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Experts Discuss Drug Company Gifts

January 25, 2006 at 12:00 AM EST
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GWEN IFILL: When you visit your doctor’s office, the notepads, the ink pens, even the mirror on the wall in the exam room are likely to be imprinted with the name of a pharmaceutical manufacturer, all provided to your physician free of charge.

But what about the drugs you’re prescribed? The authors of a new report in the Journal of the American medical Association, say 90 percent of the $21 billion pharmaceutical companies spend on marketing goes directly to physicians. The article concludes, that this poses a financial conflict of interest for medical professionals and recommends that academic medical centers ban most or all of the gift-giving, including drug samples, money for travel, paid speeches and research studies. So is the conflict real or imagined?

For two points of view, we turn to Dr. David Blumenthal, director of the Institute of Health Policy at Massachusetts General Hospital and a professor at Harvard Medical School — he is one of the report’s authors; and Daniel Troy — he was the chief counsel of the Food and Drug Administration from 2001 until 2004. He is now a partner at the law firm Sidley-Austin in Washington.

Dr. Blumenthal, in the words of the song, how long has this been going on?

DR. DAVID BLUMENTHAL: It’s been going on I think ever since drugs have been and devices have been manufactured by private industries in the United States.

GWEN IFILL: Does that mean it’s just something which is widely accepted and that people don’t even recognize if lines are being crossed?

DR. DAVID BLUMENTHAL: I think that that’s an accurate statement. I think it’s a part of the fabric of American medicine right now, for better or worse, and it continues to be.

And I think that what this article is about is getting the profession to look at itself and ask what the profession itself should be doing with respect to its relationships with pharmaceutical manufacturers.

GWEN IFILL: Daniel Troy, is what the profession doing in relation to its relationships to pharmaceutical manufacturers, is it by definition a problem?

DANIEL TROY: This is old news, and this has really been dealt with. There was a 2002 Pharmacode which stopped a lot of this behavior. And there’s some elements of this proposal which are both very bad and very foolish.

It seems to me a bad idea to take drugs out of the doctors’ offices by banning all samples because doctors use samples to start patients on a course of treatment immediately. It is a good thing for doctors to have drugs in the office.

And in terms of the ban on gifts, the current rules already ban gifts over $100. And the idea that doctors are going to somehow change their prescribing behavior because they get a pen or they get a note pad I think is frankly disrespectful to doctors.

GWEN IFILL: Let me ask you about that, Dr. Blumenthal. It seems that it would be hard to quantify when a doctor receives something and then is more likely to prescribe a drug in return. How do you know whether that happens?

DR. DAVID BLUMENTHAL: There’s lots of evidence now accumulating about what is called the gift relationship. And you have to ask yourself, why is it that drug companies and device manufacturers provide these considerations? They don’t spend the money because they get no return. They get a return on it.

And it’s not true that all the issues that exist were handled by those voluntary regulations or voluntary guidelines that Mr. Troy referred to. There are still lots of relationships that are — that do and are intended to affect physician prescribing behavior.

GWEN IFILL: Is there any evidence that patient care suffers today? We were watching the VIOXX trial is underway. Part of that claim is that a man died of a heart attack because he wasn’t informed perhaps — it’s implied that the doctor was more likely to prescribe VIOXX because MERCK, the pharmaceutical company was giving him samples.

DR. DAVID BLUMENTHAL: Well, I think there’s evidence that drug prescribing behavior is effective. And when problems occur as a result of that, I think you could infer that it has been affected by the efforts to influence physician behavior.

But I think that the key thing here is that physicians need to get information from all sources without the considerations that go along with them. You don’t need gifts in order to inform physicians.

GWEN IFILL: What about that argument Mr. Troy?

DANIEL TROY: I think doctors are able to consider the sources of information that they get. And they are well aware that when the source of information is a drug company that there’s a pecuniary interest that the drug company has in providing the information. Again, I think doctors are able to consider the source of the information.

To say, well, doctors should only spend their time reading medical journals might serve the interest of the medical journals and might be a valuable argument for academics, but physicians are — practicing physicians are extremely busy, and I think that more information is good, not false and misleading information but more information is good.

GWEN IFILL: But say you’re a practicing physician. And you’ve entertained — you’ve had hours of conversation with different drug salesmen. And you have a choice between prescribing a drug with a brand name and a drug that’s a generic choice, what are you more likely to do?

DANIEL TROY: What Dr. Blumenthal said was that there’s evidence that influences prescribing behavior. He didn’t say that it’s really harming patient care.

It may be that on the margins it affects prescribing behavior although one of the things that can and has happened at least to me is you get a branded product as a sample. You take it to the prescription, to the pharmacy. And the prescription that’s filled is a generic because the pharmacies often have the ability to substitute.

Also, these days generics are actually engaging in what’s called counter-detailing. They are providing samples. There’s also a healthy competition among the branded companies themselves.

Another use of samples, I was talking to a doctor about today, is let’s say a patient has a migraine headache. You might want to give them two different products and see which one works. That particularly would happen with something like pain medication.

So to cut off the supply of samples and to, again, cut off the flow of pens on the thought that somehow that is radically affecting patient care I think is an overreaction, especially in light of the regimes that are already in place to cut down on the worst abuses.

GWEN IFILL: What if your patient is low income elderly and as often happens, the doctor provides some of these samples as a way of taking the burden of the cost of prescription drugs –

DR. DAVID BLUMENTHAL: I think it would be terrific if pharmaceutical companies donated the value of their prescription samples to physicians and to institutions and enabled them to give those that value, the cash equivalent, to their patients to purchase the indicated medications; I think that would be terrific.

GWEN IFILL: Is there a way — is there a middle ground here? Does there have to be an outright ban as you recommend in your report or is there a disclosure — there’s a middle ground that you can come up with to address the problems you see?

DR. DAVID BLUMENTHAL: Disclosure, I think, is to some degree a palliative. It doesn’t really get at the problem. People disclose and then feel that they’ve dealt with the issue when, in fact, the evidence is that their behavior continues to be subtly, unconsciously affected.

And we’re not just talking about pens and pads of paper. We’re talking about meals that are usually at the best restaurants in town. I don’t have to get a luxurious meal in order to learn about the medicines I ought to prescribe.

We’re talking about substantial honoraria that are often provided repetitively to opinion leaders over time, and we’re talking about consulting relationships that can lead to substantial amounts of money. So I don’t think we’re just talking about things that everyone would consider trivial.

GWEN IFILL: And I might add, Mr. Troy, we’re also talking about medical devices as well. Say you’re a doctor who replaces knees or replaces hips, and you have a relationship with the company that makes the knee replacement or the hip replacement. Aren’t you more likely — and why would the patients ever know to use that particular perhaps more expensive item?

DANIEL TROY: Many of the issues that have been raised here, again, have been dealt with and are already prohibited by the Pharmacode, by the AMA Code of Medical Ethics. The meals especially it’s not supposed to be at the nicest restaurant in town. I think this is a problem that may have existed in the ’90s and the ’80s but it is not a current issue. And so I think that this is an example of overregulation that has the potential to really impede the flow of information to doctors.

GWEN IFILL: Your report is targeted particularly to academic medical centers. Is this something they have to comply with, or are you just recommending –

DR. DAVID BLUMENTHAL: No, I think it’s incorrect to call this regulation. This is self-regulation. This is something that we are asking, recommending, that the profession and the institutions of the profession impose on themselves, not that government impose it on anybody. And academic health centers are leaders in opinion. They train the next generation of physicians. They set examples.

And many of the people who do research on the next generation of pharmaceuticals can be found in these institutions so they’re a particularly important group. They’re organized so that they have the opportunity to affect more easily the behavior of the physicians who work there.

GWEN IFILL: A final word.

DANIEL TROY: I guess I would say that it’s in part because these physicians and academic medical centers are so often the experts that to basically say if a person who’s an expert in a drug or in a disease has any kind of relationship with the drug company, they can no longer educate doctors about this, there would be a huge sucking sound of expertise flowing away from the ability to inform patients about drugs and needed treatments.

GWEN IFILL: Daniel Troy, David Blumenthal, thank you both very much.

DR. DAVID BLUMENTHAL: Thank you.

DANIEL TROY: Thank you.