Is your physician immune to drug marketing?

You’re at the doctor’s office, and you see strolling up to the window a good-looking, well-dressed professional. They’re usually pulling a little discreet cart, and after a few words with the receptionist they’re rushed right back. Sometimes they’ll bring a tray of cookies, or they’ll be followed by a caterer with a cartful of food.

You think they had an appointment? No, but you can be they’re here to see the doctor.

Take a look at this wonderful – and very dismaying — article from PLOS Medicine, written by a physician and a former pharmaceutical sales rep. The practice of detailing, or in-person visits to doctors ostensibly to provide medical information on the latest pharmaceutical products, is a many-billion-dollar industry aimed at making sure your physicians prescribe what the industry wants them to prescribe. Hint: it’s the newest medicines with the biggest profit margins.

So what if the newest medicines aren’t the best for you?

You really ought to read the article. Summarizing it just won’t do it justice. You’ll see what specific techniques the reps use, and how they get the data they need to influence the doctors they’re pretending to befriend. I’ll just post one quote that sums it up:

“While it’s the doctors’ job to treat patients and not to justify their actions, it’s my job to constantly sway the doctors. It’s a job I’m paid and trained to do. Doctors are neither trained nor paid to negotiate. Most of the time they don’t even realize that’s what they’re doing …”

I’ll tell you that when the subject of drug reps comes up among doctors, most are offended by the very idea that we’re being manipulated. We think we’re far too smart for that — a bagel and smile isn’t going to change what we do. All those years of training insulate us from the effects of crass marketing, right?

Look, if it didn’t work, they wouldn’t spend billions doing it.

At my office, we have a strict policy: the reps drop off samples, and that’s it. No talking to docs, no food, no gifts allowed. I’d rather honestly go without the samples, but some families really do need them. Perhaps even allowing that is allowing the reps to go too far. I know I’m not immune. Is your physician?

Roy Benaroch is a pediatrician who blogs at The Pediatric Insider. He is also the author of Solving Health and Behavioral Problems from Birth through Preschool: A Parent’s Guide and A Guide to Getting the Best Health Care for Your Child.

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  • Shirie Leng, MD

    I tell my residents: Never take anything from any drug company or representative. Just don’t do it.

    • guest

      True but if they are online with Sermo or other similar chatrooms they are being manipulated as well.

    • Suzi Q 38

      Wise advice.

  • guest

    What’s also interesting about pharmaceutical companies is the way they use doctor related chat rooms such as Sermo to test the opinions of doctors and read in realtime what a doctor is saying about their drug. They initiate discussions about drugs to get feedback. Easier for the drug reps who don’t have to go to doctor offices anymore to get inside info. When I first looked at these sites I was thinking of joining myself. Then , I realized that these sites while alluring in many ways are like Facebook. The doctor is not the customer, The doctor is the object for marketing purposes and their responses are analyzed in real time often by pharmaceutical reps. All legal of course.
    I can’t figure out why physicians join when they make it clear that the site is for business purposes. Anyone have thoughts on that or if you are a member does this part bother you or do you feel you get more out of it it so it is a gain for you? Would love to hear feedback. Not sure if docs don’t care or don’t think about it like many don’t think about Facebook. In fact this is a quote from Sermo.

    “Our physicians are discussing your products.
    Take the pulse of our community with access to the Sermo Client Center. An intuitive dashboard interface gives you a looking glass into what physicians are saying about your brand and other topics on your radar.”

    • http://www.pediatricinsider.com/ Roy Benaroch MD

      I don’t participate on Sermo, but I believe they compensate (that’s a euphemism for “pay”) docs to participate, or to do surveys and such.

      • guest

        Oh thanks. I was wondering about that. Can’t figure out how that company could be so successful because it relies on doctors to participate. How much is the pay? hard to believe that it could be worth the time to get peanuts for their questions.

        • http://onhealthtech.blogspot.com Margalit Gur-Arie

          It’s like a peep show. While the performers get paid a little bit for certain acts, the establishment rakes in the big bucks for orchestrating the performance.

          • guest

            oh I meant I wonder why it;s worth the physicians time and money. You are right but as you point out it takes the physicians to keep this circus act going. Why would they do that for a few hundred here or there? I would think ethics might come first before a few hundred dollars–unless there are thousands and thousands paid which also seems unethical. But at least they know outright they are being used. To be honest this may be in place of the free drug lunches.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            They do that because we are all social animals and we enjoy being part of a community that reinforces our opinions on things, particularly when we are unhappy and frustrated and powerless to change our situation and we feel that the world at large is not listening to us.
            It’s not that difficult to ignore the observers on the other side of the glass wall. Other less fortunate animals in zoos and labs do it all the time….

            I would suggest to Sermo guys that they should switch to Kevin’s blog/forum :-) . You get the same satisfaction without the surveillance and bribery….

          • guest

            yeah i find it creepy when you know how it is being used. But I guess Sermo would not be Sermo without the immense funding it gets from big pharma

          • Guest

            I signed up and briefly participated in Sermo. It was free. It was fun at first, but then I came to reaffirm what I had always known: doctors are a bunch of bullies. What started as a reasonable arena to discuss difficult cases and ask medical questions became a sideshow of smack downs and opportunities to belittle. No thanks.

            I didn’t realize the forum was being manipulated and monitored.

          • guest

            Oh that sounds like medical school all over again. Appreciate a lot your commenting. I had thought about joining but when I read about how it was run I was kind of horrified. Seems unethical to me and i wondered if most docs that joined were not aware of how it was being used in real time for Big Pharma to data mine.

            Was it simply to discuss drugs or go over cases for each specialty? How do they frame it to the physicians to make them want to join? I am mystified by it to be honest. So I did not feel like joining in. And now I am forewarned. Thanks. Sorry you had that experience.

    • Tiredoc

      I don’t do surveys because they’re boring.

      Sermo is a way for pharmaceutical companies to get around their compliance agreements about off-label prescription promotion.

      For a drug to be a hit, it has to be used for more than its initial FDA indication. The only way for those uses to get out now that drug reps are barred from discussing them by their companies is physician to physician communication.

      Some physicians use drugs only according to their FDA approved indications. Other physicians prefer to prescribe according to the mechanism of action and their clinical experience.

      Sermo is of no use to the former. Is some use to the latter.

      • guest

        Appreciate that Tiredoc. Makes a bit more sense. So when docs talk to each other off label it is a legal way of promoting off label use even though it is basically being managed and PAID for by Big Pharma.
        I give it to these market strategists to come up with this stuff. Kind of brilliant getting around the off label restrictions you mentioned.
        I still am a bit baffled what the interest is for the physician in all of this. Knowing that this is their game why would any doc want to participate? Truly is baffling to me. To discuss off label uses with another doc online? Just sounds bizarre.

        • Tiredoc

          Sometimes a new drug comes out that’s the first in its class. Sometimes the class has a lot of promise hyped in the literature. Docs jump on the bandwagon and try it on everything they can think of that’s possibly related.

          Then, they get all of the weird unforeseen side effects and problems and failures. I don’t like to prescribe medications the first year or two that they have been released. Then all of that’s out there in the blogosphere.

          The off-label stuff comes 4 or 5 years after the introduction of the drug, when experience allows doctors to better predict how individual patients react to a drug.

          In my experience, new drugs are rarely rewarding to start based on the indication. Patient populations generally don’t resemble the study populations and their medication profiles certainly don’t. Unless you talk to other doctors prescribing the drug, you’re stuck with your own personal study of n less than 10. If you do that, you’re just as likely to toss out a new drug that you should have kept than find a new drug that works.

          • guest

            but do you notice that the FDA seems to be pushing new things out much more quickly than before? Before Europe would try drugs out for years before it got to us. Now it seems like it’s pretty much the same time frame. Seems like a lot more unforeseen SE occur these days becuase of that, than those of say 20 years ago.

          • Tiredoc

            It’s more like the European regulators are becoming as paranoid as the American ones. There isn’t any difference in the number of unforeseen side effects, there’s a difference in the response. The fact is that FDA safety studies are for n of 10k for a few years. You’re not going to find a side effect on the medication that occurs more frequently than 1 in about 4000 with that number. That’s why I wait a year or two before prescribing a new drug. There has to be a balance between side effect cost and lost opportunity cost. We need more drugs with different mechanisms of action, not the tenth drug of the same class.

          • guest

            that makes sense. I guess my understanding was that in the 70′s and 80′s that most European drugs were on their market for 10-15 years before they came here so that we could say(FDA)with more confidence that it was safe. It seems like that has changed. Maybe as you say the regulators in Europe are more paranoid now. Just notice many more frequent recalls in US now than then. But sounds like a good idea not to jump on the bandwagon with your pts until the drug is more vetted.

        • Tiredoc

          Off-label usage isn’t illegal. Promoting off-label usage isn’t illegal either. It has been ruled as protected speech under the first amendment.

          Big Pharma has voluntarily accepted restrictions in order to maintain its ability to set payment rates for its drugs with HHS. It has also accepted “fines” for the same reason.

          Big Pharma is certainly the biggest pig at the trough, but it’s still just a pig. If you want to change the system, you have to change the farmer.

          • guest

            OK This is news to me. So the lawsuit was that they violated their agreement to have these restrictions so they can keep their lucrative contract going with HHS. Cogs within cogs. or is that hogs?

          • Tiredoc

            Hogs is correct.

          • guest

            LOL!

          • Tiredoc

            You’re operating under the assumption that the government wants Big Pharma to stop promoting off-label use. They don’t.

            Think of the fines as indirect taxation to support government plutocrats. Big Pharma and the HHS set the rates, giving the government a “discount” for the drugs they buy. At the same time they prevent competition against their pet companies. Every few years there is a voluntary shearing off of Big Pharma to keep the states from going totally bankrupt and dumping Medicaid entirely.

            Think of Boeing. Boeing is investigated every single generation for bribery and kickbacks. Every generation the investigations bear fruit, with high profile mid level heads rolling. And every generation Boeing kills off another competitor.

            Big Pharma operates like Boeing, because if you do business with the government, normal rules don’t apply.

          • guest

            Every few years there is a voluntary shearing off of Big Pharma to keep the states from going totally bankrupt and dumping Medicaid entirely.

            What does that mean? Sorry to be so dense. I guess what you are saying above is the govt is actually fostering with whether Boeing or Big Pharma in killing off the competition?

          • Tiredoc

            All of Big Pharma has paid out multi-billion dollar “settlements” to state Medicaid budgets, ostensibly to punish them for off-label marketing. When a smaller pharmaceutical company took the OIG to court, the OIG lost and didn’t appeal.

            Boeing is investigated, and fined, and then given the government contacts. Big Pharma is investigatd, and then fined, and then their drug beats their competitor’s to market by two years. And the congressman and senator on the committee “investigating” know months in advance of the approval process. Plenty of time to buy or sell stock.

            Just in case you’re wondering, it isn’t illegal for Congress to trade on information.

          • https://www.facebook.com/arobert6 Alice Robertson

            Yes, inside trading is still legal and the Stock Act was quietly overhauled by the same traders who don’t police themselves very well but leave office often wildly more wealthy than when they went in. Our reps also sell inside committee information to hedge funders.

            But another thing to add is that a few years before a drug will go generic BigPharma will triple + the price just to make sure they make more and more money on that drug. The chart is in Consumer Reports from about a year. You see a drug that was $200 a month easily go up to $400 a month the two years before they lose control of it.

            But this is how the free market works, yet it’s flustering to do an act like this where there are rarely options to take a cheaper drug until that time period is up and the cost comes down. And getting the government involvement will make it worse. Problem is our electedofficials seem pretty highly vested in BigPharma too. And sadly some physician colleagues running the FDA know where their future jobs are….with BigPharma and sometimes their records aren’t so stellar as you can see that they helped approve drugs for the very company that will make them tons more money once they get their government pension in order and move on to the private sector.

          • Tiredoc

            The FDA is always looking for MDs. A full time FDA physician regulator starts as a GS13. With the 25% pay added for working in D.C. that’s 90K. The maximum salary of a senior MD GS15 regulator is 162K, including the D.C. bonus.

            So, the maximum salary for an FDA regulator is less than the average salary for the lowest paid MD specialty. Kind of makes you wonder what kind of MD signs up for the gig, doesn’t it?

            It certainly isn’t because of patient care, the FDA doesn’t see patients. It isn’t because of government job security, the VA pays better than that and has better hours. It isn’t for the fabulous location or the low stress work environment.

            I honestly can’t think of a single reason why any doctor would want the job.

          • https://www.facebook.com/arobert6 Alice Robertson

            Really? I can! Haven’t you read about the FDA docs who are making $250,000 and then going to BigPharma and making over $2 million a year. The same BigPharma they approved meds for before moving on (i.e.getting their bureaucratic pension in line then going private).

            I guess I sorta assumed all doctors knew this stuff. It’s over at Forbes.

          • Tiredoc

            Sorry. I meant I can’t think of a single reason why a REAL doctor would want the job.

          • guest

            Good old Us of A! Wonder if any of them thought of selling Hallmark cards. Just warms the heart.

    • karen3

      Pharma works hard to infiltrate the patient groups. they also create fake “patient support” groups that are subtle ways to sell. It’s quite disturbing.

      • guest

        this is new to me. are we talking sermo or something else with fake pt groups?

  • guest

    good point. It is legal for Big Pharma to pay off their generic competitors to NOT produce generic drugs. The Big Pharma companies have been implicated in the generic drug shortages. Yes there are still shortages just better manipulated. And in the NY Times recent editorial a group of pharmacists and docs wrote an editorial that is interesting to read–eye opening as a matter of fact. THey also related the fungal steroid compound pharmacy fiasco with the shortage driving clinics to buy from compound pharmacies because of the shortage.

  • Tiredoc

    So, it’s OK for the Feds, the States and the insurance companies to tell you how to practice, but when a salesman shows up at your door with a bagel some ethical line is crossed?

    As I see it, Big Pharma pays their share. They have to feed the FDA beast, and all of the unconstitutional “fines” in the billions to fund our bloated Medicaid budget.

    Shut up and eat your bagel. You might learn something. Some of the new drugs are actually useful.

    • guest

      I guess the difference is that when the Insurance or Feds and State tell you how to practice it is usually adversarial but it is transparent. When the Big Pharma does there thing it is clearly all manipulative. It is true they deal with the FDA but I think they can now lobby their way through that pretty easlly. I don’t feel Big Pharma pays their share. THey pay generic competitors NOT to make their drugs and that’s legal. They get any amount they ask for from medicare. Imagine selling your drugs at whatever cost you set. I guess I am not a fan. What can I say?

      • Tiredoc

        I am not a fan on big Pharma, but I realize that the source of the problem is the FDA. Unless you’re happy with the medications we have, there’s no other way to get new medications other than slogging through the regulatory process.

        According to Medicare, Medicaid and Blue Cross, my generic prescription rate is 95%. This is 2 standard deviations above the mean for my specialty. The cost of the prescriptions that I write is 3 standard deviations below the mean for my specialty.

        The branded medications that I commonly write are Colcrys, Uloric, Victoza, Tekturna and Metanx. With the exception of Colcrys, the first I heard of the medications was through drug reps. The reason that I use them is one of three possibilities. They either are more powerful than any other drug in their class, better tolerated than any other drug in their class, or have no generic medication in their class.

        I don’t go to dinners, and I hardly ever start patients with samples. (I figure that the worst possible thing to do is give a patient a medication that works spectacularly well that they can’t afford. That’s just cruel.). I find drug reps more transparent than just about any other player in this business. They always say who they are and why they’re there.

        By the way, who Big Pharma sends you says a lot about who they think you are. If all you have call on you are 25 year old females in short skirts, it says more about you than about the drug company. My drug reps are in their 40s, come in suits and can actually talk about their drugs.

        • guest

          OK but here is an example of something that seems rather shady to me. Sorry I just copied this since I was too lazy to write it out.

          “Oral colchicine had been used for many years as an unapproved drug with no prescribing information, dosage recommendations, or drug interaction warnings approved by the U.S. Food and Drug Administration (FDA).[8] On July 30, 2009 the FDA approved colchicine as a monotherapy for the treatment of three different indications (familial Mediterranean fever, acute gout flares, and for the prophylaxis of gout flares[8]), and gave URL Pharma a three-year marketing exclusivity agreement[9] in exchange for URL Pharma doing 17 new studies and investing $100 million into the product, of which $45 million went to the FDA for the application fee. URL Pharma raised the price from $0.09 per tablet to $4.85, and the FDA removed the older unapproved colchicine from the market in October 2010 both in oral and IV form, but gave pharmacies the opportunity to buy up the older unapproved colchicine.[10] Colchicine in combination withprobenecid has been FDA approved prior to 1982.[9]“

          • Tiredoc

            Colchicine is the oldest known medication. This one’s entirely o. The FDA. They shopped it around for years until they got a generic company to do their research. The entire concept of granting a patent for colchicine was purely an abuse by the regulators.

          • guest

            Well I guess I was thinking that there is funny business going on here–not just the FDA. I am doubting the FDA just came up with this out of a hat? There must be a lot of lobbying and manipulation by Big Pharma here that is kept secretive so its hard to make sense out of it. What do you think?
            But at the very least, I agree that the FDA regulators are no longer doing their job. Which makes me wonder if they have been bought off and cannot really be trusted anymore to keep the public safe. Maybe a stretch but it seems like the fox watching the henhouse at this point. At the very least poor gout pts might be out of their meds for a long while due to excessive cost. Did anyone complain about this at the time or was it in the news?

          • Tiredoc

            The FDA really did come up with this on their own. (Bush 42 appointee and plan, so stupidity is bipartisan.). Plan was to get all legacy drugs that existed prior to the existence of the FDA drug approval process approved. It’s what killed all of the “kitchen sink” children’s medications.

            Oddly enough, Colchine is probably the only drug to get a useful study out of the blatant rip-off of the American public. Turns out the old give-em-colchicine until they have diarrhea isn’t either the best or safest way. It actually works just fine once or twice a day and can be given prophylactically.

            The FDA truly has a thankless and impossible job that they perform. It’s one of the government organizations that gets press only when they screw up, even when the screw up couldn’t possibly have been averted given the statistics involved.

            The FDA is not capable of determining effective, and isn’t capable of determining safe. They should be given the task of determining safe enough. Put a warning label for the first 2 years and limit liability, and make it clear that anyone who takes it is a guinea pig for the n = 1,000,000 study.

          • guest

            That is a great idea. Seems like everyone expects the FDA to take on the full risk. Most people think as if like children that if anything goes wrong that they can sue and that once the FDA approves it, that it is vetted to be safe. But your idea is brilliant to give people the idea take at your own risk.

          • Tiredoc

            Thx. Chances of getting it done: 0. (Even if you limited price per pill to 2 dollars for the first 2 years).

            Wasn’t Bush’s idea. It’s the current obsession with placebo-controlled double-blind trials. The accumulated weight of clinical experience counts for nothing right now. Sample bias doesn’t matter, just observer bias. Of course, double-blind placebo-controlled trials do require a lot of government monitors, and jobs are important, neh?

            Just in case you want a benchmark for stupidity, Colchicine is the oldest known medication. It predates opium. There are other drugs listed in ancient pharmacopeia, but we don’t really know what they are. Colchicine, we know. It’s over 2000 years old. And the FDA gave a patent for it.

          • guest

            That’s what I was looking for. I did not realize it was 2000 years old but I knew it was around for years. We talk about waste in healthcare dollars. But this does not sound like just stupidity to me. Some drug company probably bartered it for return of something? To be sure I have no idea but I just can’t believe this all came from a dumb bureaucrat.
            So you are saying there is more of a push for evidence based medicine and some sort of disbelief that clinical empirical data is not valid?
            My jaw drops. There is a cry about waste of healthcare money and they spend it on that?

            It’s funny on another post Dr. Drake brings up a study showing EMR’s are in a couple of words—not helpful to doctors. Now why do we need a study for this? Ask any doctor. They were never invited in to voice their opinion. ANd now we need a study? hasn’t anyone asked? I don’t think they care. All the powers that be are laughing on the way to the bank.( or online deposit). too aggravating for words.

          • Tiredoc

            The generic company sold the patent to Takeda, who’s been very nice about giving it away for free to cash pay patients.

            Since it’s the only drug in its class, (other than a ridiculously expensive cancer drug), the insurance companies all pay for it.

            So, we all pay an extra $0.65 on our monthly insurance premiums to pay for FDA’s study.

            I don’t know for sure, but I think the generic company sold the patent because they weren’t making that much money off of it. I believe the reason was, appropriately enough for this thread, that their sales force was incompetent.

          • guest

            Sounds like this whole fiasco or charade was incompetence at its best. WOuld have thought someone-even insurance would refuse to go along with this.

          • Tiredoc

            Insurance doesn’t have a choice. They have to follow the lead of HHS. It’s nothing compared to the great fleecing that was Metformin.

            Metformin was invented in the 1920s. It was first released in the U.K. in 1958. It was released in Canada in 1972. It was granted a patent for release in the United States in 1995. No one bothered to apply for a U.S. patent on the chemical until BMS did.

            So, American consumers paid billions to BMS to market a drug that BMS didn’t even invent or do the primary research on.

          • guest

            You should write a book. This is incredible. How did you find this out if I may ask?

            I was reading a book from an economist Joseph Stiglitz “The price of inequality” where he describes the term rent seeking which is not as it sounded.
            The example above came to mind for rent seeking as the example you gave before. Basically extraordinary amounts of money given to a product that’s value is much less. It is done by manipulating the social or political environment in which economic activities occur, rather than by creating new wealth.

            These examples as many others are why the GNP is at nearly 20 percent for healthcare. Meanwhile Big Pharm is getting much wealthier from these examples, while pts can’t afford drugs from 1920.

          • Tiredoc

            I found this out back in the 90s from a drug rep for Glucophage (Metformin). If you look at the history of diabetes treatment, it’s a sordid one. It goes in 10 year cycles, with each new drug coming out with fanfare explaining how awful the previous one was.

            First generation sulfonyureas in the 50′s, insulin the bad guy. Phenformin came out in the ’60s, with sulfonyureas the bad guy. Second-generation sulfonyureas in the ’70s, phenformin the bad guy. Long-acting insulin in the ’80s. Metformin for the ’90s, Thiazolidinediones in the ’00s. GLP-1 antagonists and DPP-4 antagonists, not with the push against the Thiazolidinediones.

            Now, lawyers have found out that diabetics have increased rates of all types of cancer, heart disease, dementia and everything else. I’m always getting patients coming in stopping one or another medication from the bad press put out by lawyer groups. I wouldn’t be surprised if the lawyer groups are actually fronts for the new big Pharma diabetes offerings.

            Big Pharma doesn’t just manipulate doctors. It manipulates the FDA, the press, the so-called “transparent” research with pre-determined outcomes based on sample selection.

          • guest

            You know I am wondering if Big Pharma manipulates so much they actually don’t know the truth from the lies either. How do you deal with these diabetes pts then? I mean I know your job is telling them risks vs. benefits but really there is no way for any doctor to realistically know. At that point you become a private investigator trying to sort out the truth. Pretty ridiculous and sad because in a way this behavior is holding back real medical progress.
            The most jaw dropping part of your post was the part about lawyer groups being a front for the new big Pharma diabetes offerings. If that is the case it is surprising that there is not better regulation for Big Pharma. The govt is spending their time on the sunshine act. Well maybe this is not surprising. I have been reading more and more about how Big pharma are creating a monopoly for their brands by for example paying off competitive generic drug companies to NOT produce. So I guess your thinking is probably spot on since it fits the model of playing dirty to get your monopoly. So incredible and so sad.

          • Tiredoc

            I just tell my patients that their chances of whatever bad thing happening because of the drug are less than their chances of bad things happening for not treating their diabetes. Plus, if the bad thing from the drug happens, they can always join the lawsuit against big Pharma.

            Not really. I just tell the patients that we need to treat their diabetes, and give them the target numbers. Get a few pounds off of them, make sure you don’t drain their energy dry and get their numbers on target. Most people will take gravel if you prove that it works for them.

            As for Big Pharma, I assume that anything good they say about their product is half true and nothing bad that they say about their competitors is true, especially if the competition is generic.

          • guest

            Sounds like one big game. Well you sound like a really nice doc and informative. i just find it unsettling the kinds of monopolies forming and complete misinformation. Makes it hard to trust when they play these kinds of games.

          • Tiredoc

            Thank you for the compliment. I use everything but sulfonyureas. With all of the insulins available if I want the patient to have more insulin, I give them insulin.

            There’s a story in the Old Testament that bears a relationship to medicine today. The Syrian General Naaman travels to see Elisha because he hears that Elisha can heal his leprosy. Elisha sends out a servant to tell him to go jump in the river 7 times. Naaman gets mad and is about to walk away, but Naaman’s servant tells him that it’s not like he was asked to do something hard. Naaman goes into the river and is of course healed.

            We spend most of our time in medicine telling people to do things that are tedious but not difficult. About half the time no matter what we say the patients don’t do what we tell them to do. When we finally get the combination of a patient and advice coming together, it feels like an act of God.

            Everything else in medicine feels like we’re in the river with the patient, only it’s not the muddy Jordan, it’s the Amazon, and no matter what we do both the patient and the doctor come out of the water covered in giant bloodsucking leeches.

          • guest

            Well your example is hilarious, Bloodsucking leeches. Does not sound like there is any cure for that one.
            But you seem more invested in your pts. Unfortunately that is not so true of many. Just curious are sulfonyureas dangerous or we just have better treatments now?

          • Tiredoc

            Nothing to do but pick them off before going back in.

            Sulfonyureas are appropriate for people who check their blood sugars regularly. I have a fair number of functionally illiterate patients that I can’t trust to be good diabetics. It’s more of a practice pattern than anything else. I’ll stack up every insulin sensitizer before considering sulfonyureas, and by that point it just makes more sense to start insulin.

          • guest

            thanks for the explanation. I guess the newer drugs are easier to use on non compliant folks. Well not sure if the newer med are better or just easier to use.

        • karen3

          FYI, tiredoc, pay attention to the new studies coming out on salsalate. 2 point drop in A1C for me. Nice and generic.

          • Tiredoc

            Thx. Looks interesting. Certainly cheaper than Victoza.

  • Suzi Q 38

    We gave all sorts of “promotional items” to physicians, nurses, pharmacists, and receptionists. I wish that I kept a few of them in a box.
    Some were interesting and downright useful and clever.

    We also provided food, lunches, dinners, AMA meeting trips, speakers (we paid them to speak at CME lunches and dinners). We also provided “as promotion” golf afternoons, candy, a case of wine, and a bottle of Whiskey. The latter group of promotional “gifts” were suggested by physicians and a pharm D at a rather large hospital.

    We handed out samples and advertising material.

    My sister was also a pharmaceutical rep for the company that sold Acutane. A physician is being sued, and the plaintiff’s attorneys had decided to subpoena all sales reps for a deposition.

    What they will ask, one only knows.

  • Jee

    Most physicians are sales people everyday with their business and their patients. So what is wrong with a sales representative influencing or selling his/her product to use for a disease state in an ethical fashion ? Many physician probably can’t devote the quality time to keep -up with many new drugs, much less the nuances of a particular patient population to use the medication in, or the dosages or side-effects. So what is wrong with influencing a doctor to use an FDA approved product if the representative gives an ethical and balanced presentation ( presenting both positive effects and negative side effects ) to a physician ? It is up to the physician through experience to choose which products work best for his patient population.

  • artful

    Not to worry so much about big PhRMA detailing in most doctors offices since almost all their drugs marketed over the last 20 years at prices twice those of other countries will be off patent in the next 2 years.

    What we all should worry about rather is that each of these will or have been available generically and now their are multiple generic products all with the same name many of which if not most of which are made in foreign countries just as the brand drugs are with insufficient or non-existent FDA inspections, even while they all are assigned NDC’s by the FDA.
    Meanwhile big PhRMA is busy marketing their biologic products on TV that also are half the price charged to the U.S. consumer than those in other countries where the older products are becoming available as generics while states are giving big PhRMA free reign to stop generic versions from taking sales away from their brands. So these manufacturers are only interested in a hand full of specialists who infuse these products in their offices and hospitals and of course state politicians to make only their products available even while Congress funded the FDA to check the new generics that Europe has already allowed.

  • drjoekosterich

    All valid points. Lets not forget the tainted research by academics and huge fees earned by specialists who set the medical agenda by which GPs are judged

  • karen3

    A really good way to get my blood boiling is to have been waiting in reception for 45 minutes, only to see some tight, short skirted chicky chick in impossible heels, bag in tow, get whisked in for a chat.

    And when the exam room is fully fitted with pharma handouts and gewgaws, I am not surprised when the doc is insistent that the only drug for me is something new, untested, and expensive.