By Angira Patel
When I started my medical training, my pediatrics residency program banned all pharmaceutical sponsorship of activities. No free lunch in the middle of the day, no fancy dinners at expensive restaurants, or trips to conferences paid for by a pharmaceutical company. Even my lab coat was unadorned by the colorful pens given by various drug representatives. At the time, I remember thinking a pen or a free lunch would never influence how and what I prescribe to my patients.
As a young trainee, I did not appreciate why my residency program took this stance, but I do now.
A recent study looked at influence of pharmaceutical marketing on Medicare prescriptions practice and found that “gifts from pharmaceutical companies are associated with more prescriptions per patient, more costly prescriptions, and a higher proportion of branded prescriptions with variation across specialties.” More importantly, “gifts of any size had an effect and larger gifts elicited a larger impact on prescribing behaviors.”
Pharmaceutical companies know this and in fact, rely on it.
Since the completion of my residency, I have stumbled into a handful of drug sponsored lunches. And, honestly, I have eaten a sandwich or two. As a cardiology fellow, I remember wrangling with and ultimately attending a free educational conference on pacemakers sponsored by a device company. The opportunity to intensely learn over two days was something I could not discard as a fellow in training.
Now as an attending physician, I am more cognizant of avoiding sponsored activities. This may mean finding another way to learn about a new pulmonary hypertension drug that might help my patients or miss an otherwise good educational opportunity. I am also older and have personal experiences of caring for my aging family members who struggle to pay for costly prescription drugs. When I inquire more closely, there is often a less costly option that was never mentioned by their doctor.
A survey by Consumer Reports found that as drug prices continue to rise, Americans are left with rationing medications which can lead to negative health consequences. A group of independent experts just released a report that advises the government on how to use its purchasing power to negotiate prices on drugs bought through Medicare to make medicines affordable.
In order to decrease prescription drug costs, we need to improve the availability of generic drugs and evaluate exclusivity rights that companies hold to manufacture and distribute drugs. But, as physicians we must also reflect on how we can contribute in keeping prescription drugs affordable for all patients.
Individual physicians and providers need to simply say no to any and all forms of pharmaceutical gifts. But, this may not be enough. Hospitals and academic centers also need to take the lead and create institutional policy that bans all direct marketing to physicians. This can be successful as demonstrated by a study that showed restricting pharmaceutical representative visits to physicians led to a decrease in prescribing of more expensive drugs. If educational sessions are required to convey important information about a specific drug, we should do it in a fashion that is not accompanied by meals or gifts and with greater transparency.
Finally, this education must begin in medical school. The reality is that most physicians believe, in good faith, that small gifts will not influence their prescribing practice. I certainly did. But, enough evidence now exists to educate future prescribers the implications of interactions with the pharmaceutical industry and accepting gifts.
Training in a residency program that primed me to critically think about external influences has led me to be more mindful of my professional and ethical responsibility to my patients. In this day of increasing health care costs, the do no harm principle of the Hippocratic Oath must also extends to monetary costs incurred by society and our patients.
Angira Patel, MD, MPH, is assistant professor of pediatrics and medical education and a member of the Center for Bioethics and Medical Humanities at Northwestern University Feinberg School of Medicine, a pediatric cardiologist at Ann & Robert H. Lurie Children’s Hospital of Chicago, and a Public Voice Fellow through The OpEd Project.
Wood SF, Podransky J, et al. (2017). Influence of pharmaceutical marketing on Medicare prescriptions in the District of Columbia in PloS ONE 12(10): e0186060
Skinner, Ginger. Americans Say They Are Suffering as Drug Costs Continue to Rise, December 14, 2017
Making Medicines Affordable: A National Imperative, November 30, 2017
Larkin I, Ang D, et al. (2017). Association Between Academic Medical Center Pharmaceutical Detailing Policies and Physician Prescribing in JAMA 317(17): 1785-1795.