from unconflicted sources, and seek friends among those who are not paid to be friends.”

Another article in the same edition of the journal details research on the impact of drug rep visits on the use of gabapentin, the drug at the centre of the Warner-Lambert case.

The researchers analysed data extracted from reports by 97 doctors on 116 detail visits for for gabapentin that took place between 1995 and 1999.

A key finding was that while gabapentin at the time was only approved for adjunctive treatment of partial seizures, in 38 per cent of the visits, the doctors reported that the “main message” of the visit was for off-label use. The researchers concluded that the visits were perceived as valuable, although they often included messages about unapproved use, and despite their short duration, they were frequently followed by intention to increase use or advising use of the drug.

National Survey on Doctor-Industry Relationships

The last two decades has seen a flurry of writing and research about the relationship between doctors and pharmaceutical, medical device, and other medically related industries.

The authors of this survey mention a review of 16 studies published between 1982 and 1997 that suggests doctors and industry reps, on average, met four times a month, and accepted six gifts a year from them.

The study authors review the results of a survey of US doctors that was conducted by the Institute on Medicine as a Profession (IMAP) and adress three questions:

(1) What do doctors actually receive (including financial incentives) from industry reps and their companies?
(2) How often do they meet with industry reps?
(3) What characterizes the relationship between doctors and these industries?

Dr Eric Campbell at the Institute for Health Policy, Boston, and colleagues, used information about the doctors’ financial links with industry and then tried to predict the factors that influence them.

They surveyed 3,167 doctors from six specialisms: anesthesiology, cardiology, family practice, general surgery, internal medicine, and pediatrics. The response rate was over 50 per cent.

The results showed that:

— 94 per cent of doctors reported some type of relationship with the pharmaceutical industry.
— 83 per cent said these relationships involved receiving food in the workplace.
— 78 per cent said they involved receiving drug samples.
— 35 per cent received reimbursement for costs of going to professional meetings or continuing medical education (CME).
— 28 per cent received payments for consulting, giving lectures, or enrolling patients in trials.
— Cardiologists were more than twice as likely to receive payments as family doctors.
— Family doctors met with industry reps more often than did doctors in other specialisms.
— Doctors who practised on their own or in group practices met with reps more often than those working in hospitals and clinics.

In conclusion, the researchers said these results show that:

“Relationships between physicians and industry are common and underscore the variation among such relationships according to specialty, practice type, and professional activities.”

“Following the Script: How Drug Reps Make Friends and Influence Doctors.”
Adriane Fugh-Berman, Shahram Ahari.
PLoS Medicine Vol. 4, No. 4, e150
doi:10.1371/journal.pmed.0040150

Click here for Article.

“A National Survey of Physician-Industry Relationships.”
Campbell, Eric G, Gruen, Russell L, Mountford, James, Miller, Lawrence G, Cleary, Paul D, Blumenthal, David.
N Engl J Med 2007 356: 1742-1750
April 26, 2007, Number 17

click here for Article.