Bad Pharma: How Drug Companies Mislead Doctors and Harm Patients (38 page)

‘Drug reps’

Drug reps are the people who visit doctors in their offices, and try to convince them in person that their company’s drugs are the best. These people are often young and attractive; they also bear gifts, and the promise of a long, mutually beneficial relationship with a drug company. It’s hard to know how well these interactions are policed: as with all relationships, they are built incrementally, on mutual trust, so the most egregious behaviour will happen between friends. Here, because this world is harder to penetrate, I’ve stepped away from the drier world of evidence, and spoken to some drug reps in confidence: if you’re feeling melodramatic, we could call them whistleblowers, though I don’t think they’ve said anything to me that you wouldn’t hear from them in a pub.
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First, though, before we look at how they operate, there is already a wealth of published evidence on their activities. This is a huge business: the overwhelming majority of the industry’s promotional budget goes on influencing doctors, rather than patients, and about half of that gets spent on drug reps. They are not cheap, and though their numbers fluctuate, they have doubled in the past two decades,
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with one rep for every three to six doctors, depending on how you measure it.
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A systematic review found that the majority of medical students have contact with drug reps before they even qualify.
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Because the industry spends so much money on drug reps, you can be sure they influence prescribing.

Doctors repeatedly assert, in both qualitative and quantitative research – not to mention when you chat with them socially – that drug reps have no impact on their prescribing (many claim that they improve it).
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Cheeringly, they also report that their own behaviour won’t be changed by interactions with drug reps, but that other doctors’ behaviour probably will be.
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And the more drug reps you meet, the more likely you are to think they’re not having an effect on you at all.
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This is naïve arrogance. From the most current systematic review, there have been twenty-nine studies looking at the impact of drug rep visits.
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Seventeen of those twenty-nine studies found that doctors who see drug reps are more likely to prescribe the promoted drug (six had mixed results, the rest show no difference, and none show a drop in prescribing). Doctors who see drug reps also tend to have higher prescribing costs, and are less likely to follow best-practice prescribing guidelines.

To give a flavour of this research, one classic study took forty doctors who had requested that a drug should be added to their hospital formulary – the list of locally approved drugs – in the preceding two years.
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Eighty doctors from the same places who hadn’t applied to put a drug onto the formulary were then randomly selected, and the contact these two groups had had with the industry was compared. The doctors asking for new drugs to be made locally available were thirteen times more likely to have met drug reps, and nineteen times more likely to have directly accepted money from drug companies.

These visits – repeatedly shown to distort prescribing practice – take place on time that patients have paid for, and generally without the blessing of the people commissioning local services, who know that such activities increase costs, through foolish prescribing. They’re also spreading: since the new ‘nurse practitioners’ are now able to prescribe drugs in many places (a development I welcome, although it annoys many doctors), they too have become a target for promotional activity. The most recent US study in this new area found that 96 per cent of nurse prescribers reported regular contact with drug reps, and the overwhelming majority thought such contact was ‘helpful’.
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Individual visits aren’t the only way drug reps can get time to persuade doctors. One of the most prevalent exposures – and one of the hardest to avoid – is at meetings. ‘Grand Round’, for example, is a tradition in most hospitals, where one medical team presents a complex or interesting patient for discussion in front of the rest of the hospital. This is a big deal – especially for the quaking junior doctor who presents the basic history of the patient being discussed – and it’s attended by everyone, from medical students to professors, as an educational event. Grand Round generally happens at lunchtime, with sandwiches by the door, and is sponsored by a drug company: it either presents for a minute or two at the beginning from the stage, or runs a stall, with reps on hand to engage doctors in discussion.

I wouldn’t say that working hospital doctors are either particularly rich or particularly poor, compared to other graduates with similar abilities and qualifications. The UK scales are all publicly accessible: junior doctors are paid between £25,000 and £40,000 per annum for the first five or ten years, and then consultants go on to around £70,000. It’s a gritty world, without the kind of glossy corporate perks you might see in the City; but then, it’s a different kind of world. However you cut it, doctors can afford either to buy or to make their own sandwiches, and don’t need these paid commercial advert breaks embedded in normal hospital work. In the many surveys that have been published, junior doctors attend between 1.5 and eight industry-sponsored lunches or rounds each month.
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The problem isn’t just that this kind of sponsorship looks bad. Junior doctors are more likely to choose a sponsor’s drug, even if it is inappropriate, after seeing a drug rep present on it at a Grand Round meeting.
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These interactions generally start at medical school, and doctors can be very naïve about the interest being shown in their career and their well-being.
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To really understand the human impact drug reps have in the workplace, we have to veer – against my better judgement – into personal stories.

When I was doing a junior job in the middle of nowhere, I went for a team meal that was paid for by a drug rep. The evidence, going back many years, shows that people who go on drug-company dinners are more likely to prescribe that company’s drugs.
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But every other junior doctor was going, and since we all lived in hospital accommodation, if I hadn’t gone I’d have been sat in an undecorated institutional bedroom on my own with nobody to talk to. This is not a sob story, but rather a description of how objections are eroded. At the end of the meal, the friendly rep asked where everyone was going next, because we were all soon moving on to our new training jobs. Applying for these was all we’d thought about for weeks, and everyone was bubbling with information.

It was only years later, talking to other drug reps, that I realised this wasn’t a friendly chat: she wanted to know where we were going next so she could pass on her notes about us to the rep covering our new area. You might think we were naïve, but in the many years I’ve been lecturing students and doctors on how to deal with industry marketing, every single time, the doctors in the room are surprised by this creepy realisation: the drug reps who you thought were impressed by your new job are actually keeping notes on what you think and say.

It goes much further. Once you start chatting to reps, you rapidly learn that they break doctors down into types, and these have even been documented in academic papers.
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If they think you’re a crack, evidence-based medicine geek, they’ll only come to you when they have a strong case, and won’t bother promoting their weaker drugs at you. As a result, in the minds of bookish, sceptical evidence geeks, that rep will be remembered as a faithful witness to strong evidence; so when their friends ask about something the rep has said, they’re more likely to reply, ‘Well, to be fair, the reps from that company have always seemed pretty sound whenever they’ve brought new evidence to me…’ If, on the other hand, they think you’re a soft touch, then this too will be noted.

One classic paper written by a drug rep in collaboration with an academic describes these techniques in detail, and if you’re a doctor, I highly recommend reading it, because you might see your own discussions reflected back to you in an unexpected light.
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They go through various situations, and the training and methods used: how to manage the acquiescent doc who says yes to everything, just to get you out of the room? How to set boundaries on the mercenary doctor who wants more expensive dinners at restaurants like Nobu? What about the lonely GP who wants a friend? This kind of social strategic information may well appear in the notes your local drug rep keeps on you. In fact, since we have a Data Protection Act that gives you the right to this information, using a ‘Subject Access Request’, some mischievous fun could be had by any informal group of doctors who gathered and then published this information.

For myself, I stopped seeing drug reps about two years after qualifying. But that doesn’t stop me running into them. I can’t block my ears when they’re presenting at the beginning of a meeting in the place where I work, and often, in an outpatients department corridor, in a part of a building where only staff are supposed to be, you will find one waiting for you. Generally they’re let in by admin staff, often by temps. Sometimes the person who let them in has a fresh bunch of flowers on their desk when you go downstairs to ask – in your nicest voice, treading on eggshells – why an intruder who has nothing at all to do with patient care has been let through to stand in a corridor surrounded by confidential patient notes.

To NHS admin staff, in the cosmetic shambles of the public sector, a competent-looking person in a smart suit has the air of someone who is supposed to be allowed into doctors’ offices. In fact, more than many people around the NHS, reps look as if they come from a real workplace. They’re charming, well-presented, engaged, attentive; they remember details about your children (from their notes), and they’ve got expensive biscuits and free memory sticks. Good sales people are good schmoozers, and I have watched them work their magic.

But they can also be insidiously divisive. Drug reps will bring food and treats for a whole team, but the people they want to influence are the key doctors. If those don’t go on a team outing, the drug rep won’t pay next time. I’ve watched a new consultant create resentment and dislike in his first week at a new community outpatients clinic by saying he doesn’t want free drug-company treats at the weekly lunchtime team meeting. As you can probably imagine, the changeover after the departure of a longstanding consultant is a fragile and anxious time, when a service might be in transition between two very different approaches. Resentment over free food from people advertising products is just another new pressure to introduce.

So, what do drug reps do? Firstly, their presentations are as partisan as you might expect. This isn’t an area where quantitative research is well-funded – a recurring theme, in this part of the book, you’ll notice – but in general they will hand out copies (‘reprints’) of academic papers describing trials that support their drug, for example, though they won’t hand out reprints of those which show it in a bad light, for obvious reasons. This plants erroneous, distorted pictures of the research literature in doctors’ memories, and if you’re like me, you often can’t remember where you learnt something, or how you know it: you just know it.

They’ll also have lines ready to respond to objections from doctors. One rep told me he never saw a doctor pull out an academic paper in objection to his claims, unless it had been handed out by a competing company’s rep. Once reps know what objections and what papers are being rolled out by the competition, they can discuss them with the marketing department, and develop rebuttals, ready to go, elsewhere on their patch. If the issue comes up more than once, it can be passed up the chain, and all reps on that drug are trained in how to combat these new objections to prescribing their drug that are regularly coming from doctors, primed by the competition.

Since most drug reps cover a number of doctors, and aim to see each one every three months or so, this level of monitoring and refutation is fairly easy to arrange. They also have flash-cards or iPad shows, with the company branding, key words about their drug, and misleading graphs. Sometimes these graphs will play the same games that newspapers and political pamphlets do: a vertical axis that doesn’t start at zero, for example, exaggerating a modest difference. But sometimes they will be smarter: a graph that shows a huge difference on a bar chart between people having the rep’s drug, for example, and people on another treatment, but where the ‘other treatment’, on close examination, is something rubbish.

They also hand out gifts, though the regulations on this are always shifting, and vary from country to country. Since May 2011, in the UK, under a change in the ABPI code, promotional pens, mugs and trinkets have been voluntarily banned. As these regulations haven’t been heavily resisted, my hunch is that the gifts don’t achieve much, and they also have the disadvantage of being obviously seedy: a doctor can end up with an office covered in drug-company logos – on biros, calendars, memory sticks – and that’s not a good look.

In any case, from my own experience, any regulations are applied elastically: a couple of years back, when gifts were supposed to have a value of less than £6, and to have some medical use, the justifications were often tenuous (‘A doctor might need some tea from a nice posh flask on a home visit’). And I still don’t understand how the laptops I’ve seen handed out for ‘working on a project together’, to doctors I know who will read this book (I chose not to name you), fell within the £6 rule.