Pros and Cons of the Pharmaceutical Industry and Education

Many persons in authority see the interaction between the health care industry and pharmaceutical companies as either good or evil. Rarely is anything in life dichotomous, however, and in this case, the middle ground is being neglected. The debate centers primarily on money. IMS health estimated that in 2002 $5.8 billion was spent in “detailing” physicians, with another $11.5 billion in retail value drugs dispensed.1 Whether this money is spent toward the benefit of patients or to their detriment is the issue. Ashley Wazana, MD, of McGill University, published a review of 29 articles dealing with pharmaceutical marketing to physicians.2 Of those articles, 16 addressed the extent of the physician-industry interaction, 16 identified the attitudes of physicians toward the interaction, and 16 evaluated the effect of the interaction on the practitioner. The studies on attitudes used self-reporting surveys and found that residents and physicians similarly believed that pharmaceutical representatives provided accurate information about their drugs, but physicians were equivocal in their beliefs that representatives could provide accurate information on established or alternative drugs. Most physicians approached the interaction with healthy skepticism and believed that representatives prioritize product promotion above patient welfare and are likely to use unethical practices. Another 16 studies in this paper examined the effect of physician detailing and found an association between marketing and increased formulary addition requests as well as increased prescribing cost with decreased use of generic medications. A study that examined costs pointed out that physicians in academic or hospital-based practice settings had significantly lower prescribing costs than physicians in nonacademic and nonhospital practices.3 In addition, the only study that looked at rational prescribing habits noted that younger physicians were more rational in their habits than older physicians.4 This was explained partly by the patterns of information acquisition, with less reliance on general medical journals and the pharmaceutical industry by younger physicians. In an attempt to rigorously quantify the net effect of physician detailing, Mizik and Jacobson1 studied the prescribing patterns of 74,075 physicians for 3 drugs during a 2-year period, totaling over 2 million prescriptions. A positive correlation was found between detailing and prescribing, but the effect was described as modest. The authors estimated that it would take an average of 3.5 additional visits to result in a single new prescription and 35 additional drug samples to result in a single new prescription. The effect was variable among the 3 drugs studied, with drug A requiring fewer visits (0.64) and drug C requiring more visits (6.54)to effect a single new prescription. Without knowing the specific drugs studied, one cannot comment on whether the variability was due to marketing genius for drug A or less effectiveness for drug C. The authors then note that the question is no longer “Are physicians easy marks?” but rather “Why do drug companies make such extensive use of pharmaceutical sales representatives given their limited effectiveness?” While most of the debate has centered on the question of whether detailing is harmful, one must also ask the question of whether pharmaceutical support of education is beneficial. There is evidence of effective treatment for heart failure with angiotensin-converting enzyme (ACE) inhibitors since the late 1980s, β-blockers since the mid-1990s, and aldosterone antagonism since 1999. Despite this knowledge being widely disseminated by academia and interested pharmaceutical companies, putting this knowledge into practice has clearly been slow. The IMPROVEMENT heart failure registry5 found that in 2002 only 60% of patients were taking ACE inhibitors, 33% were taking β-blockers, 20% were taking a combination of ACE inhibitors and β-blockers, and 12% were taking aldosterone antagonists. It is interesting to contemplate how we would be doing without industry constantly trying to inform us of the benefits of their products in the treatment of heart failure. Noting that the debate over industry and physician detailing will rage on, an important question is “What response is required at the present time?” The obvious alternatives are to: (1) do nothing; (2) go nuclear and ban all interaction; or (3) control the interaction. Many institutions have opted for first option while awaiting further evidence and information. Several universities, notably Stanford, the University of Pittsburgh, Yale, UCLA, and now UC Davis, have opted for the nuclear option and have banned their physicians from accepting gifts and direct support for departmental educational programs from pharmaceutical companies. Since the Pharmaceutical Research and Manufacturers of America (PhRMA) guidelines eliminated the noneducational gifts long ago, the only gifts left to eliminate include drug samples for indigent patients, textbooks for physicians and residents, and educational meeting support. Academia is already struggling financially and it is unlikely that it will fill the financial gap created by banning industry support. I am throwing down the gauntlet and asking the 5 named institutions to study the effects of their decisions and report their findings in the ongoing effort to improve the quality of medical education and patient care. Outcome measures could be pharmacy acquisition costs, compliance with guidelines, meeting attendance, and specialty board passing rates. The third option is to control the interaction between physicians and pharmaceutical representatives to encourage a positive outcome. McGill University instituted guidelines that included education and training of residents on resident-industry interactions early in the curriculum.6 Guidelines were developed to address limitations on fundraising activities; restriction of direct gifts to residents; the appropriateness and awarding of industry fellowships; and the handling of drug samples, meals, and other presentations to residents. While guidelines for residents are useful adjuncts for guiding residents' interactions with the pharmaceutical industry, the authors conclude that they need to be reinforced with education and sensitization by faculty. At present, we are waiting to see whether McGill's charted course positively affects patients and physician training. To me, the choice seems apparent. The literature supports that there is a modest effect between physician detailing and behavior. This effect appears negligible in academic institutions and younger physicians, and it appears more prominent in older physicians in nonacademic settings. Banning pharmaceutical representatives from academic institutions will theoretically have little effect on patient care in academia. Practicing physicians need to be educated regarding the risks and benefits of obtaining information from pharmaceutical representatives. This education needs to start in medical school and during residency. Studies need to be conducted to see what information provided by pharmaceutical companies leads to appropriate physician education and patient care. For example, are clinical study reprints, reviews, and professional society guidelines more appropriate than detail sheets? I teach house staff to question the information they receive from pharmaceutical representatives and to speak with competing manufacturers as well as attendings to get all sides of the debate on a particular drug or disease treatment. All of this takes time and effort, but the rewards are apparent by positively changing how physicians educate themselves and how they practice medicine long after they leave the guarded halls of academia. Academia does not prepare trainees for the real world of the business side of medical practice, and now there is a movement afoot to ill prepare them for the real world of the pharmaceutical industry's role in medical education as well.

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