The Company We Keep: Why Physicians Should Refuse to See Pharmaceutical Representatives

Abstract

Whether physicians ought to interact with pharmaceutical sales representatives (reps) is a question worthy of careful ethical analysis. The issue presents a challenge to both professional integrity and time management. Empirical data suggest that interactions with pharmaceutical reps increase the chances that the physician will act contrary to duties owed to the patient. Ideally, a physician might both interact with reps and also do the research necessary to counteract the commercial bias in their messages. But a physician who actually did that research would, in turn, be devoting a good deal of time that might better be spent in other activities. The counterargument, that one is obligated to see representatives to obtain free samples to best serve one’s patients, can be shown in most practice settings not to be compelling. Physicians ought to refuse to visit with representatives as a matter of both professional integrity and sensible time management.

INTRODUCTION: A FANCIFUL ANALOGY

A majority of medical practitioners spend part of their time talking with and receiving gifts from pharmaceutical sales representatives (reps). Asked why they do so, most would initially be puzzled at the question. It is very likely that they have come to this place as a result of long-standing habit rather than conscious choice. Nonetheless, the decision to spend one’s time in this fashion has important ethical implications. I will offer an ethical analysis and approach the analysis by way of the following fanciful analogy.

Suppose I have an alcohol problem. Overall, I am making a fairly good recovery, but occasionally I fall off the wagon. In the past year, I have gotten drunk 4 times, each time while in the company of my friend Judy. Judy herself seldom drinks to excess; it is just that somehow, when I am in her company, I seem to lose the restraints that otherwise control my own drinking. Judy cheerfully rejects any suggestion that my drinking is her fault. I am an adult and can do what I like, she says.

I have many friends. Judy is not one of my closest friends, even though our acquaintance goes back a long way. Whatever I can do with Judy I could easily do with any number of other friends.

Now suppose that I say that I am deeply committed to remaining free of alcohol. Yet at the same time I insist that I will not give up seeing Judy and spending time in her company. How seriously do you take my protestations of yearning for sobriety?

This analogy may illuminate the ethical question of whether physicians should spend a portion of their time interacting with pharmaceutical reps. The more formal way of putting the argument is:

1. As a matter of professional integrity, I claim that I ought to behave in accord with certain principles.

2. Empirical evidence shows that I am highly likely to behave in ways contrary to my professional principles when I keep company with certain people.

3. My professional responsibilities do not require me to keep company with those people.

4. If, therefore, I choose to continue to keep company with those people, I cannot claim that I truly wish to adhere to those professional principles.

Ethical and Prudential Arguments

Ethical arguments about the relationship between individual physicians and reps have often been stated badly or at least incompletely. Those opposing cozy relationships often speak as if the reps are evil people or are guilty of moral wrongdoing. Standard arguments also portray physicians as akin to putty in the hands of the reps. This portrayal elicited a rebuttal that appeared in the Wall Street Journal in response to an article about a campaign by medical students to banish reps from teaching hospitals–that these arguments cast reps “as schemers with more money than sense and doctors as easily manipulated marionettes.”¹

The more complete argument is to see the issue as an interplay of ethical and prudential considerations. The prudential considerations have to do with how we as physicians elect to spend our time, given that almost all of us agree that we are extremely busy and work under tremendous time pressure. The ethical issue has to do with what professional duties we owe our patients. I will assume that the most important ethical duty is a commitment to serving the interests of the patient and avoiding potential conflicts that might divert one from that commitment.^2,3 A secondary ethical duty is to clinical competence, which includes accepting well-grounded medical evidence as the correct basis for one’s actions.

The goal of the pharmaceutical industry is to increase its profits, which includes persuading physicians to prescribe more of the most expensive drugs. Continually rising drug costs are not in the interests of our patient population as a whole, and the most expensive or most heavily marketed drug may not be the best prescription for any given patient. In a capitalist society the industry (I will assume) has every right to act this way, and pharmaceutical reps are honest business persons earning their salaries by serving their employers’ interests. The existence of a potential conflict of interest with the physician of integrity need not imply that the drug industry is acting wrongly, merely that its goals are at least somewhat different from the goals of ethical medical practice. But when does a potential conflict become an actual conflict?

The Empirical Data

A few years ago my argument could not have been made in a convincing way about physicians and reps. Those skeptical about an overly friendly relationships with the pharmaceutical industry could claim that accepting gifts from reps would very likely compromise the physician’s integrity and clinical judgment, but few empirical data existed to prove that this actually happened. More recently, the available data have grown and have spoken unequivocally.

As long as a decade ago, physician leaders within a hospital were shown to be both heavily influenced by free trips to resorts at which they received pitches from reps and oblivious to the fact that they had been so influenced.⁴ More recently, systematic reviews of the literature confirmed a direct relationship between the frequency of contact with reps and the likelihood that physicians will behave in ways favorable to the pharmaceutical industry.^5,6 Physicians who spend more time with reps are less likely to prescribe rationally.⁷ Patients with hypertension that is treated with “free” drug samples are less likely to have their hypertension controlled than are patients whose hypertension is treated by the physicians’ free choice of drugs.⁸ Yet physicians influenced by pharmaceutical marketing nonetheless believe that their information is scientific and unbiased.^9,10

The evidence available today, therefore, seems conclusive on 2 points—first, that we are indeed heavily influenced by reps; and second, that we ourselves are very poor judges of the extent of that influence.¹⁰ To the extent that we claim to be scientific practitioners, we would seem obligated to take this evidence into account in deciding upon our proper professional behavior.

Using One’s Time Wisely

Having accepted the ethical principles and the empirical data, the next question is one of prudence or efficiency—how to spend our time, assuming we want to maximize those professional values and also accept the validity of the data. Would a physician, under those circumstances, agree to spend time seeing reps?

Two aspects of the visit with the rep are receiving gifts (ranging from trinkets such as pens and notepads all the way to tickets to attend continuing education conferences in plush vacation spots) and learning information about the drugs sold by that company. There is some evidence that receiving gifts makes the physician more likely to feel a sense of debt to the company or the rep and therefore more likely to do their bidding.^10,11 If this were not so, the most profitable industry in the world is throwing about $13 billion annually down the drain.¹² So adherence to professional values—fidelity to the interests of the patient—would seem presumptively to dictate that one should not accept any gifts from reps.

What about listening to them present information? There is no empirical evidence to show what happens when reps present information only, with no exchange of gifts. It appears the gift exchange is such a basic part of the reps’ armamentarium that one is simply never encountered without the other. Available evidence suggests nonetheless that information presented by the pharmaceutical industry is substantially biased in favor of the sponsor’s product.^13,14 A dedicated and conscientious physician might therefore decide that it was consistent with his professional obligations to listen to drug reps (even perhaps professionally obligatory, on the assumption that one might first learn a useful bit of information from that source). It would then seem a necessary step that the physician immediately devote additional time to a careful search of the medical literature, or consultation with unbiased and evidence-based data sources, to double-check any information received, given that the bias of the reps’ presentation is obvious and unavoidable.

To the best of my knowledge, few if any physicians who claim the “right” to see reps and to listen to their pitches actually spend the time necessary to research the information received and to correct for bias. These physicians then appear to be in situation similar to the alcohol-challenged person in my example. If they choose to spend time in the company of the reps, where the data show unequivocally that they will encounter serious bias, and then refuse to spend the time needed to correct for that bias, how can they claim to adhere to the professional values of fidelity to the interests of the patient? On the other hand, imagine that the physician was sufficiently diligent to take the time needed to check on all the reps’ statements. That physician would seem guilty of a serious time management problem. Surely if one were taking all that time independently to research pharmaceuticals, one need not spend any further time to meet with reps at all. Why divert that additional time away from patient care? Given how busy the average physician claims to be, could this use of one’s time truly be the most efficient?¹⁵

The obvious rejoinder is that meeting with the reps is fun because they are friendly people and know precisely how to stroke physicianly egos, and they give out nice gifts.¹⁵ This means, incidentally, that the analogy to the recovering alcoholic was not as far-fetched as it may have seemed. Spending time with reps and seeking their handouts are akin to an addiction. Medical students and residents are carefully seduced into this habit long before they become practitioners.¹⁶ In this case, however, the reasons for meeting with them are purely personal, not professional, and should not be justified by any presumed claims toward professional education or service. One sees one’s golfing buddies outside office hours.

An Objection

My argument could be claimed to fall apart with its premise 3: My professional responsibilities do not require me to keep company with those people. The rejoinder is: My professional responsibility requires that I try my best to serve my indigent patients, which in turn means keeping a generous stock of free samples, and I can do so only by seeing the reps and listening to their pitches.

In some medical settings I believe the rejoinder is persuasive. My colleague the wound surgeon, for example, can treat his poor nursing home patients with severe decubiti only by applying very expensive products, which he can obtain as samples from the reps, but which would be prohibitively expensive if he tried to purchase them himself for the patients. Some primary care physicians with overwhelmingly low-income practices might be in similar straits.

In the more usual practice setting, however, there are several problems with the rejoinder. First, many samples never reach indigent patients but instead go home with the physicians and office staff.¹⁷ (Other samples go to well-off patients as a matter of convenience, not need.) Second, if the average primary care group were to stock the sample cupboard with generic drugs that are used to treat the most frequently encountered problems in their practice, the cost of the drugs would be well within their means to pay for out of practice or personal funds.¹⁸ A generic drug sample cupboard would save them from starting treatment with an expensive drug because a free sample was handy, and then having the patient remain on an irrational or expensive drug simply because it is easier to prescribe again rather than to start anew with a more sensible alternative.¹⁹ Westfall, in arguing why family physicians should avoid seeing reps, argued that there is almost always a superior way to secure needed drugs for indigent patients other than to rely on samples.²⁰

CONCLUSION

Reps are not evil, but they are time-consuming and serve interests that often are at odds with those of our patients. To spend time with reps in a manner that preserves professional integrity would require both refusing to accept their gifts and spending a great deal of valuable time double-checking their information. I propose that the vast majority of physicians could spend their time in better ways.

Lately everyone seems to be concerned about our ethical integrity. The pharmaceutical companies themselves announced with great fanfare in 2002 a new code of ethics that would limit the more outrageous gifts.²¹ The Federal government later that year announced investigations into whether some gift-giving schemes violated anti-kickback laws.²² The American College of Physicians issued stricter guidelines for individual physicians.²³

Despite these authoritative pronouncements, the drug rep habit has proved extremely difficult to break. As far back as 1961, thoughtful physicians made the same ethical arguments that one hears today, apparently with little effect during the interim.²⁴ Two reasons for our resistance to this ethical message may be that our medical culture stresses a sense of entitlement to reps’ goodies and that we have an apparently endless ability to rationalize why we see reps and accept their gifts while imagining we are little influenced as a result.^10,15

One further ethical analysis is hardly likely to produce a sea change in our attitudes and behavior when this change has been so difficult to produce previously. Nonetheless, I remain hopeful that stressing the prudential time-management aspect of the problem might catch the attention of some of us who are otherwise resistant to the message. Given how busy most of us are, it seems increasingly hard to defend a practice that further robs us of valuable time.

As important as time management is, one would still wish that our profession cared even more about professional integrity and commitment to the well-being of our patients. Reps are honest business people, mostly, who have no power over our professional integrity; it belongs to us. Once we are firmly committed to regaining our integrity, we will have no trouble deciding that it is worth more to us than any number of pens, coffee mugs, and sandwiches.