My take: Bribing patients, Dr. Naturopaths, drug samples

1) How do you get patients to take their TB meds? Reward them with free cellular air time.

This is similar to paying patients to quit smoking or lose weight. It’s somewhat sad that physicians have to resort to bribing patients for their own good. Better health doesn’t seem to be reward enough.

2) Naturopaths in Minnesota can now call themselves “Doctor” with confidence.

Before one concludes that the controversy is stirred up by turf-protecting MDs, consider how easy it is to become a “certified” naturopathic provider.

3) A reader writes: “I wondered if you’ve covered the issue of free drug samples.”

Drug reps, Big Pharma and drug samples are common topics here.

Free samples are simply a gateway to a lifetime of expensive brand-name medications. So, the only samples that I’ll accept are ones where there are no generic equivalent.

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Comments

My Family Doctor
Kevin, I agree with your take on the samples. Of course the reps are a little more stingy with the ones we use a lot.
James Hubbard, M.D., M.P.H.
Publisher, James Hubbard’s Family Doctor
http://www.familydoctormag.com
Anonymous
I bet it’s cheaper to offer presents to the patients than to chase them down. Honey vs. vinegar, at the risk of comparing patients to flies.
Anonymous
Friend of mine does monitored TB treatment. She’d get various foreign patients who turned out to have TB caught in their country of origin.
She offer the various inducements as allowed. She said some of the patients were incredulous. They’d be lucky to be offered any treatment where they came from. Here it’s “you come to my house and give me medicine and pay me for it??”
Anonymous
Bribing people to comply infantilizes them. It would be ok for children and the mentally retarded, but for the rest ought to be insulting. If it isn’t insulting, then THAT is a terrifying thought. It says that the psychological regression encouraged by the loss of freedom and responsibility has gone even further than I ever imagined.
The idea that it is somehow somebody else’s job to get people to take care of themselves–whether by bribe or punishment–is a notion that the medical profession has long encouraged (seat belt laws, anti-tobacco laws, now insurance mandates) but with destructive ramifications throughout society–which in the end return back to us in malpractice allegations for the consequences of other peoples behavior.
Anonymous
Regarding the naturaopaths calling themselves “Dr” and “physician”, it is just another example that shows we are back to the pre-Flexnerian age of buyer beware.
Patients often do not know the difference. I have known many many patients who thought their social worker or their PA was a doctor.
Now we have “nurse doctor”, “medical psychologists” (who put MP after their name which is often confused with MD), “chiropractic physicians”, “naturopathic phsicians”, etc.
Caveat emptor
Anonymous
The carrot and stick approach does not work without a stick. How about ” You need to comply with taking this medication for your good, and for the public good. If you cannot, will not, choose not, you will be tracked down and institutionalized (TB asylum like)for the public good.” In other words, your freedom of choice stops when your freedom of choice endangers me.
Anonymous
You Have Now Been Sampled
While the pharmaceutical industry’s image and reputation has suffered, as stated by others, which further damage has occurred with their overall reduction in profits due to such variables as patent expiration, the pharma companies still insist on keeping their gift-givers, which is their promoters what some may argue still is an over-saturation that possibly does not completely correlate with the most efficient method to maximize their profits.
As a big pharma ex drug rep for over a decade, which, by the way, the number of drug reps tripled, a drug rep’s vocation has become more ridiculous, and possibly void of any true sense of accomplishment due to their customers preventing them from following the directives of their employer, which is to influence their prescribing habits via direct dialogue. The job has become an objective of doing lunches and leaving samples at offices, for the most part. My objective perception formed from my own analysis of how drug reps operate in today’s environment in the medical community.
So they may be named at times in different ways, these promoters will be referred to now only as drug reps, which number close to 100,000 in the U.S. presently, it is believed, yet is probably less now due to big pharma cutting thousands of reps recently. The cost to the pharmaceutical industry of these drug reps is around 5 billion dollars a year. Income for each rep grosses close to or above 100,000 grand a year on average, along with great benefits and a company car, as well as stock options as they gladly work from their homes and set their own hours, which I understand is much less than 8 a day.
The main function these days of drug reps, I believe, is primarily to offer doctors various types of inducements of a certain value. The drug sampling of doctors may be considered an inducement, and a rather valuable one for the drug rep, as many believe that these samples are what ultimately influence the doctor’s prescribing habits over anything else, including statements from drug reps. This may be why the drug industry spends around 20 billion every year on samples. Yet I want to be clear on what I am saying: drug reps are some of the smartest people you will meet that do in fact have great paying jobs with great benefits. Most importantly and my opinion, I believe most reps really WANT to do well for their employers, yet are prohibited from doing so.
Many years ago, drug reps have used their persuasive, yet ethical, abilities to influence the prescribing habits of doctors in an honest and ethical manner, as they focused on the benefits for the doctor’s patients with a particular drug. However presently, most health care providers now simply prevent drug reps to speak with them- now this is especially true when they are in clinic treating and assessing patients. More and more medical establishments are completely banning drug reps from their locations, and I speculate that this is occurring for many reasons, which may include the following:
The doctors lose money. Doctors are normally busy, so their time is valuable. As a drug rep, you are a waste of their time. Yet they will accept your samples still. The credibility you possibly have as a drug rep is no longer viewed to exist by the prescriber. For example and this is based on my experience and my colleagues concurring with me, doctors view any information you may provide to them as biased and embellished. In my opinion, based on information and belief, their view is accurate due to the statistical gymnastics the employers of drug reps engage in, which effectively and ultimately is permitting and encouraging the drug reps to lie to the doctor- possibly due to their denial that most doctors by their very nature seek answers objectively. And doctors do in fact find out about drugs through other methods besides the representative of the drug’s maker, such as the internet. Most drug reps in this country in particular mostly hire drug reps based on such qualities as the candidate’s looks as well as their personality, overall.
Furthermore, it is possible that pharmaceutical companies desire their drug reps to be obedient and to not question what is asked of them. Upon speculation, this can be possibly determined by the background of the candidate, which may indicate they seek popularity as well as are money driven. In addition, most drug reps do not have degrees remotely related to any aspect of anything of a scientific or clinical nature.
During my decade as a drug rep, I would encounter another rep that may have been a nurse or researcher, yet this type of training is rare for a drug rep. In fact, based on my opinion, many do not particularly care to acquire education related to such subjects. They learn the basics in order to sell their promoted products. Yet anyone who has ever worked with doctors in a clinical setting, or in a hospital working in a clinical nature, likely they would agree that a drug rep should want to and seek all related to the complexities involved in the restoration of another’s health.
Many drug reps, it is believed, are void of any complete, and I believe what are necessary, ethical considerations due to their possible deliberate ignorance created by the necessity of what they are required to say or do by their employers. This allows them with encouragement and coercion of their employer to embellish the benefits of their promoted products at times in addition to offering inducements to doctors in various ways- most of all of which are rather covert, yet performed and issued to select prescribers upon instruction of their employer. Examples may be creating a check from your company to a certain supporter of your company’s products for doing little if anything for your employer. Or tangible items are given to such prescribers, such as TVs or DVDs which may or may not be utilized in a particular doctor’s office.
From the drug rep’s perspective, it is unlikely they will even consider the possibility to question their pharmaceutical employer due to the great risk of losing income and benefits that they are unlikely to acquire at another place of employment. Because of their consistent and conscious effort to keep their high-paying jobs, the drug reps are always anxious to please their superiors, regardless of any ethics or legalities regarding any activity they may be required to perform. With big pharma in particular, each drug rep is given a variety of budgets, such as a chunk of cash for doctor office lunches that they are required to spend in a certain period of time. Another chunk of cash may be assigned to a rep to pay assigned or registered speakers of their employer to speak to other prescribers about a disease state related to the drug rep’s promoted product. These activities, in my time with big pharma, were never monitored or questioned by managers or superiors. What I did notice is that my annual raises were greater than others according to the amount I spent for that particular year, as this, according to a big pharma company, was a very objective and noticeable variable with my employment in big pharma.
While legally risky, the drug companies continue to dispense to their reps these large budgets their drug reps are in effect coerced to dispense with complete autonomy and possibly the spending can be fabricated, which is too complicated to fully explain. This design perhaps is why there are now various state and federal disclosure laws are presently being considered to mandate the release of all funds dispensed from pharmaceutical companies as far as why a company’s funds were spent, and in what method. Because, according to the lobbyists of pharma companies, they consistently insist that whatever they spend always is for the benefit of public health. As mentioned earlier, presently such activities are quite covert. Yet if such laws are mandated, it is likely the accounting of pharma companies will become rather creative and incomplete. In summary, as a big pharma drug rep, my budgets were unlimited, and I typically spent more than I made though the activities I have mentioned so far. And this is not an isolated case.
Another issue is what is referred to as data mining. The American Medical Association sells this prescribing data on individual doctors to pharmaceutical companies or pharmacies, by providing others identifying numbers of a particular doctor, such as a state license number or DEA number, which allows them to track the scripts a doctor writes not far from real time availability. This data shows the volume of scripts of a particular doctor and what the doctor has been prescribing for the doctor’s patient for their disease state, and this data reveals competitor products to the drug rep as well. Aside from being deceiving and dishonest, the data allows a pharma company to ‘reward’ those doctors who support their products, while treating the other doctors with ‘neglect’, which means the non-supporters of a pharma company will not receive any inducement or remuneration from a particular pharma company. The data, by the way, only reflects numbers linked with particular products, and fortunately is free of patient names- this data that is provided to all drug reps. What has been described is the method typical with all big pharma companies, in my opinion, and I worked for three of them. It appears to be manipulative in a psychological paradigm- a combination of Pavlovian responses combined with positive and negative reinforcement.
So such methods create a toxic culture required to be absorbed by those members of such a pharma company. Furthermore, the tactics implemented by pharma companies vacuum the judgment of prescribers, which may prevent patients from receiving objective treatment. Yet on the most basic level, it is the samples left with prescribers that ultimately determine their prescribing habits- with various inducements to some doctors running close in second place. Yet remarkably, prescribers are prescribing more and more generics, which typically are not sampled to prescribers. I find this comforting that the manipulation efforts of the pharma industry are not as effective as they believe they are in a rather delusional way. Yet what is happening now in regards of branded meds vs. generic meds, insurance companies are flat out paying doctors to switch patients to a generic if one is available, as well as initiating generic medication treatment for their patients. I speculate they are paying doctors for this as a response of what pharma has been doing for quite a long time. From a clinical paradigm, if a medication is providing desired treatment and good tolerability for a particular patient, one could argue it would be unethical to switch treatment for financial gain, further complicated by the fact that most patients are aware that insurance company payments to doctors for this even occur.
It is likely and I believe that most drug reps are good and intelligent people who unfortunately are coerced to do things that may be considered corruptive to others in order to maintain their employment. In other words, the drug reps have compromised their integrity, ultimately.
It seems that external regulation is necessary to prevent the drug companies from allowing the autonomy of drug reps that exists, with their encouragement, which forces the reps to do the wrong thing for the medical community, possibly. Because it is obvious that internal controls with such corporations exist on paper often, but clearly are discouraged to be enforced. It is possible that these pharma companies falsely believe that being an ethical company would make them a company without excess profit. One can only speculate on their true motives. Yet it appears that overt greed has replaced ethics with this element of the health care system, which is the pharmaceutical industry, as illustrated with what occurs within these companies. However, reversing this misguided focus of drug companies is not impossible if the right action is taken for the benefit of public health. Likely, if there are no drug reps, there is no one to employ such tactics mentioned earlier. Because authentically educating doctors does not appear to be the reason for their vocation. This is far from being the responsibility of a pharmaceutical sales representative. Perhaps most frightening is that most drug reps fail to dig deep enough to realize that what they do at times may damage public health.
“What you don’t do can be a destructive force.” — Eleanor Roosevelt
Dan Abshear
Author’s note: What has been written was based upon information and belief.
Info
Good point about using generics. A doctor at the Dartmouth Medical School published a prescription drug survival guide for lower income patients. Take a look here: http://www.dartmouth.edu/~cardio/Patients/survivalguide.html

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