Share The Wealth by Chris Gupta
March 08, 2004

More Drug Marketing Tricks

..."We've shown that in our local community here, that physicians who see pharmaceutical drug reps more often, tend to prescribe, for example, antibiotics more frequently for common respiratory infections that don't really need an antibiotic...

...The drug companies spend a great deal on marketing and they don't do it without knowing why they're spending that money and they know exactly what they're doing. And they're very good at it....

....Why should patients care?
Patients, when they sit with the doctor, want their doctor to be unbiased, to be completely objective, to base their decision based on their knowledge and their skill and their understanding of the science of drugs and when all of that is influenced in the background by this pharmaceutical drug information that the pharmaceutical drug reps have, and that the doctors don't have, that's of great concern."...

This most informative interview on the CBC Disclosure: Targeting Doctors program is yet again another behind the scenes pharma ploy to extract money from the medical system. Health concern of the their customer is surely not a concern but only a pretense to get our confidence in the system.

Next time you go to a pharmacy - demand that they not sell or hand out your prescription information to anyone.

Also if you are ever asked by your doctor to participate in trial, ask him what the drug company conducting the trial is paying him for you to participate in the trial. This conflict interest is often not disclosed to the trusting patients. Strangely, in these type of conflict of interest situations, one should have expected our regulators like, Health Canada, to be up and front batting for us - their constituents. But, hell no, they are too busy chasing innocuous health products that are in competition with their pharma friends toxic drugs....

Chris Gupta

Dr. Dick Zoutman is an infectious disease specialist at Kingston General Hospital. His biggest worry is the impact prescription profiles have on peoples' health. "Doctors don't realize that they're being influenced," he says. "We think we're immune. We think we're very powerful and we're immune but we're not."

Dr. Zoutman is about to publish his latest research. It shows how doctors influenced by drug reps are more likely to prescribe inappropriate drugs.
What was it that you saw that prompted you to look into this?
It was the fact that physicians' data was being compiled about individual practitioners in great detail that worried us.

I have been in practice now for some fifteen years and I was not aware it was happening. So it surprised me and we started asking some questions of the various companies who are collecting this data. We found this is a common practice, it's widespread, it's multinational in countries around the world - and that was a surprise to me. Most of my colleagues were unaware that it was happening either.

Then we did some research and realized that the Canadian Medical Association was aware of this practice and in 1997 issued a policy statement about the issue of physician profiling and data prescription mining.

How does it work? A doctor writes a prescription, the patient goes to the pharmacy. Then what happens?
There are several layers here. It appears that the information is entered into the computer by a pharmacist or a pharmacy technician. From there the information is removed and taken off either by another piece of software... It ends up in the hands of large data corporations who make it their job to profile the physicians by drug class and by geographical location, etc., to determine in great detail my prescribing behaviour around all aspects of every prescription that I write. This isn't happening in hospitals, it's in the community retail pharmacy area where we're seeing this.

Who is the biggest seller of this information?
There are at least two companies that we know of. We believe the largest company in Canada is an organization called IMS Health. That they are one of the biggest players in this. But we also know there are others.

What do they sell, IMS?
These companies are selling information about the physician's prescribing behaviour in great detail back to drug companies.

Why do the drug companies want the information?
One particular use of the information that concerns us is that it's used to profile physician prescribing exactly. That information is provided to pharmaceutical drug representatives who visit doctors. That information allows the pharmaceutical drug representatives to have detailed information about the prescribing behaviour of the physician.

Why do they want it?
They want it so that they can determine whether you are a high prescriber or a low prescriber for a particular targeted drug and then they ... talk to you about your prescribing habits, why you're using one drug versus another drug and so forth.

The difficulty with this is that the vast majority of physicians don't know what's going on and are unaware that the pharmaceutical drug rep sitting in their office has a detailed profile. That information is hugely powerful to influence. If you're sitting there with the pharmaceutical drug rep in your office and you don't realize that they've got this information ... and not being able to see the information to critique it for its accuracy and its validity - you're at a severe disadvantage.

We know that this prescriber information is very powerful as a way to, in a form, coerce physicians in a passive kind of way into changing their prescribing behaviour. There's no doubt that physicians who are seeing pharmaceutical drug representatives are being influenced by what they're learning from the pharmaceutical drug representatives.

Why does it have an impact?
I'm not able to look at my own prescribing dispassionately and say: 'Well, maybe I'm prescribing too much of this and not enough of the other. Maybe I'm too old fashioned or I'm picking up the new drugs too soon.' Because of that, my not having that [information], but the pharmaceutical drug rep is having it, I'm at a severe disadvantage.

Because I'm not able to be on the same footing. They're sitting in the room having a great deal of information about me that I don't have. And that's able to influence me. They're able to do a direct strike, a very targeted intervention to try and convince me to use one drug or the other, provide you with information about their drug. That may not be information about other drugs and about the whole therapeutic issue that's being addressed.

We've shown that in our local community here, that physicians who see pharmaceutical drug reps more often, tend to prescribe, for example, antibiotics more frequently for common respiratory infections that don't really need an antibiotic.

And they also prescribe antibiotics that tend to be the newer more expensive varieties that we're all concerned about developing resistant bacteria too - we've shown locally here in Kingston area that that's an issue. And that's been shown over and over in other therapeutic areas. You know, cardiovascular drugs, cancer drugs; the impact of the pharmaceutical drug representatives is very powerful.

The drug companies spend a great deal on marketing and they don't do it without knowing why they're spending that money and they know exactly what they're doing. And they're very good at it.

The problem is, doctors don't realize that they're being influenced. We think we're immune. We think we're very powerful and we're immune but we're not. And that's something physicians have to realize, that we are influenced by it.

Why should patients care?
Patients, when they sit with the doctor, want their doctor to be unbiased, to be completely objective, to base their decision based on their knowledge and their skill and their understanding of the science of drugs and when all of that is influenced in the background by this pharmaceutical drug information that the pharmaceutical drug reps have, and that the doctors don't have, that's of great concern.

Don't doctors like visits from drug reps?
Some do, some don't. I don't have much time in my schedule to meet with pharmaceutical drug reps. We have formal committees in the hospital. I can't speak for my colleagues who are in community practice however. But we do know that the average number of doctors, the average number of visits is four pharmaceutical drug rep visits per month in the office. That's about one a week, on average. Some more, some less.

Overall, I do not believe that physicians are being informed adequately and sufficiently that this practice is going on, as I wrote in our article in the Canadian Medical Association Journal.

We think that's an important issue: that physicians really are not aware and physicians need to be made aware so that they can give informed consent. I believe physicians should consent to this data being profiled about their prescribing habits. I believe it's confidential information, and many other people believe it is as well.

A lot of doctors will say that they need the information that comes from the sales reps.
That's true. The sales reps can keep physicians up to date about new drugs, new drugs that are being released, new issues around adverse effects and proper use of drugs. Pharmaceutical drug representatives have a code of ethics and they are people who are trying to do a good job for their company to sell their drug.

The concern that we have is the fact that physicians' data is being profiled without the physicians' consent up front - despite some mail outs that have gone on from several of these data collection companies, there's no opportunity for direct, positive informed consent. We believe that needs to be part of the process. Physicians need to be asked: Do you want to be profiled, yes or no? And if yes, fine. If not, then you have the option to have your name taken off the list.

Why do you think that doctors are so easily influenced this way?
I think all human beings are influenced. Why are there billboards along the highway? Why is television full of advertising? In many ways it pays the freight and we accept that in our society.

There's something unique though about the physician-patient relationship, there's something sacred and special about the level of trust. It has to be at the highest possible level for patients to feel they can really trust what their physicians are doing, their physicians are uninfluenced and biased, and unbiased, in their decision-making.

I think this prescription data is very important and very valuable information. It is not only influential to physicians, but can be used to inform and educate physicians to optimize drug use. But in order for that to happen, the information has to be provided back to physicians on a regular basis in the form of a report.

What I'm suggesting is that if this data is available, it should probably be collected -- collected in a different way, by different people, I would think. I think it should be collected by the Canadian Medical Association or perhaps the Canadian Pharmaceutical Association ... I think if they were to collect the data together, they would be able to provide this information back to pharmacists and back to doctors so we could get reports back on a monthly or quarterly basis. That would be very helpful to me as a practitioner.

Has your research shown that it makes a difference in the way doctors prescribe - whether they've been visited or not?
We found that physicians who were visited by pharmaceutical drug reps were more likely to prescribe antibiotics for things where antibiotics weren't indicated and also to prescribe antibiotics that were more expensive and very broad spectrum.

What would be the difference in prescribing practice according to whether you had a visit from a drug rep?
The drugs that are prescribed tend to be the more broad spectrum, newer antibiotics. We've also found that there's more likelihood, if you've been visited by pharmaceutical drug representatives, to be prescribing antibiotics when they're not even indicated - for things like coughs and colds and upper respiratory ailments that we see every winter.

The link to a visit by a sales rep - why do you think that happens?
The visit from the sales rep presumably has an impact on the physician's thinking about the merits of a new drug that may have a broader spectrum, therefore kills more bacteria, might be more effective and the concern that the patients may find the drug more acceptable. The drug may also be able to be taken less frequently. Once a day, twice a day dosing is easier, there's no question.

But those are all kinds of the issues and the physician is influenced because they've been told about the one drug - but not about all the others that are part of their choices. The marketing is aimed at the broader spectrum drugs.

Because that's where the money is.

So the doctors that get all these visits aren't prescribing the cheaper, older drugs?
We want doctors to be prescribing the most appropriate drugs for the condition. We do know from the literature - not from our own research but from the literature - that physicians who have contact with pharmaceutical drug reps are more likely to be prescribing the newer drugs and ...

Which are more expensive?
Which are invariably more expensive and that's been shown.

When Dr. Schumacher complained to the Privacy Commissioner, the Commissioner said that ultimately there is no invasion of privacy. What did you think of that?
Well, I respected the review that the Privacy Commissioner did of the issue. I thought it was very thorough and had the same findings that we had. However, I don't agree with his conclusions. When the Privacy Commissioner described the value of a prescription to society, he described it as a product of our work. And therefore it's not confidential.

He compared us, the medical profession, in his report, to chefs and to roofers and to mechanics. And all deference to the important value of chefs, roofers and mechanics and the important work they do in our society, it's a very different relationship between me and a chef when I'm in a restaurant. If the chef cooks a meal that I don't like, I may not come back or I may not leave a tip.

But the relationship between a physician and a patient is very different. I'm able, when I'm dealing in a restaurant or with a roofer or a mechanic, to say what I want to do. I'm in a situation of fairly equal power. The physician-patient relationship is very lopsided towards the physician who has a great deal of power over the patient and that has to be acknowledged.

I'm most concerned, not so much entirely about just the confidentiality, I'm most concerned about how the data is used to influence physicians to prescribe one way or the other. That to me, I think, is the big issue around this prescription data mining issue.

We've talked to IMS and they say that the information they sell to drug companies does not have individual doctors' names on it - that it's aggregate information.
That's right. The information is aggregated by the amounts of drugs that are being prescribed. So it's aggregated by the drug classes and by the amount of drug. But within that aggregated database are physician identifying numbers so that it's not very difficult then to link it back to another database which they have of all the physicians names, addresses and the identification numbers. You link up by the identification numbers and you've got the physician-identified database that allows you to profile physicians precisely.

It starts off being aggregated by the amount of drug being prescribed. But if it can be de-aggregated directly to the physician, then the aggregation is more apparent than real.

Because their data has a physician identifier number. You have a separate data set that has that identifying number linked directly to my name, for example.

How many pharmacists are involved?
I believe it's a fairly widespread practice. I certainly know that it's international across many countriesÂ… The information we have is that approximately 4,000 pharmacies across the country, which will include some of the chains, are participating in this program to supply information to the data miner, the prescription data mining companies.

Our research shows that the information is acquired at the pharmacy level. The Privacy Commission's report corroborates that information, that it is acquired at the pharmacy level. And from there it is used to produce reports.

IMS says they do this doctor profiling, but primarily the drug companies want this because it's a moral responsibility to know the prescribing trends of doctors. In other words, they're suggesting this is not about money; it's about health.
It's about money too. It's about influencing physicians. It's about affecting drug prescribing behavior. It's about using this information to subtly coerce physicians in an indirect kind of way by this information. It's been well studied that this information is very powerful information to convince physicians about prescribing one way or the other. So on that, I agree that the data is very powerful. But it's also about sales. It has to be.

How valuable do you think it would be to drug companies?
I think this information is of immense value. It allows them to direct their marketing activities. It also would be of immense value to physicians to be able to look at their prescribing activities, to optimize them. It has great value. Of that there's no doubt.

You're obviously concerned about this. But why aren't governments concerned about this?
I think the governments should be concerned. It's the health of patients is affected by the prescriptions that the doctors hand out. If the physicians are being influenced by this information unwittingly, then I think we should all be concerned.

I would prefer to see the data collected by a third party agency that does not have a commercial vested interest in the use of this data. Now that could be the Canadian Pharmaceutical Association that represents the pharmacists and the Canadian Medical Association, for example, with some government funding. And that data could be run through the local medical schools for analysis and they give feedback from your colleague.

That would be very, very useful and powerful information to optimize prescribing. That's how I would view as an ideal situation. But that's not what's going on right now.

What about the Canadian Medical Association? Are there any rules that would prevent this or suggest it might be wrong?
The Canadian Medical Association became aware of this issue in about 1996 and in 1997 published guidelines on the issue of prescription data mining. Some of the key principles that the information should be collected with physician consent, that the data should be provided back to physicians in an educational manner so that physicians get profiles on a regular basis. Those are things that aren't happening right now.

March 5th 2004 Disclusure Interview


posted by Chris Gupta on Monday March 8 2004
updated on Saturday September 24 2005

URL of this article:



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Readers' Comments

Published on You Have Now Been Sampled While the pharmaceutical industry's image and reputation has and appears to continue to suffer, added damage has expressed itself with costly patent expirations. Yet the big pharma task forces still insist that reps provide incredible value, and the more the better, as the drug reps are the givers of gifts, and reciprocity in the form of prescriptions just has to occur, as the samples reps dispense are around 20 billion a year, along with the reps themselves costing about 5 billion a year by the pharmaceutical industry. It is possible for prescribers to order samples on the internet to be delivered to their practice, but this remains rare presently. As a big pharma ex drug rep for over a decade, which during that period the number of drug reps actually tripled, the drug rep's vocation has become more ridiculous, and possibly void of any true sense of accomplishment due to their customers preventing them from interaction or even presence in order for the drug reps to follow directives of the health care givers, and not their own employers, which is to influence their prescribing habits via direct dialogue along with the giving of gifts. The job has become nothing more than doing lunches and leaving samples at offices, for the most part. My perception formed from my own analysis of how drug reps operate in today's environment in the medical community has led me to draw such conclusions, which I believe to be accurate. So they may be named at times in different ways, these promoters will be referred to now only as drug reps, which number close to 100,000 in the U.S. presently to influence close to 1 million prescribers in this country, it is believed, yet is probably less now due to big pharma cutting thousands of reps recently. The cost to the pharmaceutical industry of these drug reps is around 5 billion dollars a year. Income for each rep grosses close to or above 100,000 grand a year on average, along with great benefits and a company car, as well as stock options as they gladly work from their homes and set their own hours, which I understand is much less than 8 hours a day. The main function these days of drug reps, I believe, is primarily to offer doctors various types of inducements of a certain value that are not gifts, but bribes, by definition. And these prescribers visited by drug reps are known as targets. Targets are determined by what is known as 'data mining'. The American Medical Association releases identifying information on doctors that allows pharmaceutical companies to track their prescribing habits. If a doctor, for example, is a high prescriber of prescriptions for particular disease states, or a doctor has an affinity for a product promoted by a drug company, they become a target. The drug sampling of doctors may be considered an inducement, and a rather valuable one for the drug rep, as many believe that these samples are what ultimately influence the doctor's prescribing habits over anything else, including statements from drug reps. Perhaps this may be why the drug industry spends around 20 billion every year on samples. Yet I want to be clear on what I am saying: drug reps are some of the smartest people you will meet that do in fact have great paying jobs with great benefits. Most importantly and my opinion, I believe most reps really WANT to do well for their employers, yet are prohibited from doing so now because of how their employers are now viewed in their medical community. Many years ago, drug reps have used their persuasive, yet ethical, abilities to influence the prescribing habits of doctors in an honest and ethical manner, as they focused on the benefits for the doctor's patients with a particular drug that the detailer may promote to such a doctor. However presently, most health care providers now simply prevent drug reps to speak with them- now this is especially true when they are in clinic treating and assessing patients. More and more medical establishments are completely banning drug reps from their locations, and I speculate that this is occurring for many reasons, which may include the following: The doctors lose money. Doctors are normally busy, so their time is valuable. As a drug rep, you are an incredible waste of their time. Yet they will accept your samples still. The credibility you possibly have thought you had and were perceived as such by doctors as a drug rep is no longer viewed to exist to any noticeable degree by the prescriber. For example and this is based on my experience and my colleagues, doctors view any information you may provide to them as biased and embellished. In my opinion, based on information and belief, their view regarding their assessment of you as a drug rep is accurate due to the statistical gymnastics the employers of drug reps engage in, which effectively and ultimately is permitting and encouraging the drug reps to lie to the doctor and likely are unaware of the statements stated by them are misleading. Doctors by their very nature seek answers objectively. And doctors do in fact find out about drugs through other methods besides the representative of the drug's maker, such as the internet and experience with certain medications. Most drug reps in this country in particular mostly hire drug reps based on such qualities as the candidate's looks as well as their personality, overall. Furthermore, it is possible that pharmaceutical companies desire their drug reps to be obedient and to not question what is asked of them. Upon speculation, this can be possibly determined by the background of the candidate, which may indicate they seek popularity as well as are money driven. In addition, most drug reps do not have degrees remotely related to any aspect of anything of a scientific or clinical nature. During my decade as a drug rep, I would encounter on very rare occasion another rep that may have been a nurse or researcher, and this is concerning that others do not have similar backgrounds because the type of training necessary is rare for a drug rep. In fact, based on my opinion, many do not particularly care to acquire education related to such medical or clinical topics. They learn the basics in order to sell their promoted products. Yet anyone who has ever worked with doctors in a clinical setting, or in a hospital working in a clinical nature, likely they would agree that a drug rep should want to and seek all related to the complexities involved in the restoration of another's health. Many drug reps, it is believed, are void of any complete interest in medicine completely, and I believe this to be necessary. In addition, ethical considerations due to their possible deliberate ignorance created by the necessity of what they are required to say or do by their employers may be viewed as a disturbing fallacy as well. This allows them with the encouragement and coercion of their employer to embellish the benefits of their promoted products at times in addition to offering inducements to doctors in various ways- most of all of which are rather covert, yet performed and issued to select prescribers upon instruction of their employer. Examples may be creating a check from your company to a certain supporting doctor and handing this check to thank a doctor for supporting your company's products for doing little if anything for your employer to justify this check. Or tangible items are given to such prescribers, such as TVs or DVDs which may or may not be utilized in a particular doctor's office. It happens often, such activities. From the drug rep's perspective, it is unlikely they will even consider the possibility to question their pharmaceutical employer due to the great risk of losing income and benefits that they are unlikely to acquire at another place of employment. Because of their consistent and conscious effort to keep their high-paying jobs, the drug reps always appear overtly anxious to please their superiors- regardless of any ethics or legalities regarding any activity they may be required to perform. With big pharma in particular, each drug rep is given a variety of budgets, such as a chunk of cash for doctor office lunches that they are required to spend in a certain period of time. Another chunk of cash may be assigned to a rep to pay assigned or registered speakers of their employer to speak to other prescribers about a disease state related to the drug rep's promoted product. These activities, in my time with big pharma, were never monitored or questioned by managers or superiors. What I did notice is that my annual raises were greater than others according to the amount I spent for that particular year, as this, according to a big pharma company, was a very objective and noticeable variable with securing and keeping your employment in big pharma. While legally risky, the drug companies continue to dispense to their reps these large budgets their drug reps are in effect coerced to dispense with complete autonomy and possibly the spending can be fabricated, which is too complicated to fully explain. This design perhaps is why there are now various state and federal disclosure laws that are presently being considered to mandate the release of all funds dispensed from pharmaceutical companies as far as why a company's funds were spent and for what reason or method. Because, according to the lobbyists of pharma companies, they consistently insist that whatever they spend always is for the benefit of public health. As mentioned earlier, presently such activities are quite covert. Yet if such
laws are mandated, it is likely the accounting of pharma companies will become rather creative and incomplete. In summary, as a big pharma drug rep, my budgets were unlimited, and I typically spent more than I made though the activities I have mentioned so far. And this is not an isolated case. Historically, pharma lavished doctors with expensive gifts and trips. Now it is about funding for them, such as financial grants. Basically, the two remain synonymous and ethically conflicting. Then there is the issue is what again is referred to as data mining. The American Medical Association sells this prescribing data on individual doctors to pharmaceutical companies or pharmacies, by providing others identifying numbers of a particular doctor, such as a state license number or DEA number, which allows them to track the scripts a doctor writes not far from real time availability. This data shows the volume of scripts of a particular doctor and what the doctor has been prescribing for the doctor's patient for their disease state, and this data reveals competitor products to the drug rep as well. Aside from being deceiving and dishonest, the data allows a pharma company to 'reward' those doctors who support their products, while treating the other doctors with 'neglect', which means the non-supporters of a pharma company will not receive any inducement or remuneration from a particular pharma company. The data, by the way, only reflects numbers linked with particular products, and fortunately is free of patient names- this data that is provided to all drug reps. What has been described is the method typical with all big pharma companies, in my opinion, and I worked for three of them. It appears to be manipulative in a psychological paradigm- a combination of Pavlovian responses combined with positive and negative reinforcement. So such methods create a toxic culture required to be absorbed by those members of such a pharma company. Furthermore, the tactics implemented by pharma companies vacuum the judgment of prescribers, which may prevent patients from receiving objective treatment. Yet on the most basic level, it is the samples left with prescribers that ultimately determine their prescribing habits- with various inducements to some doctors running close in second place. Yet remarkably, prescribers are prescribing more and more generics, which typically are not sampled to prescribers. I find this comforting that the manipulation efforts of the pharma industry are not as effective as they believe they are in a rather delusional way. Yet what is happening now in regards of branded meds vs. generic meds, insurance companies are flat out paying doctors to switch patients to a generic if one is available, as well as initiating generic medication treatment for their patients. I speculate they are paying doctors for this as a response of what pharma has been doing for quite a long time. From a clinical paradigm, if a medication is providing desired treatment and good tolerability for a particular patient, one could argue it would be unethical to switch treatment for financial gain, further complicated by the fact that most patients are aware that insurance company payments to doctors for this even occur. It is likely and I believe that most drug reps are good and intelligent people who unfortunately are coerced to do things that may be considered corruptive to others in order to maintain their employment. In other words, the drug reps have compromised their integrity, ultimately. It seems that external regulation is necessary to prevent the drug companies from allowing the autonomy of drug reps that exists, with their encouragement, which forces the reps to do the wrong thing for the medical community, possibly. Because it is obvious that internal controls with such corporations exist on paper often, but clearly are discouraged to be enforced. It is possible that these pharma companies falsely believe that being an ethical company would make them a company without excess profit. One can only speculate on their true motives. Yet it appears that overt greed has replaced ethics with this element of the health care system, which is the pharmaceutical industry, as illustrated with what occurs within these companies. However, reversing this misguided focus of drug companies is not impossible if the right action is taken for the benefit of public health. Likely, if there are no drug reps, there is no one to employ such tactics mentioned earlier. Because authentically educating doctors does not appear to be the reason for their vocation. This is far from being the responsibility of a pharmaceutical sales representative. Perhaps most frightening is that most drug reps fail to dig deep enough to realize that what they do at times may damage public health. "Fear ensures loyalty.�? --- Author unknown Dan Abshear (what has been written is based upon information and belief)

Posted by: Dan on July 20, 2009 08:42 AM


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