26 November 2007

Who Should Prescribe?

Offhand, the answer seems easy and obvious: only doctors should prescribe.

That is the correct answer, of course, (and that is probably what your teacher told you in school) but not necessarily what happens in reality. In the local scene, for example, the most common people who prescribe are common people --- a friend, an officemate, a classmate, your parents, your boss, a relative, and don't forget, the salesperson at your favorite local drugstore. I think drugstore salespersons get the most consultations for free, and nonchalantly prescribe medicines like specialists to naive customers who take everything they're told like gospel truth.

Should you blame these people? "Oh, no!" they will say. They're only trying to help. Also, the assumption that what works for Juan will work for Jose and Pedro is still predominant around here. Even if it involves antibiotics. Who cares about finishing the whole 1-week course when you're already feeling better? It's the cheaper alternative, and when you live in a place where people put more importance on putting food on the table for family members rather than buying medicines, you can bet with certainty who they will listen to most of the time.

Consulting a doctor always involves expense whether it's a measly P100 (I still know some who charge this low) or an astronomical P1,000 and these days, most will rather gamble and take the free advice offered by friends and salespersons.

But this post is not about scolding people who take prescriptions from friends and promoting consultations with doctors who can prescribe.

Why? Because sometimes, even doctors do not know what to prescribe. You probably heard of doctors attending medical conventions, right? Do you know the purpose of such conventions? The idea is, doctors meet annually to discuss the latest trends in clinical diagnosis and management, and get "courted" or convinced by assigned convention speakers on what medicines to prescribe for the usual ailments they encounter in practice.

These convention speakers are usually respected physicians in their fields and doctors who have been part of, or familiar with research studies concerning the benefits of the drugs/medicines being discussed. In addition, these speakers are either paid in cash or in kind or lavished with enviable perks by pharmaceutical companies who sponsored the talks they were assigned to give. "Honorarium" is the better technical term used. And, that is where the "gnawing of the doctor's conscience" begins, if, that happens at all.

In yesterday's NYTimes Magazine, Dr. Daniel Carlat, an assistant clinical professor of psychiatry at Tufts University School of Medicine, wrote an excellent piece titled, Dr. DrugRep, in which, after a year of giving talks to fellow doctors on antidepressants, he realized that getting paid can cloud his judgment. Here's an excerpt:
Was I swallowing the message whole? Certainly not. I knew that this was hardly impartial medical education, and that we were being fed a marketing line. But when you are treated like the anointed, wined and dined in Manhattan and placed among the leaders of the field, you inevitably put some of your critical faculties on hold. I was truly impressed with Effexor’s remission numbers, and like any physician, I was hopeful that something new and different had been introduced to my quiver of therapeutic options.

At the end of the last lecture, we were all handed envelopes as we left the conference room. Inside were checks for $750. It was time to enjoy ourselves in the city.

I think his revelations from his experiences are no different from what happens here. The question is, how many doctor-speakers will be willing to admit it? As Dr. Carlat said, perks can cloud the way one thinks. Here are some more disclosures:

  • How many doctors speak for drug companies? We don’t know for sure, but one recent study indicates that at least 25 percent of all doctors in the United States receive drug money for lecturing to physicians or for helping to market drugs in other ways. This meant that I was about to join some 200,000 American physicians who are being paid by companies to promote their drugs. I felt quite flattered to have been recruited, and I assumed that the rep had picked me because of some special personal or professional quality.

  • Regardless of how I preferred to think of myself (an educator, a psychiatrist, a consultant), I was now classified as one facet of a lunch helping to pitch a drug, a convincing sidekick to help the sales rep. Eventually, with an internal wince, I began to introduce myself as "Dr. Carlat, here for the Wyeth lunch."

  • Na├»ve as I was, I found myself astonished at the level of detail that drug companies were able to acquire about doctors’ prescribing habits. I asked my reps about it; they told me that they received printouts tracking local doctors’ prescriptions every week. The process is called "prescription data-mining," in which specialized pharmacy-information companies (like IMS Health and Verispan) buy prescription data from local pharmacies, repackage it, then sell it to pharmaceutical companies. This information is then passed on to the drug reps, who use it to tailor their drug-detailing strategies. This may include deciding which physicians to aim for, as my Wyeth reps did, but it can help sales in other ways.

  • I realized that in my canned talks, I was blithely minimizing the hypertension risks, conveniently overlooking the fact that hypertension is a dangerous condition and not one to be trifled with. Why, I began to wonder, would anyone prescribe an antidepressant that could cause hypertension when there were many other alternatives? And why wasn’t I asking this obvious question out loud during my talks?

  • At that moment, I decided my career as an industry-sponsored speaker was over. The manager’s message couldn’t be clearer: I was being paid to enthusiastically endorse their drug. Once I stopped doing that, I was of little value to them, no matter how much "medical education" I provided.

  • A year after starting my educational talks for drug companies (I had also given two talks for Forest Pharmaceuticals, pushing the antidepressant Lexapro), I quit. I had made about $30,000 in supplemental income from these talks, a significant addition to the $140,000 or so I made from my private practice. Now, I publish a medical-education newsletter for psychiatrists that is not financed by the pharmaceutical industry and that tries to critically assess drug research and marketing claims.

Money is always a temptation, no matter where it finds itself. It's a real problem when it enters the supposed-to-be sacred realm of doctor-patient interaction. What happens indeed, when doctors' judgment levels are clouded? Will the "blinded doctor" lead the other "blind doctors" who, in turn, will lead more "blind patients?" Only pharmaceutical companies will benefit while most will suffer.

Never take money from pharma companies. Doctors should be independent thinkers. We should always strive to do our own research and journal readings. We were trained to do so, anyway.

Who should prescribe? Only doctors should. But there should be a prerequisite. Doctors should be not be influenced by monetary and other material temptations from drug companies. Only their clear judgement (and clear conscience) based on existing current medical data should guide them. They owe it to their dear patients. Trust, like respect, is earned, they say. As doctors, let that be an inspiration.

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