Drug Companies Get Too Close for Med School's Comfort

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Drug Companies Get Too Close for Med School's Comfort

By Dan Shapiro, the New York Times

January 20, 2004

One of our psychiatry residents smiles and leans against the wall. A woman, a few years younger, stops filling the mailboxes with pens and sheets of paper advertising a new antidepressant and faces him squarely. Her voice is melodic and bouncing. Her eyes open wide and she laughs at something. He smiles. He moves to scratch his cheek and she makes the same movement, they are scratching in unison now. They remind me of a flirting couple on a first date.

He has completed medical school and is in the second of four years of psychiatric training. Assuming all goes as planned, in a few years he will be licensed as a psychiatrist.

When he starts practicing independently he will write thousands of prescriptions every year; he already writes hundreds. She is "detailing him," teaching him new uses for her company's antidepressant.

My office sits just outside the mailboxes and I've been watching her. She's been lurking, slowly filling the mailboxes. He is the third resident she has "detailed" in an hour.

Our psychiatry department at the University of Arizona is divided over these interactions. On one hand, a number of professors and a few residents have grown concerned that the department is allowing the pharmaceutical industry to teach our residents to embrace newer, more expensive drugs. On the other, many residents have argued against restrictions, suggesting that they should learn to respond to the marketing now and that prohibiting contact would leave them unprepared for the future. A minority have argued that academic freedom gives the faculty and residents the right to speak with whomever they choose.

There have been debates in a grand rounds forum, in faculty meetings, and in the weekly resident lunch. In response, our department head recently formed a committee to draft a new policy governing relationships with the pharmaceutical industry.

Drug company representatives are a major presence. They sponsor Journal Club (where trainees learn to review new data and research), they pay for many of our weekly speakers and regularly offer free dinners for the residents and faculty. They enjoy free access to our mailboxes and regularly detail our trainees in their offices, hallways and in our little kitchen.

This is not uncommon. Meredith Rosenthal at the Harvard School of Public Health reported in The New England Journal of Medicine that the industry spends roughly $15.7 billion annually marketing medications, with $4.8 billion dedicated to detailing individual physicians, or roughly $6,000 to $11,000 a doctor a year.

Studies indicate that most physicians meet with pharmaceutical representatives four times a month.

Studies also reveal that most physicians erroneously believe the representatives do not influence prescribing habits.

When doctors and trainees meet with reps, they change their prescribing habits and are far more likely to prescribe the drugs described, even when they are more expensive or have no benefit over alternatives. They are also more willing to request illogical changes to hospital guidelines that govern which drugs can be prescribed.

Estimates suggest that roughly $1 billion was spent advertising antidepressants to health professionals in 2000.

More than 400 psychiatrists were asked by Dr. Timothy Peterson and his colleagues at Harvard to describe their beliefs about antidepressants. More than half said they believed that newer agents were more effective than older antidepressants known as tricyclic antidepressants and that newer antidepressants, called selective serotonin reuptake inhibitors, or S.S.R.I.'s, had fewer side effects than generic S.S.R.I.'s.

But studies conducted at Oxford , Duke, the University of Manchester and the Canadian Coordinating Office for Health Technology that used a statistical strategy called meta-analysis to combine the results of hundreds of independent studies found that S.S.R.I.'s were as effective as tricyclic antidepressants or slightly less effective. They also revealed that S.S.R.I.'s were tolerated by slightly more patients but had as many side effects.

In an 2002 article, Dr. Peterson wrote: "Despite the lack of evidence of a significant difference in efficacy between older and newer agents, clinicians perceive the newer agents to be more efficacious — these findings are significant as they highlight the discrepancy between empirical evidence and clinical practices and suggest that other factors influence clinicians' medication choices in the treatment of depression."

The effect is easy to see in our department. The antidepressants fluoxetine, known popularly as Prozac, and paroxetine, known as Paxil, are now generic and cost patients and insurers pennies a day. Newer, rival drugs including sertraline (Zoloft), escitalopram (Lexapro) and Venlafaxine (Effexor) are 5 to 20 times as expensive.

In the last seven years, I have watched our residents prescribe the newest medications almost exclusively.

While doctors' prescriptions are based on more than efficacy and cost — they must also consider potential drug interactions, lethality of the drug if overdosed, the patient's prior history and patient preference — the abandonment of older medications by our residents cannot be justified given available data.

Programs that limit contact between industry and trainees do result in changes in behavior and attitudes.

In 2001, Dr. Brendan McCormick of the University of Toronto and his colleagues published a study in The Journal of the American Medical Association. The research compared internal medicine residents at McMaster University , who were prohibited from meeting with drug representatives during training, with trainees at the University of Toronto , across town, who had no such limitations.

After training, when they were free to meet with whomever they chose, the McMaster trainees had less contact with company representatives and were less likely to find such contact helpful.

In 1999, in response to growing concern in academic medicine, most pharmaceutical companies voluntarily adopted American Medical Association policies restricting lavish gift-giving to doctors. Some training programs went further, developing strict policies that limit access to medical students and residents. Policies adopted by the University of Michigan , the University of Iowa and New York-Presbyterian Hospital, among others, have restricted pharmaceutical sponsorship of educational activities, have limited or completely eliminated their representatives' contact with trainees and have restricted gifts and where they can be displayed.

Unfortunately many programs have failed to address the issue.

In his Pulitzer Prize-winning book for 1984, "The Social Transformation of American Medicine," Dr. Paul Starr, the Princeton sociologist, argued that doctors won legitimacy during the early 20th century by aggressively taking on charlatans who offered cures and remedies. At the time, the American Medical Association argued that only doctors were objective enough to evaluate the benefits of competing medications. While there were other factors, the association leveraged physician objectivity to garner greater independence in practice, higher salaries and the legitimacy doctors have enjoyed since.

If medical schools are unwilling to separate trainees from pharmaceutical company representatives, we risk the appearance of being "bought and sold."

This is sure to lead to governmental regulation and greater erosion of independence. And it should.