Pharmaceuticals – Pads, Pens and Prescriptions

It has become stylish to trash doctors for accepting lunch, pens, pencils, pads or even samples from representatives of pharmaceutical companies.  The theory is that pharmaceutical marketing raises the cost of prescription medications to patients and the health care system. Once the patient gets started on a new medication, which costs more than generic products in the same medication class, they stay on the more expensive medicine. Ethics experts consider a discussion with a pharmaceutical representative unprofessional and unethical.

In certain states it is now illegal to receive any gift (I.e., a pen, paper, samples, etc.) from a pharmaceutical representative including a discussion of the new product line over lunch in your office provided by the pharmaceutical company for your staff.  Purists claim we should be learning about new products from the scientific medical literature.  Let me join the chorus of those who say this is pure nonsense.

Physicians are trained to be independent thinkers and evaluators. For thirty years of private practice I have taken the position that, unless I am dealing with an orphan drug for a lethal disease, I want the product out on the market in my community for at least a year before I will prescribe it to my patients. Let someone else’s patients be the community guinea pigs. After a year of reflection, evaluation, reading about the community experience and discussion with my colleagues, I will try the samples if the drug offers distinctive advantages over existing products.

Where do the pharmaceutical representatives fit in?  They let me know there is something new out there and they tell me why they think it is different and improved over existing products. That is the introduction that piques my interest in beginning my due diligence into the product with its benefits and risks.  I do not know how the rest of my colleagues treat new products but I am willing to bet their inquiries are similar. To think that because someone brings me a pen or a tuna fish sandwich for lunch I will give my cherished patient their new product without doing a background check first is an insult to my professionalism and my colleagues.

Articles and reviews in medical journals are outstanding for reviewing data on a product. The journals would be have far more credibility if they hadn’t compromised years ago and started selling full page glossy ads to pharmaceutical companies to cover their costs.  Reading about a product is not the same as using it. I give the analogy of two mechanics trying to service an automobile by reading the auto manual. Both are similarly inexperienced but one has a master mechanic at his side to guide him through the pitfalls. They both can read the manual but the one with some hands-on experience and guidance figures it out much quicker and with much less aggravation than the mechanic just using the written material.  New pharmaceutical samples give me an opportunity to gain some experience with the product without my patient incurring expenses. If the medication does provide a distinct advantage to the existing products I have helped my patient in my field trials. If the medication doesn’t live up to the billing then I do not use it again!

I have tried the computerized on line drug “detailing,” provided by pharmaceutical companies to replace human representatives, but frankly once you log in they don’t cover the material in a quick and timely fashion like our experienced drug representatives do. I don’t want to spend 15- 30 minutes online listening to the companies’ educational spiel. I want the “Cliff Notes” version as the basis for me beginning my investigation.

I am additionally tired of hearing lecturer’s at my CME courses disavow all relationships with pharmaceutical companies before beginning their lecture on a topic. I still believe that most speakers present a fair and objective viewpoint of the topic they are asked to speak about. Their presentation is only one piece of data for me to review and consider before I add that product to my repertoire or reject it.

The same “ethical” physicians attacking pharmaceutical advertising are using generic products with absolutely no knowledge of their true safety, efficacy or even their nation of origin. The last time I looked at this question I was told generic products had to have at least 80% of the “bioavailability” of the brand product. The actual research is done by the generic pharmaceutical company with the data submitted to the FDA for their review. Isn’t that like letting the fox into the chicken coop and asking it to maintain order?  Where are the double blind studies showing the efficacy of each generic as compared to the brand name product?  Where are the certified lab studies showing that with similar performance efficacy there are similar blood and tissue levels of the active agent and similar adverse effect profiles?

I think it’s high time that physicians and legislators realize it’s all about the money with insurance companies looking to keep their pharmaceutical costs down at all costs with as little investment in research and development as they can get away with.  I will continue to break bread with the pharmaceutical reps willing to bring in a lunch to my office staff while discussing a new product. I will wait a year for the new products to exhibit their benefits and risks in my community on someone else’s patients before I use them. I will perform my due diligence before subjecting my patients to a new product but I will not for one second feel any less professional for having accepted a pen or a pad or a bagel from a pharmaceutical representative while discussing a new product.

NICA, Florida’s Newborn Injury Compensation Act – 2010

In the early 1980’s there was a major medical malpractice insurance crisis in my home state of Florida.  Obstetricians and gynecologists could not afford to purchase medical malpractice insurance at the price it was being offered at, when it rarely was being offered. The fear was that an Ob-GGYN would deliver a deformed or injured child while performing his hospital required emergency department coverage and be sued for a staggering sum to pay the medical costs and damages for the infant for the rest of his or her life. Obstetricians stopped agreeing to see and treat pregnant women because of the risk involved.

The Florida State Legislature then came up with the idea of creating the Newborn Injury Compensation Act which created a fund to pay for the medical care and damages associated with injuries occurring during the childbirth process.  This fund was supposed to keep obstetricians out of court. This compromise legislation was initially supported by the Florida Medical Association as a short term solution to a problem. Every doctor in Florida was fined, or taxed, $250 per year to pay for birthing injuries while obstetricians paid $5000 per year. The first thing that happened after this was signed into law is that the Florida Trial Lawyers Association found away around it so they could continue to sue obstetricians for medical malpractice.  The second thing that has occurred in the twenty some odd years since its inception is that the NICA fund has never paid out anything to an injured party.

NICA is essentially an additional $250 per year tax on physicians for the privilege of practicing medicine in the State of Florida. The Legislature has decided that expectant mothers who live on a diet of barbecue potato chips, pineapple soda pop and Marlboro’s and has their first pre natal visit when in their ninth month and crowning are the legal responsibility of doctors only. The Florida Medical Association has been so busy with so many issues that it has not had the time or resources to work for the abolition of this unfair tax on physicians.

It’s time this unfair tax is repealed. Reproductive education, prenatal care and visits to a doctor when pregnant are not only the responsibility of the physicians’ community alone but of the public at large.