May 22, 2013

Practicing medicine pharma-free in a drug rep-filled world

UW Health Sciences/UW Medicine

A rural Oregon family medicine group is an example for other community physicians seeking to wean themselves from pharmaceutical industry influence.

An Ethics Feature in the May-June issue of the Journal of the American Board of Family Medicine describes the lessons learned as the Madras Medical Group transformed itself into a pharma-free clinic.  The small, private clinic of five physicians no longer has contact with detailers – representatives from the pharmaceutical industry who visit physicians to educate them about medications. The clinic also refuses drug samples, gifts and lunches from pharmaceutical companies.

Pharma-free medical practices refuse gifts, lunches and samples from pharmaceutical industries.

Alice C. Gray

Pharma-free medical practices refuse gifts, lunches, educational programs and samples from pharmaceutical industries.

The corresponding author of the paper, David V. Evans, practiced at the clinic and is now an assistant professor of family medicine at the University of Washington. He and his colleagues at the Oregon State University College of Pharmacy and at University of Oregon Health & Sciences University  examined the clinic’s successful methods to change a culture ingrained in medicine.

“Detailing – selling drugs by educating physicians –  was first reported as a problem in the late 1950’s,” Evans said.  Since then, extensive research indicates that detailing can encourage physicians to prescribe medicines that may not be appropriate, necessary or cost-effective for patients, and that may pose safety concerns.

Academic medical centers, such as medical schools and teaching hospitals,  Evans noted, have critically looked at detailing,  have advocated against it nationally, and have set institutional policies prohibiting or limiting student, resident and faculty contact with detailers .

However, he added, three-fourths of the country’s physicians practice in the community, where interactions between physicians and pharmaceutical representatives are still commonplace.  Although some states have curbed contact between drug reps and physicians, most physicians in small, independent practices have little guidance on how to become pharma-free, the authors of the paper observed.

“Changing this situation is not easy, but with a deliberate and thoughtful approach it can occur,” Evans said.  Although his clinic’s personnel were not unanimous in wanting to go pharma-free, approaching it in smaller steps helped to decrease dissent.

First, those championing a pharma-free clinic quantified the presence of detailers and their marketing strategies.  This data helped convince the physicians and staff that a problem existed.  The staff and physicians then voiced their concerns. These included doing without prescription samples for patients.

The clinic then scheduled sessions for their health professionals to keep current about medications by reviewing rigorous scientific studies. To replace the pharma-sponsored lunches, the clinic held its own regular lunches for their clinicians and staff.  Clinic staff told patients about the change, and news media in the local area informed the nearby public.  The clinic also created a chart comparing average monthly costs of many heavily marketed drugs with first-line, less-expensive or generic drugs, if such alternatives were available.

“Becoming pharma-free at our clinic was not an overnight thing,” said Evans. “Cultural change takes time.  Eventually even the initial dissenters in the clinic came to feel good about the change, and it became a point of pride.”

Now, as a UW medical school faculty member who teaches medical students and residents, Evans, along with colleague Pam Pentin, educate future physicians on effectively managing drug detailers, including how to turn all of them away.

“One of the concerns,” Evans said, “is that medical students and residents may come up through their education without ever having interacted with a drug representative.  It’s important to teach medical students and residents how detailers operate in the real world. At the UW, family medicine residents learn about detailer strategies during their third-year practice management curriculum.  This year’s graduating residents will be the first to have taken the training.”

As of 2009, there was one drug sales representative for every eight physicians.  Despite increased scrutiny and regulation, Evans and his colleagues noted that the percentage of primary care physicians with industrial relationships remains high at 84 percent.  Evans explained that most drug reps are well trained and personable. They use marketing strategies time-tested in the social sciences.

“It’s a sophisticated operation. For example, before they go in to see physicians,” he said, “detailers sit in their cars data-mining on their electronic devices. They find out the physicians’ prescribing patterns from databases in which the patients’ names and other identifying information have been removed. They know how much a doctor has prescribed of drug A, and will either thank the doctor or encourage him or her to prescribe drug B instead.”

Beginning in August 2013, as part of the Affordable Care Act of 2013, a national web site will contain information for patients on the monetary value of what individual physicians accept from pharmaceutical firms.  The Physician Payment Sunshine Act will require manufacturers of drugs, devices and biologics to report all payments to physicians and teaching hospitals to a public web database.

What else can patients do to mitigate undesirable effects of drug marketing?  Evans advises asking their physicians about the issue. He suggests refusing drug samples if they are offered. Patients can also become aware of the effects of drug advertising on their own treatment choices.

The authors of the paper, “Breaking Up is Hard to Do: Lessons Learned from a Pharma-Free Practice Transformation,” wrote that they hope their description of how a clinic changed its practice “contributes to the ongoing discussion of the potential clinical influences and the ethics of the relationship between practicing physicians and pharmaceutical marketing.”

The other authors were Daniel M. Hartung and Denise Beasley of the Department of Pharmacy Practice, Oregon State University College of Pharmacy in Portland. The senior author was Lyle J. Fagnan, a physician in the Oregon Rural Practice-based Research Network in the Department of Family Practice, Oregon Health & Science University School of Medicine.

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The externally peer-reviewed analysis of the clinic transformation received no funding and the researchers declared no conflicts of interest.

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