"Say, is that a Novartis Pen You're Using? You're Under Arrest!"

A physician survey published in The New England Journal of Medicine this week reveals that 94% of the respondents from six different specialties (anesthesiology, cardiology, family practice, general surgery, internal medicine, and pediatrics) "reported some type of relationship with the pharmaceutical industry, and most of these relationships involved receiving food in the workplace (83%) or receiving drug samples (78%)."

This is news? Doctors have been receiving free items from Big Pharma (hereafter referred to as BP) for decades; why are these researchers wasting our precious natural resources by once again printing the obvious? Their answer is that this survey was designed to update and expand upon the previous data reported in numerous earlier studies of doctors and their relationship to the pharma industry. The results were indeed enlightening, at least to me.

Many of these previous studies are now somewhat dated or focused on particular specialties or geographic areas or on physicians in training. Also, none have systematically explored the full range of possible predictors of physician-industry relationships such as the physician's sex, patient mix, practice setting, other professional activities, or type of clinical reimbursement.

Notice they said predictors of relationships, which means determining what type of physicians are more likely to accept booty from BP. Here are the results of what doctors receive, as published in the NEJM article:

I find it interesting that if one eliminates drug samples and "food or beverages in workplace" (egad - not another tub of cold fettucini alfredo, please), the frequency of relationships (what is this, "Love Line"?) drops to a maximum of 26%, hardly a pervasive infiltration of the medical rank and file by the proselytizers. Is our way of life at risk of disintegrating into anarchy because doctors get honoraria from BP? Don't all Congress-peoples and Senators get millions of dollars of free travel, dining and golf - every single day? According to one commenter, apparently a resident of Mount Olympus, the crisis demands mortification, if not mass deportation to the nearest gulag.

Dr. Jerome P. Kassirer, a professor at Tufts University School of Medicine, who was not involved in the research, said the guidelines should be expanded because many of the marketing tactics used by industry fall outside them. "The whole notion of 'benefit to the patient' is too lax," he said. "Just because a pharmaceutical company gives medical students stethoscopes doesn't mean they should take them." Kassirer said that although some gifts, such as free samples, seem innocuous, they can lead to prescriptions for new, expensive drugs that may be no better than older, cheaper ones. "Giving a patient free samples means the doctor has to finish off the course of treatment with a prescription," said Kassirer, a former editor of the journal.

I wonder if he knows how much a package of Emend (aprepitant), a new drug for chemotherapy-induced nausea and vomiting (CINV), costs? Last time I checked it was around $400 for three pills. Holy Mother of God! What kind of capitalist tool would even considering prescribing it for poor old grandma? Of course it is a major advance in the relief of CINV. Do I dare to give her a free sample, or should I instead tell her to eat cake, or take prochlorperazine like we used to do in the 1980s?

Scheißdreck! Not all doctors are hypnotized by the lure of free samples for their patients, but if we see proof that a new, expensive medicine is an improvement in patient care we use it. This is an example of "evidence-based medicine," which loosely translated means "don't use inferior treatments, dumbkopf." If a new drug is a breakthrough, then we'll do everything we can to get it for our patients - even give free samples.

Let's wrap this up by commenting on some of the highlights of the data. The multvariate analysis of predictors of a physician-industry relationship, found in Table 3 of the article, shows the odds ratio for physician-industry relationships (samples, gifts, reimbursements & payments) based on personal and professional characteristics of the doctors. Here is my take on the data:

Cardiologists are more likely to accept samples and payments. (In this field there are always new drugs coming out for cardiovascular disease, and multiple clinical trials are running at any one time).

Pediatricians are less likely to accept anything. (Kids don't usually need complicated, expensive meds).

Private practice docs are more likely to accept samples than staff-model HMO or academic docs. (Drug reps are often banned from access to the latter two by fiat. The authors also suggest that HMO docs have to abide by a limited list of meds in the formulary).

Academic doctors are more likely to take payments for lecturing than docs in private practice. (Duh! Professors are experts in the subject, not lil' ol' country docs like me; also, academic docs frequently need to pad their meager salaries by hitting the lecture circuit).

The bottom line on all this, at least to me, is that doctors are more susceptible to influence-peddling when they prescibe a medicine without taking the time to educate themselves on it, especially on the drug's efficacy compared to the current standard of care. Without perfoming this due diligence they do a disservice to those who have entrusted them with their care.