August 27, 2008

What Happens If Pharmaceutical Marketing Disappears? Part 1

Everyone (including me) thinks Pharma is too heavily involved with the practice of medicine.  So we try to think of ways to stop this.  Restrict gifts and consultant fees to doctors; decrease, or at least separate, industry funding from research; and, of course, no more reps in doctors' offices.

These all sound like great ideas, how could you even come up with an argument against any of them?

Here goes.

As a bonus, I even offer a practical long term solution.

The core issue is that Pharma exposure represents a conflict of interest.  Does anyone understand what that term actually means?  Ok, let me ask you a question.  What is the plural of "conflict of interest?"

a. conflicts of interest
b. conflict of interests
c. conflicts of interests

Not so easy to answer, because any of them could be correct.  You can't create a workable policy against something so vague it can't be pluralized . You have to target the individual conflict and weigh it against the individual interest.  It may be a conflict of interest to take money from Merck while doing AIDS research; it might also be a conflict not to.

Ask The Question Differently:

Instead of asking what should be done to curb COIs (clever, huh?) ask: what would happen if we succeeded?

1. No more reps.

I don't know what goes on in other branches of medicine, but if you get rid of reps-- and detailing, and "lunch and learns" and all that goes with them-- psychiatry will instantly grind to a halt, and people will die.

It is an indisputable point that reps know more about the medicines than the doctors do.  Worse, doctors don't know much more than a patient on the Google.  We can argue whether Lilly hid the diabetes risk of Zyprexa, but it took Pfizer's (launching Geodon) to tell us about it.  Don't tell me that we would have learned about it from the extensive journal articles written in 2000 (three.)  Doctors only recently discovered Vioxx had a cardiac risk, though Yahoo! News had an article about it in 1999.  Abbott et al may have rammed Depakote down our throats through 2008, but it took Astra Zeneca to kill it.

2. No more Pharma education money.

A frequent complaint is that there's $1B of Pharma money in CME.  Is that just extra money?  What's going to happen if you take it away?  Then there's no more education.  All of post graduate medical education is done by Pharma.  The residency didn't buy the textbooks for the residents, Pharma did. Pharma sponsors the short "throwaways" and supplements that at least get some readers, unlike the regular journals which get no readers.  Pharma also pays for the CME. 

Who's going to pay the CME lecturers?  Who is going to pick the topics?   The government?

Here's an anecdote: I'm talking to a psychiatrist, and finding it difficult to keep all the receptor pharmacology straight he says, "these new drugs are no better than the old ones, we should go back to them."  Is that a fact, commtard?  You want to go back to Trilafon and Pamelor?  If perphenazine is so great now, how come it wasn't when they called it Trilafon?

If your reason for prescribing a generic is that it is a generic-- I don't mean sertraline vs. Zoloft, I mean imipramine vs. Zoloft-- you are worse than the guy who prescribes Abilify because Pharma paid him.

(More on separating Pharma from CME.)

3.  No more Pharma research money.

Do you know how many clinical trials are done by Pharma?  Lots.  You know how many are done by NIH? Not lots.  If there exists one person on the planet who can tell me what society got from the $68M tapayer dollars spent on CATIE, I'm listening.

Clinical research is performed for two reasons.  Secondarily, it is to promote the science.  Primarily, however, it is deficit spending.  It gives jobs to people.  Few clinical researchers end up studying their passion; they study what's being funded.  If Depakote's paying, we're studying Depakote.  You want a job at Harvard in 2004?  Make sure you can spell Depakote.  You want one in 2009?  It's S-E-R-O-Q-U-E-L. 

If Pharma stops paying, then there will be much less research, even if it is biased. People are missing the hidden benefit of the "biased" Pharma trials: they are still information.  I know Depakote isn't a maintenance agent because of the failed trial that Depakote paid for.  I know Zyprexa causes diabetes and weight gain because of Lilly's own data (and the data from comparator trials done by other Pharma companies.)  I recognize Pharma spins the data, but you can't tell me the data is non-existent.  (Though that is preposterously what was argued about Vioxx.)

If Pharma did not pay for these trials-- if we had to wait for the NIH to investigate Zyprexa's diabetes-- we'd wait a long time.  And, per #1, without Pharma  to inform us a study was even done, we simply wouldn't know.

4. No more Pharma building money.

You know that new wing of your university hospital?  Who do you think paid for it?  The New England Journal of Medicine?  My favorite of all Pharma ironies is that a university will take $25M to build something that it will then ban reps from entering. 

5. No handouts to doctors.

Why do doctors get entangled with Pharma at all?  Is it really just greed?  Then why not just move to California and prescribe marijuana out of a shack?

I'm going to write something that so extraordinarily impolitic that no doctor will even admit to hearing this argument, let alone agreeing with it:

Doctors don't view this as extra money, they view this as money they are entitled to. 

$120k may seem like a lot of money, but no academic doctor thinks that university salary is what he deserves.  So he does extra things for Pharma, or gets some unrestricted grants from Pharma to free up time (so that he can do "other" things).  His assumption is he is worth, say, $200k, the University only pays $120k, and he's going to make the rest up.

BTW, that's why the University gets away with paying you $120k.

The same is true for non-academic docs.  They didn't imagine they'd be getting paid so little to do not exactly the job they thought they had signed up for.  So they make up the difference.

I'm not justifying it, I am explaining it.  If you completely ban all Pharma money going into doctors' pockets, they will demand it from somewhere else.  They are not going to be satisfied with $120k.  Or 15 minute med checks at $30 a pop.   And you'll have a brain drain-- many docs will actually go work for Pharma.  I can't tell you how many times I've been offered jobs at Pharma-- easy jobs, at 2-3x what I make now.   Good students will think twice about medicine.  Maybe they try biotech.  Or law.

Do not email me "what ever happened to working for the common good?"  The only people who say that are not working for anyone, let alone the common good.  Doctors do have a nobler sense of purpose, but not at half price.  Sorry.  It's America.

Before you take that money away, makes sure you have a plan B.


In order to solve the problem, you have to adequately explain the problem. Right off: patients are not the customers of Pharma.  Doctors are.  Pharma isn't making medicines that people want/need, they are making medicines that doctors want/need, i.e. that they will prescribe.  So the way Pharma operates is to either identify what doctors will use, and market it, or they wil find a way to take an existing chemical and market it so that doctors will use it.  Viagra, a drug "for" pulmonary hypertension, was decided to be marketed as a penis pump.

Like everything else in life, the solution is the demand side.

(Part II here.)


Bravo! One of the best post... (Below threshold)

August 27, 2008 9:29 PM | Posted by Navy Shrink: | Reply

Bravo! One of the best posts I've ever read. It's so refreshing to see the truth. You'll never read anything like this in a letter to NEJM. I've been saying for years that if you restrict pharma too much, medicine will come to a grinding halt. We would see Atlas Shrugged played out before our eyes: PhDs would pack up their toys and go home (or at least somewhere in biotech that's still lucrative). So, if not pharma (sponsoring studies) than who? The government? Whenever I see some media piece on greedy pharma, I always wait to hear their solution. I never hear one.

So, I'm looking forward to part II.

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So, what about inelasticity... (Below threshold)

August 27, 2008 11:56 PM | Posted by xon: | Reply

So, what about inelasticity? I'm not at all convinced that the dozens of billions of dollars will just disappear like no-doc mortgages.

Folks will still want a little pill to fix their problems. Enterprising folks will still try to cater to that need.

And the idealistic prognostications is that the next destination of that trade might be less rotten and corrupt than the current. No guarantees, but at least we know pretty well what we've got now. . .

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There is a lot of headroom ... (Below threshold)

August 28, 2008 9:20 AM | Posted by MedsVsTherapy: | Reply

There is a lot of headroom for improvement in the actual world of the practice of psychiatry. Vast amounts of room for improvement. It is truly a challenge to think of what things would be like if the tentacles of Pharma were not everywhere - but two consequences might be: 1. that everyone involved starts thinking of meds as just one part of "treatment" and other things: stress management, the concept of chronic illness management, benefits of social support, benefits of psychotherapy, etc., as all beneficial; 2. research goes in that direction as well as upon the next new drug. Because the gains to be made -the 'headroom' is not in drugs, which continue to be developed but are mostly yielding only incremental benefits, but the headroom is in effectiveness: what does it take to actually get a person with a mental illness to his or her optimal level of functioning, while giving them maximal autonomy and choice, and minimal side effects. It tkaes drugs, and it takes various skills, attitudes, beliefs, habits, a certain level of continuity of care across treatment components, access to treatment, access to health insurance, etc. Any change in one of those that leads to lower handicap due to the illness is, to me, the same whether the benefit comes from a new drug or from a person with a mental illness learning from a psychosocial program on mental illness management such as hosted by national alliance for the mentally ill (sadly, they are gradually being bought off just as the fda, academic psych departments, cme providers, etc are being bought off).

Who will pay for the educational materials? The CME? Well, how does psychology do it? How do master's level counselors manage to get CMEs reliably each yr? The argument that Pharma is necessary to provide CME is laughable.

So, those are my knee-jerk responses.

Thanks for the great post.

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There is one significant co... (Below threshold)

August 28, 2008 11:33 AM | Posted by YP78NH: | Reply

There is one significant conflict of interests that you do not address in your post: the conflict between your desire to be known as the greatest bullshit detector in the world of Psychiatry and your desire to see your pharma stocks grow. I see this post nothing but a sad attempt at reconciling these two.

First of all, you are lumping two distinct types of CoIs together: (1) Pharma's sponsoring of original research (2) Pharma sponsored dissemination of original research.

As long as all the clinical trials are registered with the FDA and their methods/ results made available to the public, I think the benefits of Pharma's sponsoring of original research outweigh its risks (i.e.: discovering new drugs, new indications, new side effects VERSUS emphasis on disease maintenance rather than cure, biased designs).

However, when it comes to the dissemination of research the exact opposite is true. For example, you know very well from the publicized email correspondence between Eli Lilly managers that they knew about the diabetes risk associated with Zyprexa way before all the hell broke loose. You also know that these guys are not stupid and they took a highly calculated risk: The cost of litigation was going to be miniscule compared to all the profit they were making. I hate to sound like a loony scientologist, but in this case they literally got away with MURDER, Mr. Last Psychiatrist. Simply put, there is no benefit in having drug reps "educating" (aka brain washing) doctors so that they would prescribe Seroquel or Zyprexa but not Trilafon. Once the industry sponsored CMEs and interactions between reps and MDs are banned, we (I am a Psychiatrist, too) will still be required to read articles and attend lectures in order to maintain our licenses. As noted above in a different comment, we will then find other ways to continue learning about the new developments in our field. I am quite capable of looking up the APA guidelines, IOM reports, Micromedex, Cochrane Reviews as well as attending the non-pharma-sponsored grand rounds. So are you and the rest of us. So, once and for all, stop talking to reps everyone!

Alone's response: Ok, great comment, here's my response:

I almost never invest in Pharma stocks, as per this post #5.

Pharma sponsored dissemination of research: there isn't any other kind of dissemination. That's my whole problem with psychiatry. No one reads; and the articles are full of postulates masquerading as background information or outright untruths. On top of that there is the bias in the journals themselves, leaving only the "throwaways" as publications psychaitrists read. And they're all sponsored by Pharma. So my argument is not that Pharma dissemination is a good thing, but that it is unfortunately the only game in town. So how do we rework it to be more fair?

You mentioned the APA Guidelines. Are these the same ones that put Depakote at the top of every flowchart? On no evidence? On the vote of select opinion leaders-- all under Pharma sponsorship?The ones who never put a generic drug anywehere in their guidelines until the NIH started sponsoring them (CATIE, STEP, STAR?) $68M would get Trilafon to the top of any flowchart any day

You and another commenter mentioned other areas for unbiased information. The problem isn't that such places don't exist, it's that no one reads them, ever. You know how I know? Because here is the last sentence of the ABSTRACT of a Cochrane review in 2001:(hover for link) "At present, the observed shift of prescribing practice to valproate is not based on reliable evidence of efficacy." That was 2001. I'll repeat: 2001.

All of your points are valid, but apply to a different world. Maybe surgery, where outcomes matter, are measured.

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YPZ8NH and Meds vs therapy ... (Below threshold)

August 28, 2008 11:43 AM | Posted by Diane Abus: | Reply

YPZ8NH and Meds vs therapy -to you both ,a bit of truth-telling.thks much......................

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Since when are behaviours d... (Below threshold)

August 28, 2008 3:19 PM | Posted by mark p.s.: | Reply

Since when are behaviours diseases? no more money to promote false chemical cures for a non physical illness (MENTAL illness)? Great!

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mark, I cry bullshit on tha... (Below threshold)

August 28, 2008 4:16 PM | Posted by seemoreglass: | Reply

mark, I cry bullshit on that last comment.

A behaviour can be a symptom of a disease (BP1, Schiz, Tourettes etc...) or group of learned coping mechanisms (behaviours) can be (falsely) called a "disease" because there is quite the pile of money being made from pharma to study and "cures" for "diseases". Not ALL mental illnesses are treatable through therapy alone. If that was true my panic attacks would have gone away after YEARS of working hard in therapy---they finally went away when I sucked it up and added Lexapro to the occassion after years of anti-pharma attitudes on my part. Do I want to be on meds my whole life? No. Do I wish that I would have started on meds EARLIER instead of being convined that it was a cash scheme created by pharmacuetical companies instead of a viable SOULUTION (cure) to my PROBLEM (disease?)

I'm not going to compare my mental issues with REAL diseases (cancer, diabetes, parkinson's, ALS et all...) but I've heard that Canadian scientists have discovered some isotope of some drug that may cure cancer, and funding has stopped for that research...because there was no money in it. No, I can't confirm this (which makes it a weak argument) but profit is a part of medicine. Period.

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Anyone who thinks doctors a... (Below threshold)

August 28, 2008 10:17 PM | Posted by Anonymous: | Reply

Anyone who thinks doctors are being educated through pharma sponsored CME's needs to lay off the crack. Go onto Medscape and spend about 3 minutes and you, too, can have CME's in any disease you choose. It's a joke. You don't need any medical training whatsoever to answer the questions successfully & get CME's. You just point & click & keep guessing until you get the correct answer. Med boards really need to rethink their qualifications for CME's. It's pathetic. I would be willing to bet most docs are not even reading those articles.

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Given the choice I would ra... (Below threshold)

August 28, 2008 10:37 PM | Posted by Anonymous: | Reply

Given the choice I would rather see a physician who did not also work for a pharm company making money promoting a particular drug. I think patients should have access to that info & let them decide. There would probably be those who didn't care. But, I think many patients would care & would choose the docs who weren't tied to pharm companies.

My previous doc also worked for Wyeth. I later found out he was known as Dr. Effexor around town, because that's what his patients got. I'm sure it was just a weird coincidence & had no influence whatsoever on his prescribing practices.

Alone's response: and there's the rub.

What most people say is that they don't want to see docs who "work" for Pharma. The sentiment is certainly understandable, but again, think about what would happen. First, whether academics are great docs or not, at least give them credit for being in the upper percentile of knowledge-- 90% percent receive Pharma money in some form. So they're all out? Next, private practice docs. Contrary to popular wisdom, Pharma speakers aren't chosen because they are big prescribers; they are chosen because they have knowledge to give other docs DESPITE the fact that they have to use an FDA approved slide deck. In other words, they're chosen because they're knowledgeable.

So avoiding docs who work for Pharma just on that basis is very likely to do you more harm than good.

But your last sentence is the important one. What about the link between speaking and prescribing? Here you have a solid point, to which I am working on a solution. But as a debating point only, ask yourself the following question: if your doctor prescribes Effexor over any other antidepressant because he was paid to do so, aside from ethical concerns, what is the actual harm to patients? Be careful. No one is saying Effexor doesn't work; and no one is saying docs are prescribing it to people who shouldn;t be getting it. We're saying he chooses it over Wellbutrin, by reflex. What's the damage? Once you answer that, answer this: how is it any different to the patient (again, ethics aside) whether he chooses Effexor because he was paid, or because he was "convinced" that it's the best? (To help you: substitute Depakote for Effexor.) Again, I'm sure his morality quotient is higher because he prescribes what he believes in, but this is reality, not the Matrix. It doesn't matter what he believes, it matters what is true. Is it the best? Are they all the same-- and if so, does it matter if he chooses that one first, for any reason?

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This is my first time to th... (Below threshold)

August 29, 2008 1:48 AM | Posted by Isaac Freeman: | Reply

This is my first time to this blog and I have no medical degree myself. However, I do find it very refreshing to see people taking a realistic look at the medical industry instead of flinging the same old anti-corporate reactionary anecdotes. I don't think anyone will argue that our medical system has is flaws, but as a student of economics I always laugh at the proposed solutions. Anywhere from fully socializing it, to regulations so tight you need to get approval before sneezing; it's all so naive and simplistic.

You mentioned something about how Pharma works for doctors. Well, I'm not familiar with the business practices in the respect, but I will say that big problem is that doctors work for the insurance industry as opposed to the patient. And to make the situation worse, the insurance industry has been set up to work primarily for employers, not the patients. You can thank our asinine tax structure for that. Businesses get huge tax write-offs for offering health plans to employees, but good luck getting that for yourself unless you incorporate yourself and work as a sort of sub-contractor.

All of this greatly distorts the market for medical services.

Anyways, I'll stop myself before I go on a tangent, but I just wanted to say that I agree with you most of the way.

A Four-Step Health-Care Solution:

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Isaac: good comment. One ti... (Below threshold)

August 29, 2008 9:07 AM | Posted by MedsVsTherapy: | Reply

Isaac: good comment. One tidbit that is of interest to people that actually think through these things in economic terms: It has been suggested that the Pharma strategy is, alas, not to resolve these mental health problems, but to gather the low-hanging fruit.

If you read about efficacy, and people's blogs and experiances with Pharma drugs, plus with various complementary/alternative medicines, colon cleansings, Rikki, etc., you will see that, with some intervention, there is a decent response. Maybe even better with a med that has some actual impact upon neurotransmitters. So, the blockbuster drug comes out, and it gets tried on everyone.

Some find relief, and stick with it. Most people drop out of regular psych care even if they find a benefit - we humans just do that. So, the docs are really going for the people who 1. have that private insurance and 2. show up regularly and 3. either experience (perhaps only subjectively) some benefit or abide by the sacred societal roles of doctor-pateint and comply because they don't want to violate a societal contract, or violate the 'sick role' (a la Parsons). also, this is why psych drugs are so common for the kiddies: cuz mom or dad is in control - is the one bringing the kid back (but not experiencing the side effects).

Seemoreglass is the exception to the typical patient that many docs are seeing: someone who complies, and tries out the latest-and-greatest cuz the rep just provided lunch and a cartoon-level 'article' last week.

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RE: seemoreglass "I cry bul... (Below threshold)

August 29, 2008 9:44 AM | Posted by mark p.s.: | Reply

RE: seemoreglass "I cry bullshit"
You confuse voluntary and involuntary coercive psychiatry, as most people do.

What if you don't want or need help?

You call them doctors, from your perspective they are helping people.
From my perspective they are imprisoning innocent people and poisoning them into silence/compliance.

I experienced the poisoning and jailing personally. No court or jury before the poisoning and jail.

People forget through the use of language, reality is manipulated and changed.

You say I was in the hospital, I say I was unjustly put in prison.
You say the chemicals are helpful antipsychotics, I say they are just tranquilizers and poisons.

With the transformation of jail to hospital, no judge or jury need be asked of the truth of my guilt or innocence of thinking illegally, diseased thoughts.

With the antipsychotic thought of as medicine, "giving" ( not forcing it on your prisoners) it to people who don't want it, is caring compassionate medicine.

If you are going to have a prison and take peoples freedoms away, you need a real justice system to judge your prisoners as guilty or innocent with lawyers pro and con, instead of one person judge and jury, the psychiatrist.

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Drug reps don’t know more a... (Below threshold)

August 29, 2008 2:09 PM | Posted by Steve : | Reply

Drug reps don’t know more about meds than doctors do. Why not?

a. They have never prescribed them
b. They have never managed their side effects
c. They have never spent hours a day listening to patients who actually use them

Not to mention that the primary criteria for being hired as a drug rep is physical attractiveness, not intelligence.

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Pharma does more than "maki... (Below threshold)

August 29, 2008 5:22 PM | Posted by Anonymous: | Reply

Pharma does more than "making medicines that doctors want/need, i.e. that they will prescribe," pharma is running cooked, sham trials which are actually marketing ploys. From David Gorski's excellent article in Science-Based Medicine on the ADVANTAGE trials for Vioxx:

For seeding trials, however, the exact scientific question being asked is almost besides the point, an afterthought. The real, unstated purpose of such trials is to expose as many doctors as possible to using the drug and thereby make them comfortable using it. The real purpose of seeding studies is to make these physicians advocates for the new drug. The real purpose of seeding trials is marketing, not science.

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I can't argue with much of ... (Below threshold)

August 29, 2008 7:13 PM | Posted by Anonymous: | Reply

I can't argue with much of your rebuttal to my concerns about Dr. Effexor. I do kind of disagree that speakers are chosen based upon knowledge - I know a couple of NP's that do this on the side & while I think they're nice people I'm not certain they're all that bright. Pharma wants med professionals to sell their goods to other med professionals & anybody w/ a license can get that gig.

I want transparency. If my doctor is making oodles from promoting a particular drug & also prescribing this drug to patients then I think patients should have access to that info before they decide whether or not they want to take the med. No, I cannot say for certain that the doc is influenced by the $$ they're receiving from Pharma but I cannot help but think it has an impact on the promotion of that drug in their offices. All I want is the info to be public - it's my decision to take or not take the medicine & since this info would influence my decision I should have access to it.

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""It is an indisputable poi... (Below threshold)

August 31, 2008 11:10 AM | Posted by whatever: | Reply

""It is an indisputable point that reps know more about the medicines than the doctors do. Worse, doctors don't know much more than a patient on the Google.""


And THIS is why I am the final decider about what meds I think are safe for me to try or not try (unless the doctor is being REASONABLE and maybe citing thier sources when correcting me)... and I get labeled a difficult patient for it. I even have had to deal with doctors deneying well known FACTS about certain medications to try and "prove to me" that there is no way a nuttcase like myself could ever know something the doctor didn't tell me.

I'll comment on the rest of the article later.

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Are Drug Reps Really Necess... (Below threshold)

October 9, 2008 8:47 PM | Posted by Dan: | Reply

Are Drug Reps Really Necessary?

One of the main functions of pharmaceutical representatives is to provide free samples to doctors’ offices instead of what has historically been their vocation: implementing authentic and ethical persuasion via presentations. Yet presently, samples are a priority and delivering them is the primary function for drug reps, and these samples in themselves cost billions to the pharmaceutical industry. Yet arguably, samples are the most influential tool in influencing the prescribing habit of the healthcare provider. Let me be clear on that point: it’s samples, not a representative, as the true catalyst of establishing the prescribing habits of a prescriber.
Yet considering that drug promotion cost, overall, is approaching $20 billion a year, which includes the approximately $5 billion spent on drug reps themselves, what if there is another way for doctors to get free drug samples? What if prescribers could, with great elation, avoid drug reps entirely, yet still receive drug samples for their patients?
There is actually a way to do this, but it is a limited process.
With some select, smaller pharmaceutical companies, doctors have the ability to order samples by printing order forms obtained on certain drug company sites on the internet for medications associated with the manufacturers. Examples of such branded medications that can or have be ordered in this way are Keflex, Extendryl, and Allerx. Possibly several more can or are available to prescribers in this way. Others, however, cannot be acquired by this method, yet this method may be the most preferable both from a business and efficiency point of view. Customer satisfaction would clearly be elevated.
So in some situations, a doctor can go online, print off a sample order form, fax it into a designated fax number after completion of the form, and the samples are shipped directly to the doctor’s office. There is no review of the doctor’s prescribing habits nor are there any possible embellishments from reps. And that appears desirable to many health care providers, yet most drug companies apparently place unneeded value on the impact potential of a sales rep of their company to a level of some sort of delusion based on metrics that are possibly categorized as types of fantasies with the copious amounts of drug reps today.
Now, why is this not done more often? Apparently, it is legal. If samples are the number one influencer of prescribing habits, why spend all the money on drug reps to deliver samples personally, as this is essentially their primary duty?
It’s worth exploring, possibly, since the drug rep profession has evolved essentially into those who become a specialized delivery person, dressed in a nice suit, one could say. In other words, and in my opinion as a drug rep, most doctors will not and prefer not to dialogue with you during your visit to their medical clinic.
Think of the money that could be saved if more pharma companies offered samples to doctors in this manner. Furthermore, there is no interruption of the doctor’s practice. And again, there is no risk of bias presented to the doctor.
Doctors again would be able to order and utilize samples according to their discretion, and would be free of interference from the marketing elements of various pharmaceutical corporations. Patients benefit when this occurs, likely. For example, health care providers would be free of possible embellishments and exaggerations voiced by reps on their promoted meds. Inducements would not be offered or accepted. Reciprocity would not be so insisted upon with the absence of drug reps, possibly. In fact, doctors may write more scripts for shipped samples than delivered samples because their discretion is free from interference they have experienced to some degree, and doctors are or would be possibly thankful for this.
Considering the high costs associated with the pharmaceutical industry, having samples shipped directly to doctor’s offices should be utilized more than it is presently — regardless of the size of the pharmaceutical company, perhaps. And the pharmaceutical companies would save quite a bit of money as well without a sales force that may likely not be needed after all. Drug prices may improve.
Something to think about as one ponders cost savings regarding this issue, and improving the efficiency of patient care and treatment.

The new source of power is not money in the hands of a few but information in the hands of many.
— John Naisbitt

Dan Abshear

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Really? Clearly you've nev... (Below threshold)

October 14, 2008 6:28 PM | Posted, in reply to Steve 's comment, by Brian: | Reply

Really? Clearly you've never seen me.

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My name is Thomas Kane and ... (Below threshold)

February 19, 2009 3:22 AM | Posted by Zoloft Prescription Medication: | Reply

My name is Thomas Kane and i would like to show you my personal experience with Zoloft.

I am 57 years old. Have been on Zocor for 3 months now. My experience is that there is a minimal dose required to be effective, and that there is a maximum dose above which the effectiveness wears off. At the proper dose, the effect is darned near magic. Whoever said that the generic is not as good as the real Zoloft is exactly right. There is a profound difference, and it's not made up by increasing the dose. The drug acts very quickly, and the loss of sexual desire is almost immediate. I haven't gained weight yet, but I can see how it would be possible. I have a yearning for donuts and recommend an aggressive program. Also, the combination with alcohol is out.

I have experienced some of these side effects -
difficulty maintaining a quality diet; difficulty getting up in the morning

I hope this information will be useful to others,
Thomas Kane

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