Nurse practitioners and their relationships with pharma

Doctors have been under significant scrutiny over the years regarding their relationships with pharmaceutical companies.

Some states have even gone as far as banning events like drug company-sponsored dinners and other pharma-funded educational events. An increasing number of medical schools and hospitals simply won’t allow an industry presence.

Whether you think it’s gone too far is certainly debatable, but let’s look at another group which can prescribe medications and examine their relationship with the drug industry.

I’m talking about nurse practitioners.

There’s little question that, with the physician shortage, nurse practitioners and physician assistants will be relied upon to provide more patient care. Like doctors, they also have prescribing authority. And pharmaceutical companies have taken notice.

From the WSJ’s Health Blog, a study found the following interesting findings about nurse practitioner attitudes towards industry:

A full 96% said they have regular contact with pharma-industry reps, and 83% said the information they received was reliable. Almost everyone (96%) said they’d attended CME courses sponsored by industry, with 91% saying the information they received there was at least somewhat reliable.

Most (66%) reported giving out drug samples, said they were at least somewhat helpful in learning about new meds (73%) and acknowledged that samples encourage the prescription of new branded (and heavily marketed) drugs (62%).

As for the free meals, 49% reported attending lunch events in the past 6 months, and 64% said the same about dinner events. And 48% said they were then more likely to prescribe one of the drugs featured at these events. Almost all (90%) said it was acceptable to attend these sponsored meals and 75% said it was fine for a speaker appearing there to be paid by a pharma company. Most (61%) said it was fine for practices to accept small gifties and free meals from pharma companies.

NPs were asked if the free gifts distributed by sales reps had any effect on their likelihood of prescribing a certain drug; 93% said no.

With accountable care organizations upcoming, nurse practitioners will play a larger role in patient care, especially in the primary care setting. When it comes to relationships with the pharmaceutical industry, they need to come under the same scrutiny that physicians are subjected to.

 is an internal medicine physician and on the Board of Contributors at USA Today.  He is founder and editor of KevinMD.com, also on FacebookTwitterGoogle+, and LinkedIn.

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  • anonymous

    Thanks for calling attention to this. I think drug companies are counting on NPs and other non-MD prescribers as being the next gold mine, now that MDs are becoming more skeptical of their tactics. (Of course, we should have been skeptical all along, but that’s another story….)

    In fact, NPs may be even MORE impressionable than MDs because of their relative lack of formal medical training. I work with two psychiatric NPs and it is shocking (and frightening) how much of their knowledge about drugs– and even about psychiatric disease!– comes from the drug reps who visit our office.

    • http://abnormalfacies.wordpress.com/ Jim

      That was well-stated.

      As was the article, Dr. Pho.

  • http://www.kevinclauson.com Kevin Clauson

    Kevin,

    I continue to be surprised this topic hasn’t garnered more attention too. We published a similar study two years prior to the one cited in WSJ in which 92 nurses reported about the relationship between pharma and nurse practitioners/nurses with prescriptive authority. Those nurses reported concerns such as pharmaceuticai sales representatives (PSRs) failing to be sensitive about how their products affect patients (44%), PSRs being critical of competitors’ producs (87%), and PSRs inability to accept criticism (61%). Additionally, while the specifics were unclear, 33 of the 92 nurses stated they had been offered compensation in exchange for preferential prescribing (note: this was back in 2007). On balance, there were also a lot of positive views of PSRs by nurses and they clearly believed PSRs knowledgable about their products (88%), etc.

    As there continues to be minimal awareness about this topic, and nurses (and others) are viewed as physician-extenders and have/gain authority to prescribe, I imagine their importance to pharma will parallel that growth.

    Kevin

    Clauson KA, Khanfar NM, Polen HH, Gibson F. Nurse prescribers’ interactions with and perceptions of pharmaceutical sales representatives. J Clin Nurs. 2009 Jan;18(2):228-33

  • ninguem

    When I get credentialed for insurance, there is great concern over my hospital admitting privileges, over my after-hours availability, handicapped access, parking lots, on and on.

    The same insurers don’t seem to care when credentialing free-standing clinics run by midlevels.

    So, not surprised at all. The double standard has been going on for some time.

    • pj

      Excellent points- I presume the overseeing Docs of these midlevels are subjected to as much scrutiny as are you. If not, someone needs to start filing lawsuits….

  • http://drpullen.com medical blog

    You can add PAs to this list too. At our practice I find PAs and NPs more prone to reach for samples than physicians.

    • maria

      Perhaps that’s because they’re more sensitive to the insurance and socioeconomic issues of their patients than the MDs. And, incidentally, all six of the doctors I work with use far more samples than I ( a PA) do.

  • ninguem

    Seems to me, the drug companies would be better off consolidating their effort and bribe the administrators.

    Then the administrators can just order everyone to use their product.

  • IndiePsychNP

    I think the pro-Pharma inculcation starts before licensure. I went to a well respected Ivy BSN to MSN program which allowed absolutely no pharma sponsorship of any student or school events. While 2 buildings down there multiple events per week: luncheons wine and cheese events, a rock band once came all sponsored by different pharmaceutical companies. And while docs like to shudder at how under educated we NPs are (really it’s a miracle the morgues are littered with our unwitting victims to hear many of the posts to KevinMD) perhaps the solution would be to cut lose with federal funding for nursing schools and practicum placements like federal dollars are given for MDs to train.
    Most of my posts are ignored on KevinMD, because, I think it is easier to demean a whole profession than to engage in ideas to remedy what some members in the doc community see as the great defecits of NPs. Regardless of whether MDs on this site want to engage this idea, we NPs will just keep taking care of patients and having great patient outcomes. Check those studies in JAMA.

  • http://www.ehrrx.com Andre MD

    What ultimately counts is treatment outcome, which should generally be based on knowledge and experience. Perks (call them whatever you wish) are designed to influence behavior, hence treatment. Self-reporting is known to be flawed; unfortunately we don’t know ourselves very well. Corporations are profit driven and will engage in any behavior suited to advance their goals. If perks didn’t work, there wouldn’t be any. You do the math.

  • Dave Mittman, PA

    I have to tell you that you physicians are amazing. The pharmaceutical industry found that it could totally manipulate physicians and spent the last 50 years (remember Valium guys…) and billions of dollars doing it. They gave frequent flyer miles to docs for prescribing their products. Now we come to NPs and PAs and you are all SURE that we are more gullible than you were and more prone to be taken up by their “sales pitch”. I for one am not sure. Your track record is not stellar. Look in the mirror.
    But put US down you must.
    Shame on you. Let’s work together.
    Dave

    • ninguem

      Is there a physician here who’s ever been offered a frequent flyer mile? I haven’t seen it in 25 years practice. I wish I’d been practicing in these places where the drug companies gave these vacations and all the things I always hear about.

    • pj

      I’ve never heard of it happening either.

  • Kimberly Spering, MSN, CRNP

    Interesting commentary. I feel physicians may be JUST as “gullible,” IMHO.

    In my office, we have NO drug reps stopping by for lunches, advisement, etc. They drop off samples if they wish, get their signatures, and leave. This policy has been in place for over two years. Do we get less samples as a result? Probably. Have my collaborating physician and I stuck to our commitment to use generics whenever possible? Yes.

    Please…if you want to focus on NPs and drug rep influence in your little article, go ahead. However, please be fair and note all of the other previous research which points our pharmaceutical influence on PHYSICIANS as well.

    Kimberly Spering, MSN, CRNP, FNP-B.C.

  • http://barkingdoc.com maggie kozel, MD

    Pharmaceutical companies are expert at marketing, and spend hundreds of millions of dollars on it. They do things because they work. They peddled directly to physicians because it worked. For years, physicians insisted that they were not influenced by reps but studies showed proved us wrong. It sounds like nurse practitioners are now having a similar experience. I bet their learning curve will be shorter as a result of the realities physicians have come to acknowledge about our own vulnerabilities to marketing.
    Pharma has adjusted as well, with much more marketing directly to consumers, bypassing the providers all together. Again, they know what works.

  • http://www.BocaConciergeDoc.com Steven Reznick MD

    Its an individual thing. We are professionals and some will research a product and prescribe based on the data and others will rely on the pharmaceutical ads, meetings and representatives. This is not a physician vs. NP vs PA issue. I agree with Kevin in a thought provoking piece that the scrutiny must be profession wide and include the same scrutiny of all practicing irrespective of the letters after their name.

  • Edward Mathes, PA-C

    Funny how, in 30 years of practice, I have yet to do even 9 holes of golf. Certainly not making any kickback money using certain catheters/prosthesis/etc. Really can’t refer to the pen in my pocket for drug selection advice. How about a cruise or Disney? Never offered.

    I like to think I’ve never been influenced by a drug rep…..

    I have been to a few dinners. Even allowed lunch to be catered in to the office. I have several friends who are pharm reps, although many are now pursuing “other careers” due to Pharma and cutbacks….. Note, drug prices aren’t down…. But that’s a different discussion.

    What’s the saying? “He who is without guilt can cast the first stone”. My response, “Physician, heal thyself” first. Police your own. Also, consider the patient who comes in and demand samples.

    In my (old) practice, it was the physicians who reached for the samples more often than the PAs.

    Are we (PAs, MDs and NPs) ever going to get along? Our Focus on the patient.

    Ed

  • RD

    I am a nurse practitioner. The ONLY reason I ever have contact with drug reps is because my collaborating physician has contact and we have the occasional office lunch. I’ll listen to the schpiel but my utmost concern is always for the patient, not the rep and I will make my own decision based on research, efficacy and affordability.

  • doctor

    The saying to remember is , “What’s good for the goose…”
    Frankly, the most gullible seem to be the front office workers and medical assistants. They seem to attend all the dinners. I would also be cautious about all the studies that purport to show all prescribers are very susceptible to sales tactics. They are usually sponsored by big pharma as well.

  • http://Outlook Deb Pittman (DP aprn$

    I have been practicing for over 13 yrs in outpt mental health. I started at the tailend of pharmaceutical co freedom. My prescribing principles have always been pt focused in spite of programs and meals in the past. I have witnessed obsene abuse of pharm goodies in the medical community as well as no pharm favors policies. An ethical prescriber remains true to principles with or without lunch. In Mass generics are by law first line and justification is necessary for namebrand. I go through the paperwork if it will benefit my pt and my reps are aware of this upon meeting me.

  • K. ANP-BC

    I think this discussion is quite biased. I have to say that in 33 years in nursing and the last 3 as a NP, I do not think a salad or a pen ( when they were allowed) can MAKE me prescribe a particular medication. My attendings give out more samples than I do & the ones I give out are to those economically disadvantaged people we see, so they get the same quality of care as those with insurance. Can all you MD’s say the same? I do attend some educational sessions, to see what research is presented and then I look at scholarly research to see what the science has to say about a product. Isn’t that what evidence based practice is about? Educational sessions give us a bite of information, it is up to us to do the rest and use the information garnered to do what is correct for each patient.

  • Randall Sexton

    Funny, today during a staff meeting a physician passed out pens from a Geodon rep!

    Right now I’m reading a book titled, “The Use and Misuse of Psychiatric Drugs: An evidence-based critique. I recommend it.

    I have no contact with drug reps.

  • IndiePsychNP

    Great comments. It is interesting that we prescribers are carrying on this ethical discourse (which is good) while the truly alarming pharma practice of direct to patient advertising goes on with very few checks here and there. The argument can be made that prescribers are persuadable, however, without a doubt patients want to feel better and have every reason to believe the Madison Avenue TV commercials. (But I think they can be dissuaded by “explosive diarrhea”.)
    Given our shared experiences of “bankruptcy by Medicare”, “starvation secondary to student loans” and guilt vs. martyrdom with so many patients who can’t pay their bills right now, perhaps we should work together. Health care reforms has highlighted that we are all just widgets to private and Federal insurance companies. I predict that once the wave of retiring providers subsides, we will unite and refuse to accept our designated roles as “widgets with hearts of gold”.

  • PAULMD

    @IndiePsychNP,
    Very well said.

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