Drug reps. You always hear about them, but as a med student you don’t often get a chance to interact with them. This is because they don’t care about you – you can’t prescribe drugs yet! (Also related to my school’s policy regarding them.) I’ve been on my family medicine rotation in a private practice outside of Richmond, and for the first time I’ve really gotten the opportunity to see exactly how they function. A few days ago a friendly, well-dressed attractive woman came in to see the doctor I was working with that day. She said she wanted to follow-up on how patients were doing after the doctor started them on a new diabetes drug her company was marketing. The doctor introduced me to her, and she started to tell me about the drug as well. Apparently the main benefit over other similar drugs made by competitors is that this drug is minimally excreted through the kidney, thus making it a good choice in patients with co-existing kidney disease. It is true that kidney disease often accompanies diabetes, so I could see how this could be a benefit. Yet how important of a contribution to diabetes treatment is this drug really? Without going into too much detail, it’s one of a class of drugs that acts to increase a substance normally found in the body that acts to increase insulin release and decrease glucagon release, leading to lower blood glucose levels (which is the big problem in diabetes). All of the drugs in this class are relatively new (and extremely expensive), so there are no long-term data on the safety. Overall they appear pretty safe (although have been linked to pancreatitis in some people), and don’t seem to cause dangerously low blood sugar like some older diabetes drugs. Unfortunately, they just don’t really work very well, measured by %hemoglobin A1C levels which are used to estimate average blood glucose levels over the past 3 months. It would be difficult to make an argument to start with them instead of a tried-and-true drug like metformin, which is the first-line, much cheaper drug to treat type 2 diabetes.

Well, that type of thing is all interesting and plays into bigger conversations about the incentives for new drug development, including truly novel drugs to treat important diseases like diabetes. But I was more interested in finding out how this drug rep viewed her role in medicine and what she thought about the industry she was working in. I asked her about the Avanda fiasco. Briefly, GlaxoSmithKline, the maker of Avandia, recently pled guilty to intentionally suppressing information that the top-selling diabetes drug  increased risk of heart attacks and continuing to market it as safe. This was always a controversial link because diabetes itself is a huge risk factor for heart attacks. Now, I can’t speak to quality of all the complex data analysis that went into teasing out how many heart attacks were due to use of the drug and how many would have happened anyway, but it has become pretty clear that GlaxoSmithKline did hide information when there was cause for concern.

So, what did she think about it? She told me that her company was viewing it as an opportunity because there was now a gap in the market with one less diabetes drug. She also said she had spoken with people who were familiar with the types of data analysis and the risk of heart attack was overblown as a scare tactic in the media. And what if, I asked, it was later determined that her company had suppressed information about the safety of the drug she was promoting? What if it turned out it had a terrible side effect? How would she feel? She artfully dodged the question and attempted to side with me, “I’m a skeptic too! I like to see the data! And the data in these trials shows that this is a safe drug and a good option for patients with diabetes and kidney disease!”

Then the doctor I was working with returned. One of the realities of 3rd year is that grading is very subjective, and I don’t want to seem like an argumentative person who is difficult to get along with, so I gave up on the questioning. The doctor is way more important to talk to anyway, and she quickly turned her attention to asking about his family and some interests that they shared.

To a certain extent, each physician practice setting can develop its own rules as to how it will deal with drug reps, and a considerable amount of attention has been brought to the issue of salespeople influencing physician prescribing habits. The influence of Big Pharma is wide-reaching and often one step ahead of public information and policy-making. Indeed, one has to appreciate the ingenuity of approaches Pharma has taken in order to butter up physicians.

The common denominator of these approaches involves exploiting that most doctors think of themselves as pretty smart people. As a result, most doctors think they’re immune to the tricks of salespeople and resist the idea that they would alter their drug-prescribing habits based on talking to a salesperson or even getting to know them. This isn’t the case. In fact, physicians may be in a particularly dangerous and even vulnerable situation. Medical school is hard, and there is considerable emphasis given to the importance of development of critical thinking and analytical skills in classes. It’s pretty difficult to know how well those analytical skills have sunk in or remained over the years, as most of the national medical licensing exams are multiple choice (there is at least one national required test where you’re evaluated by seeing patients). What is probably more important is that in medical school we are taught to believe that we HAVE developed these skills and are thus less susceptible to influence by outside sources.

Thinking of oneself as intelligent is not something I’m faulting doctors for – everyone, of course, wants to feel this way! Doctors deserve to be respected for dedicating a substantial part of the prime of their lives to learning an enormous amount of information in order to be able to relieve some suffering one day. I honestly believe most people go into medicine because they are interested in the subject matter and want to provide a valuable service to humanity. Drug reps know this, and take great pains to emphasize how the drug is better for the patients and how smart they think the doctors are. They give them glossy information packets about new medications that include copies of relevant research studies (as if a busy doctor in private practice is going to actually not only read every study handed to them by a rep, but critically evaluate strengths and weaknesses!) They give samples of the medication to the office, which seems to me to have the undertone of emphasizing they are trying to make expensive medications available to patients who otherwise wouldn’t be able to afford them, playing on most doctors’ tendencies towards altruism. Unfortunately, when the samples run out, the patient is still taking an expensive brand-name drug and may prefer it because it’s what they’re used to.

Another way drug reps appeal to doctors’ desires to think of themselves as pretty smart folks is asking them to be a (paid) speaker, calling them things like “thought leaders.” They’re supposed to give talks to other doctors about the condition the drug is for and the side effects and advantages of the drug. They view themselves as providing a good service to other doctors and their patients. In reality, something about the psychological effect of getting paid by the company actually influences the prescription writing of the doctors (who were only approached as a “thought leader” because they already wrote a lot of prescriptions for the drug!) It may be that they have to justify it to themselves to prevent cognitive dissonance of speaking for something they don’t truly believe in.

So how can doctors protect themselves from this type of coercion? One very simple way seems to be to refuse to meet with drug reps and rely on obtaining information about new treatments through other, less biased sources. In reality, every source has a bias, but it seems hard to imagine a less objective source than a person whose very career depends on convincing people of the superiority of their product.

In 2013, every doctor that takes money from drug companies will be available to the public. Here’s a database in the meantime. And here’s the website  of No Free Lunch, an organization that’s dedicated to making sure that patient care isn’t dominated by the coercion of drug companies. They have their work cut out for them.