No More Drug Company Pens: A Trojan Horse?

I fear the Greeks...

I fear the Greeks...

As of January 1, 2009 drug company sales representatives are no longer supposed to be distributing branded trinkets such as pens and pads to doctors.  Hearing of this, I could not help thinking of the Trojan priest Laocoon. During the Trojan War Laocoon was rightfully suspicious of a certain wooden horse left by the Greeks on the beach.  “I fear the Greeks even when they bring gifts,” he is quoted by Vergil as saying.  Unfortunately, for his audacity (and for throwing a spear into the side of the Trojan Horse) he was punished by Minerva, protectress of the Greeks.  She sent two sea serpents who, after eating Laocon’s two children, proceeded to devour him.  I guess this illustrates the dangers of speaking truth to power.

The new rules are reflected in a revised Code on Interactions with Healthcare Professionals adopted by the Pharmaceutical Research and Manufacturers of America (PhRMA).  These regulations had been adopted in 2008, but did not go into effect until January 1.  They cover a variety of ways in which pharmaceutical representatives can interact with physicians.  For example while pharmaceutical representatives can provide meals if they are making a presentation, they can no longer: “provide any entertainment or recreational items, such as tickets to the theater or sporting events, sporting equipment, or leisure or vacation trips, to any healthcare professional who is not a salaried employee of the company.”

With respect to branded trinkets the rules state:

Providing items for healthcare professionals’ use that do not advance disease or treatment education — even if they are practice-related items of  minimal value (such as pens, note pads, mugs and similar “reminder” items with company or product logos) — may foster misperceptions that company interactions with healthcare professionals are not based on informing them about medical and scientific issues. Such non-educational items should not be offered to healthcare professionals or members of their staff, even if they are accompanied by patient or physician educational materials.

Items intended for the personal benefit of healthcare professionals (such as floral arrangements, artwork, music CDs or tickets to a sporting event) likewise should not be offered.

Payments in cash or cash equivalents (such as gift certificates) should not be offered to healthcare professionals either directly or indirectly, except as compensation for bona fide services (as described in Sections 6 and 7). Cash or equivalent payments of any kind create a potential appearance of impropriety or conflict of interest.

It seems a big disingenous to think that providing branded mugs fosters just the “misperception” that interactions are not based strictly on the science.  In fact, the very description of what is prohibited is a laundry of the unsavory types of interactions that have long characterized the work of drug reps.  (See our previous posting Former Pharmaceutical Reps Tell All).  The PharmedOut website has some interesting new videos in which drug reps discuss how they ply their trade.

So, is this really a “gift” from Big Pharma? Or a Trojan Horse?  Or a bit of both?  Here are some comments we have received as we have asked our colleagues what they think of these new rules.

1. This is big.

Activist groups, such as No Free Lunch, the National Physicians Alliance and Healthy Skepticism, have long wanted to see branded trinkets out of doctors’ offices.   This has been reflected in efforts such as No Free Lunch’s Pen Amnesty and NPA’s Unbranded Doctor campaign.  It really is quite meaningful that doctors are no longer allow their bodies and their workspaces to serve as barkers for the drug companies.  This is big in that sense.

2. This is a small drop in a big bucket leaving the drug companies with many other ways to influence phyiscians and patients.

To put this change in context,  it is useful to reflect on the overall size of drug promotion to physicians.   According to a 2008 article by  Marc-André Gagnon and Joel Lexchin in PLOS: Pharmaceutical promotion in the United States in 2004 is as high as $57.5 billion compared to the figure of $27.7 billion given by IMS. Excluding direct-to-consumers advertising and promotion towards pharmacists, the industry spent around $61,000 in promotion per practicing physician.”

Well, $61K per doctor clearly is not buying trinkets.  What kinds of things are not covered by this exclusion?

1. The industry is still a major player in continuing medical education for physicians.  The role of big Pharma in CME was the subject of the August 30, 2008 British Medical Journal which reports that half of all CME is sponsored by pharmaceutical and medical device companies (see Roy Moynihan’s article:  Is the relationship between pharma and medical education on the rocks?

2. The industry will still be allowed to give free samples for patients. [It would, of course, be so  much nicer if they just took the $57.5 billion spent on advertising and lowered their prices.]

3. The industry can still produce patient education materials and pursue direct-to-consumer advertising.  It is not clear if infomercials, like the dreadful CNN Accent Health (hosted by our future Surgeon-General Dr. Sanjay Gupta) will continue to be allowed.

4. Drug representatives will continue to be allowed to give “informational presentations” to physicians along with free lunches.

5. The drug company can still hire physician “experts” to serve as paid consultants and speakers.  Members of committees which set drug formularies can be speakers and consultants as long as they disclose this to the drug company.

6. And drug companies can continue to gain access to the prescription history of individual physicians.  This may be the Trojan Horse in this gift.

4. These voluntary limits may be intended to forestall legislation with a far wider impact.

Current practice allows the pharmaceutical companies to purchase information on drugs prescribed by individual doctors. This is done without the consent of the physician or the physician’s patients.  The American Medical Association colludes with this policy by selling its Masterfile of physicians to the drug companies.  Sales of the Masterfile amounted to $44.5 million in income for the AMA in 2005.  (This information is drawn from an NPA issue brief).  This arrangement has been described as making the drug company “a silent third party in the examining room.”  Actually it’s more like the fourth party, because the insurance company also seems to be watching over every encounter.  Further background can be found at the NPA site.

New Hampshire, Vermont and Maine have all banned the sale of such data to the pharmaceutical companies, see a posting by the Electronic Privacy Information Center.  And a similar campaign is underway currently here in New York State.

In addition there are a number of laws on the books or proposed that would require physicians to make public any gifts or payments by drug companies.  Impetus for these laws came from 2007 and 2008 hearings held by Iowa Senator Charles Grassey of the Special Committee on Aging.

Given all these threats, Big Pharma may have decided it was better to get rid of the trinkets.

5. Why didn’t this come from the doctors?

The drug companies are facing an increasingly hostile and critical international movement.  Many of the most active members of this movement are physicians.  But they seem a minority within medicine.  The bulk of physicians seemed content to take trinkets.  There was no mass movement of physicians to “unbrand.”  And the AMA has been resistant to discontinuing its role in data-mining.

Whose side are we on anyway?

posted by Matt Anderson, MD

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13 Responses to “No More Drug Company Pens: A Trojan Horse?”

  1. 1Resteraunt Dan

    Thanks bronx doc. Had another incedent today. The offices i prep food for continue to complain about their orders and are now starting to bring heat from our coorprate office. I almost feel like they figured out that if they complain they get more free gift cards and other cupons. I’m just very frustrated because they are working the system and there is nothing i can do. Any suggestions?

  2. 2bronxdoc

    Dear Dan, The free lunches during “educational sessions” are one of the loopholes in the PhRMA code. These sessions are usually highly biased discussions of benefits of the sponsoring companies drugs. Many of us feel that no doctor – or health care professional – should be getting free lunches for listening to advertising. Best, Matt Anderson

  3. 3Resteraunt Dan

    I work in a restaraunt that packs takeout orders for doctors offices near my business. the orders gtet quite extensive and sometimes rediculous. Aside from the pens, i think these offices are taking gross advantage of these lunches. Who ever heard of cheesecake and $25 surf and turf for lunch. Further more quite offten the drug reps are disgusted by the ammount of food orderd and then proceed to not tip. I don’t know about you but i at least throw 5 bucks on a hundred plus dollar takeout order. I guess my point is that the questionable ethics not only comes from the rep but also from the offices. Don’t get me wrong, not all offices do this. But enough do.

  4. 4bronxdoc

    In a follow-up to the question about doctors taking gifts this news item from the AP (9/2/2009) gives a sense of perspective on drug company “gifts”:

    Pfizer to pay record $2.3B penalty for drug promos

    By DEVLIN BARRETT, Associated Press Writer Devlin Barrett, Associated Press Writer Wed Sep 2, 9:19 pm ET

    WASHINGTON – Federal prosecutors hit Pfizer Inc. with a record-breaking $2.3 billion in fines Wednesday and called the world’s largest drugmaker a repeating corporate cheat for illegal drug promotions that plied doctors with free golf, massages, and resort junkets.

    Announcing the penalty as a warning to all drug manufacturers, Justice Department officials said the overall settlement is the largest ever paid by a drug company for alleged violations of federal drug rules, and the $1.2 billion criminal fine is the largest ever in any U.S. criminal case. The total includes $1 billion in civil penalties and a $100 million criminal forfeiture.

    Authorities called Pfizer a repeat offender, noting it is the company’s fourth such settlement of government charges in the last decade. The allegations surround the marketing of 13 different drugs, including big sellers such as Viagra, Zoloft, and Lipitor.

    The rest of the story is at: http://news.yahoocom/s/ap/20090903/ap_on_go_ca_st_pe/us_pfizer_settlement

  5. 5bronxdoc

    Dear Kevin, Thanks for sharing your experiences working in a doctor’s office. It is perfectly possible that physicians you work with were not in any way influenced by the gifts provided by the drug representatives. But there is a pretty extensive literature showing that – as a group – physicians are influenced by such gifts. The Portal has a number of posts about this. Here is are some:

    A UCSF website containing internal drug company documents on the marketing of Vioxx and other drugs:

    A discussion of unbranding doctors:

    Comments by former drug company representatives about their tactics:

    The comments of Dr. Peter Mansfield who runs an Australian group called Healthy Skepticism:

    Best, Matt Anderson

  6. 6Kevin

    This is absolutely ridiculous. I work in a doctors office and I see and hear what drug reps say and what they bring in. They inform the doctors on the studies and show them materials on them. The pens and pads have no effect on what the Doctor prescribes. Do you really think a doctor would prescribe Crestor instead of Lipitor because of a pen. They prescribe it because of the different uses. I can see about getting rid of the cash gifts but not the pens and pads. Also, they tried to get rid of the free samples which is even worse because there are many patients that use them to see how the drug interacts with them before they have to spend money on them and many patients cannot afford some medication and they receive it through the free samples.

  7. 7Luisella Grandori

    This is a true problem.
    I would liìke inform that exist a lot of groups in the world and also in Europe, as well as No free lunch and Healthy Skepticism you quote.

    No grazie, pago io! in Italy, Nogracias in Spain and Colombia, Gezonde scepsis in Holland, Mein essen zahl ich Selbst in Germany.

    You can see their websites at this link

  8. 8Dr. Sickels

    Mike: the problem is that what the drug reps are serving up isn’t education it’s indoctrination and propaganda. They misrepresent the data and even use data cooked up by the drug companies to make the drugs seems more useful than they are. I’ve caught them lying but only because I happened to have read the data they were talking about. If I didn’t already know it would have sounded legitimate.
    There is no sense in trying to learn from advertisements. Would consider yourself educated by watching infomercials all night?

  9. 9Hans Moleman

    Wow, why did I bother getting accepted into medical school? I have lost faith in Capitalism…might as well move to one of those countries I dislike…crap, I had big plans.

  10. 10Mike

    Most of the time the nurses leave for lunch. When the drug reps bring in lunch, the nurses are still required to clock out. The drug companies provide lunch to the nurses which are not getting paid. In return the nurses are able to gain knowledge to better educate their patients on the medications. Why is this a crime? This time would not be available to better patient education.

  11. 11Mrs. V

    Mr. Anderson, I am glad that I found your article I was starting ot wonder if I was the only person who did not agree with this and how this was able to go into affect with out anyone stating that they do not agree with this. I work in a large pharmacy with over 15 technicians. I corresponde with almost all drug reps for almost every top drug companys. When I heard of this news Dec. 2007 I was shocked. We use the pens through out the pharmacy as well as the pens. They in no way make me,my technicians, pharmacist, doctors or nurses feel that we have to purchase this drug. Now durning a free lunch that they give us which we use as CE lunches and they provide us with pens and pads to write out information on. This is how we use these so called trinkets. I have asked so many times as to why this went into effect without further research. Had they done so and came on to a govt. installation where we all work they would have realized how these trinkets are being used. They in no way gave consideration to others only to those who felt the need to stir up some controversy because they have nothing else to do or they probaby were solicted by a drug rep to whom they did not take a liking too. Any how I am not happy about this as well as the 500 adn something employees and I am making it my business to find out how some of this could be rectified.

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