• Pharma gift bans for medical students

    Somehow I missed the initial studies, so I’m pleased this news story brought them to my attention:

    The gift restrictions adopted in medical schools and residency programs are linked to less prescribing of brand-name drugs, said two recently published studies that appear to be the first attempts to gauge the clinical practice impact of efforts within medicine to rein in pharma’s influence.

    One study, published Jan. 31 in the British medical journal BMJ, examined the effect of bans on gifts from pharmaceutical companies and device-makers at 14 U.S. medical schools by analyzing the drug orders of about 2,500 doctors. Researchers compared the prescribing practices of physicians trained at those schools after they banned gifts in 2004 with those trained at the same schools before the bans, as well as with a matched set of doctors who attended medical schools that allowed gifts such as industry-funded meals.

    They then looked at how these doctors — 46% general internists, 23% pediatricians, 10% psychiatrists and the remainder practicing other specialties — responded to three new drugs that were marketed in 2008 and 2009.

    The physicians who attended no-gift med schools were 56% less likely than the other doctors to prescribe Shire’s Vyvanse (lisdexamfetamine), a stimulant used to treat attention-deficit/hyperactivity disorder. They also were 75% less likely to order Janssen’s Invega (paliperidone), an antipsychotic. For a third medicine, Pfizer’s antidepressant Pristiq (desvenlafaxine), there was no statistically significant difference in prescribing.

    Another study is cited as well:

    [I]n the February issue of Medical Care looked at the prescribing habits of nearly 1,700 psychiatrists. About half graduated from residency programs in 2001 before gift bans were in vogue, and the other half completed their training in 2008, after many programs banned gifts from industry as part of following the Assn. of American Medical Colleges’ conflict-of-interest guidelines.

    The 2008 graduates were less likely than their 2001 counterparts to prescribe heavily promoted, brand-name antidepressants, the study found. The prescribing gap ranged from 3.6 percentage points to 6.2 percentage points, with stricter residency program rules of conflicts being tied to lower prescribing of the brand-name drugs.

    Here’s a link to the BMJ study. Here’s one to the Medical Care study.

    The impact of the pharmaceutical industry on medical trainees has long been an interest of mine:

    The primary goal of pharmaceutical companies, like all large businesses, is maximization of product sales and profits. Because physicians act as the gatekeepers to prescription drugs, it is no surprise that the majority of pharmaceutical companies’ marketing strategies target physicians. Despite a dramatic increase in direct-to-consumer advertising, ∼90% of the pharmaceutical industry’s $21 billion marketing budget is still aimed at physicians (including residents and medical students). Interactions between pharmaceutical companies and physicians are pervasive and range from seemingly inconsequential exchanges (eg, dispensing inexpensive gifts such as logo-inscribed pens and notepads) to much more significant and potentially problematic interactions (eg, payment of large honoraria to prominent physicians who speak about the merits of a company’s products or payment of trip expenses for physicians who commonly prescribe a company’s products).

    Although the existence of physician–pharmaceutical company interactions is unquestioned, debate continues over whether these interactions actually influence physician behavior, either positively or negatively. Many physicians believe that their interactions with pharmaceutical companies have a positive educational value, and they are confident that their own behavior is in no way influenced by these interactions. However, social science literature has suggested that it would be very unusual if physician behavior was not influenced by both small- and large-scale interactions with pharmaceutical companies. In the past 25 years, 2 reviews of the literature have examined the extent of the physician–pharmaceutical industry interaction and its impact on physician behavior. Both reviews showed strong evidence that physician–pharmaceutical company interactions have a negative impact on physician knowledge, attitude, and behavior.

    That’s from a systematic review I had published in Pediatrics in 2007. You might find that piece interesting as well. It talks about the evidence available to inform educational interventions to affect Industry-Physician relationships. I’m pleased to see the work continues.


    • I’m all for saving money in healthcare. I ususally prescribe generics myself.
      But studies like these PRESUME that prescribing trade name drugs must be bad medical practice. I wonder if the outcomes in patient care are any different (patients feel better, fewer days missed at work, fewer hospitalizations, fewer suicides, etc.)?

      • No they don’t presume that at all. Go read them. Plus, the studies you “wonder” about exist, but don’t have the results you might expect.

      • The article does not imply there is something wrong with prescribing brand name drugs. The article implies that there is something wrong with a physician prescribing a drug because he was paid to do it.

        If drug A and B are the same price, but be knows drug A may be a bit more effective for a particular patient, what reason is there to ever prescribe drug B? The studies show that some physicians are in fact prescribing drug B over A because prescribing drug B gets them an all-expense paid vacation.

        • And could it be that the information presented to the provider/student acutally did contain evidence that their product was in fact superior, which could lead to higher use?

      • The BMJ study says about the new brand name drugs:

        “None of these medications represented radical breakthroughs in their respective classes.”

        I actually looked for that specifically when I read this post, to see how they controlled for that, issue, that occurred to me too.

        Several years ago, I’d asked a psychiatrist friend about some new psychiatric drug she had literature about (maybe in her house I saw some pamphlet or something I don’t remember), and about the whole idea of prescribing those, or old ones. I was basically curious about whether poor mental patients were getting outdated less effective drugs! Or if drug companies were just pushing new drugs that weren’t even as good just because they made the damn drug. I have heard about that happening too.

        At any rate, the conversation was many years ago, and I can’t remember the details. But I do remember the general gist = that in some cases, new drugs were not any more effective than the old psychiatric drugs for the same things, and in some cases might be less effective or have less known about them. But that they could be useful to prescribe for certain patients under certain circumstances. Say if a patient didn’t tolerate the old drug, or wasn’t likely to take it if prescribed, or if it just didn’t work. Things like that. Sounds perfectly logical.

        But to consider that perhaps gifts & such would have the effect (and it seems to according to these studies), to prescribe the new drugs even when there’s not circumstances that would prompt them to do so for logical & purely medical reasons…
        Advertising works, we know that. So this probably shouldn’t be very surprising, that physicians are not totally immune to the efficacy of advertising!

        But what was most surprising to me… and I’d really like the take of a practicing doctor on this issue…

        What was most surprising to me is that they were able to see such a marked level of prescribing of the new drugs, being that as a patient, I’ve noticed over the past 10 years, my doctors becoming VERY “insurance conscious” when prescribing.
        I haven’t had prescription coverage in 10 years now, yet over the years, I’ve seen this more & more. Every time a doctor prescribes me anything, they specifically ask me if I have insurance, and what type, and then make their prescribing decision.
        In one case, a doctor actually said he could NOT prescribe me a drug that I’d taken before because my insurance required that he first try the less expensive class… even though the insurance wasn’t going to be paying for it because I had no prescription coverage!

        So anyway, that’s why it was surprising to me. I would’ve thought insurance coverage (or lack thereof) would’ve muted a lot of the effects of any robust prescribing of new drugs. But apparently not.

        So then MY question is… is my experience rather unusual & most doctors most people see are not so conscious of this?

        And in regards to the study, who are these doctors in the study, and who were they prescribing to?? (what type of patients in general?)

        It does say, in the study I read:

        “In addition, the models accounted for method of prescription payment (Medicaid, third party, or cash), sex and specialty of the physician, and the physician’s total number of in-class prescriptions.”

        But it doesn’t specify how that was accounted for. ?

    • How do physicians learn about new promising treatments without *some* direct interaction with Big Pharma? Sometimes I wonder if one unintended consequence of limiting direct to physician marketing is less experimentation with various treatments. Those experimentations can help determine efficacy and perhaps potential unknown beneficial alternative effects. Is an all or none approach the only one that is feasible?

      • Believe me, drugs that actually work – and work well – need no “advertising”. They’re published in big journals, trumpeted to the heavens, and used widely.

        Experimentation should occur in “experiments” and not willy nilly in physician offices without IRB oversight and safety controls.

      • I find this comment mind-boggling. Does anyone think that the pharmaceutical company literature and presentations are fair and unbiased about the side effects, price-effectiveness, or plain old effectiveness of the drug they are promoting?

        Sure, sometimes there’s a wonder drug, but I think a doctor should read journals which would discuss them. Plenty of the time, the drug being promoted is not better than cheaper options.

    • Most doctors hotly deny that they are influenced by gifts, stipends, etc. from drug companies but this and other evidence shows that doctors can be bribed relatively cheaply.
      These bans are a good thing.
      As far as “education”, there are many sources of unbiased drug information (The Medical Letter, etc.) that don’t come with a free sandwich and the obligation to return the favor.