** UPDATE **
We didn't get to the topic of Conflict of Interest last week, so we devoted an entire class session to the topic today. The discussion, as well as the student questions, migrated toward the influence of the pharmaceutical industry, which was supposed to be next week's topic. So, this week and next will be a mixture of ideas and opinions on these two related topics.
Short post this week. In response to this article, please consider the following:
Where should we draw the line - at the point at which we recognize a potential conflict of interest or at the point where our patients may consider our judgment compromised?
Should this be an individual choice or a company/institution policy?
In what situations should we as pharmacists be required to declare any real or perceived conflicts of interest and to whom should we declare these?
9 comments:
Donnie, Seeing no other comments, am I really late or the first?
Edit as you see fit. clark
Drug companies want to sell their product, and advertising, promotions and gifts all help increase sales. The drug company wants to make money but they have to have a prescriber writing prescriptions for this to happen. Does this mean that because I am using a pen with Geodon® on it that all my patients are going to get Geodon® today? I hope not.
The small token gift from the pharmaceutical sales person does have an effect. It keeps their product in front of you and acts as a reminder for when an indication does appear. Advertising is effective. When I worked in central pharmacy order entry, we would make jokes about which pharmacy company sales representatives had been to the hospital, as we would see multiple orders written for Precedex® or Levaquin® or other new to the market drugs. These patients could have been treated with other medications on our formulary and probably for a lower price. Physicians want to “try” new medications to see how effective and beneficial they will be to patients. A long time ago, a new non-steroidal anti-inflammatory drug (NSAID), similar to ibuprofen, was introduced to the drug market. It worked okay as an NSAID but there soon showed up a unique side effect. It turned patient’s fingernails blue, sort of a blue-purple actually and it did not go away. We filled a lot of prescriptions for it before the FDA finally pulled it off of the market. The Lilly sales lady was good at her job.
At University of Colorado Hospital, we have now adopted the policy for academic medical centers regarding zero-dollar gifts (not even a pen), drug samples and continuing education. The university has increased the quantity of educational programs to help disseminate new product information in an unbiased format for the health-system students in all programs. This balanced presentation in my opinion is a much better way to learn. I do miss the free lunches though. But, was it really free?
We are required to list any conflict of interest with pharmaceutical companies when presenting at Pharmacy and Therapeutics committee, giving educational lectures, research proposals or projects and writing articles. For me, when I see that an author has accepted money from a drug company, my skeptical side is ramped up. I read his paper more critically looking for biases or favorable treatment for products made by that company.
Clark Lyda, PharmD
Clinical Pharmacist, Operating Room Pharmacy
University of Colorado Hospital
Please share your experiences with drug reps, both positive and negative.
Nicole Reiber
ni.reiber@wingate.edu
Have you ever been in a situation where you felt pressured to push a certain drug against your judgement? or witnessed this?
Christal Willis
cewillis@wingate.edu
Do you think it is a good idea that pharmaceutical companies pay for doctor and pharmacist CE credit meetings as gifts?
Jeff Katz
je.katz@wingate.edu
From your unique perspective, what are some lesser known benefits of having drugs reps interact with physicians? Benefits, ultimately, being in the patients' best interest?
Virginia Bailey
Do you feel that drug reps disregard restrictions that may currently be in effect, to "promote" the purchase of their product?
Lauren Hawkins
l.m.hawkins@wingate.edu
My experience with drug reps has been relatively limited but here are my thoughts/examples:
I first encountered drug reps at the community pharmacy I worked at during school. They would drop off free pens and coupons. I utilized drug reps in my 4th year of pharmacy school to obtain free materials and coupons to develop a smoking cessation community outreach program. I also attended ASHPs Midyear Meeting before the new regulations where I collected numerous items of pharmaceutical memorabilia from drug reps that eventually wound up in the garbage.
As a PGY1 resident, I was included on regular drug rep meetings with the director of the drug information center. I had some interesting observations as my preceptor was very knowledgeable of the literature and would bluntly point out limitations of the studies backing up various medications and indications. In addition drug reps were useful in provided patient demonstration materials such as insulin pens etc. for use in the pharmacotherapy clinic I rotated through.
As a PGY2 drug reps have been helpful in providing medication samples and information regarding patient assistance programs. As a longitudinal experience I work with a large indigent patient population in inner city Baltimore and the free medication and education material have been very helpful. I also teach diabetes group sessions using Conversation Maps which are sponsored by Merck.
Subsidies to underwrite the costs of CE programs, professional meetings or research can have a positive impact on patient care and are important. Guidelines have been developed by ASHP and others to regulate this. Funding these types of events and activities can contribute to the improvement of patient care. As long as the providers of the CE etc maintain control of the program content I find this to be permissible and often research, CE etc would not be possible without drug company/rep funding.
I have never been in a situation where I have felt pressured to use a product against my judgment. What I do on a daily basis is driven by guidelines, best practices and the practicality related to an individual patient (utilizing brand name drugs through PAP programs, $4 generic lists, easiest to administer related to compliance etc.). Drug reps can be a resource but certainly do not drive my practice.
Overall I have met some very intelligent and talented drug reps and some who were not so gifted.
Zack Deyo
Resident at U of MD
zdeyo@rx.umaryland.edu
Drug reps are often categorized as the bad guy in the pharmaceutical world. Not long ago, they would come into a pharmacy, put some pens and notepads on the counter, give a quick spiel on their drug, and be on their way. Now, they do the same thing, but without the gifts. Honestly, I have never had a ‘negative’ experience with a drug rep. I actually appreciate the clinical data that they provide; it aids in my understanding of prescribers’ rationale for using certain drugs so that I can incorporate myself into the patient care relationship.
Drug companies offer substantial rebates on their products, which they pass along to patients in the form of drug discount cards and vouchers. This is helpful, especially if the patient could not afford the medication otherwise. Drug samples are also helpful, especially for dermatologic products for acne, oral contraceptives, and first dose antibiotics when the patient may not have access to a pharmacy right away. Patient compliance is all about perceived benefit, and this can be achieved (at least initially) by providing a sample to trial for effectiveness and side effects, followed by a voucher to make the drug affordable when the sample runs out.
Pharmaceutical companies can and do pay for CE all the time, especially those in pharmacy magazines. If this CE is “free of charge,” does that make it a gift? If there is a charge, does that make it any less of a conflict of interest? Drug company CE is as much a lesson in new drug data as it is in professional judgment. The information is what it is… you have to use your critical thinking skills to remove the bias and apply to practice. One of my most difficult professional challenges is staying current on new drugs and changes to disease state management. I think I would be uninformed on these aspects of practice if drug companies didn’t communicate their data to prescribers and pharmacists.
_______________________________
Erica Harms, Pharm.D., R.Ph.
Staff Pharmacist - Target
Charlotte, NC
eharms@carolina.rr.com
On one of my rotations as a student I spent one day with a drug rep. She was knowledgable about the drugs she was trying to sell and really believed in it. After following her for a day I realized that someone has to do it. Someone has to advertise and sell the drugs to make up for the cost of research and everything that goes into it. It was a different experience seeing what she does everyday and what she goes through. We went around to several physician's offices to drop off samples, coupons and candy (since now they can't give away pens). I never knew this but some physicians offices have a closet full of samples. It's amazing how many samples they have. She worked for a larger drug company, so many of the physicians knew her and she was very personable to not only the physicians but also the staff. Like most drug reps she had a evidence to back up the new medication but she was also able to apply the medication to guideliens and tell the physicians where the med fits. The experience was great and definitley made me see a different side of drug reps and their purpose. During this experience I also realized that for some physicians, drug reps are their only source of information on new medications and changing guidelines.
Ying-Tang Ng, Pharm.D.
PGY1 Pediatric Pharmacy Resident
Wolfson Children's Hospital
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