Purpose The physician-pharmaceutical industry relationship has come under increasing scrutiny. Little guidance exists concerning how smaller practices should manage this relationship. In 2006, Madras Medical Group, a small family practice in rural Oregon, implemented a policy prohibiting visits from representatives of the pharmaceutical industry and the acceptance of drug samples. This qualitative study documents the attitudes of clinic personnel in response to this policy.
Methods Semistructured interviews were conducted using standardized questions related to 4 areas of policy perception: verification of policy decision, impact on clinic operations, influence of pharmaceutical industry, and lessons to share. Common themes were identified.
Results Three physicians and 3 nurses participated in the study. There was consensus on the existence and effectiveness of the clinic policy. Key themes identified from both groups of interviewees included the perception of enhanced clinic operation after eliminating interruptions from pharmaceutical representatives, positive response from the public, and reduced diversion of samples for personal use. Clinicians interviewed agreed that samples were of questionable benefit, that information obtained from industry representatives was incomplete or of questionable veracity or objectivity, and that it was helpful to substitute other drug information sources and clinic-sponsored lunches for past industry offerings.
Conclusion In this case study, a policy prohibiting pharmaceutical representatives from a small family practice was well accepted and a source of pride among physicians and nurses. Other clinics wishing to enact a similar policy may wish to supplement their efforts by proactively using other sources of drug information.
A 2004 national survey of more than 3100 American physicians in 6 specialties reported that 94% had some type of relationship with the pharmaceutical industry, mostly involving the receipt of food in the workplace (83%) or free drug samples (78%).1 Family physicians met with industry representatives more frequently, on average 16 times per month, than other specialties.1 But at what expense?
Physician interaction with the pharmaceutical industry and acceptance of drug samples has been shown to increase prescription costs and nonevidence-based prescribing.2-4 Furthermore, evidence suggests that samples are not distributed to the neediest of patients,5 and that sampled medicines may be distributed with inadequate labeling, instruction, or discussion of adverse effects.6,7
Evidence suggests doctors receive little value from detailing visits.8,9 Physician organizations, including the National Physicians Alliance,10 No Free Lunch,11 and the American Medical Student Association,12 have explicit policies refusing gifts from drug companies and encourage members to examine the ethical implications of interactions with drug detailers. However, little guidance or evidence exists concerning the development of individual clinic policies regarding access of pharmaceutical representatives, the use of drug samples, or how such policies might affect prescribing practices of physicians.
Concerned about the operational impact of increased detailer visits on their private practice, the 5 physicians affiliated with Madras Medical Group decided by consensus to discontinue seeing pharmaceutical representatives and accepting and distributing drug samples. At the same time, they instituted scheduled group educational meetings to review nonindustry-supported, objective pharmaceutical resources. They also participated in a qualitative study to gain insight into the impact of this policy change on physician and nurse attitudes toward the practice of pharmaceutical detailing.
The study team, which included academic researchers unaffiliated with Madras Medical Group, used semistructured interviews with clinicians and key staff members at the rural family practice office. After a detailed literature review, the team created a set of 5 open-ended questions to obtain physician and nurse perceptions in 4 areas:
- verification of the decision process and policy change banning pharmaceutical representatives and drug samples
- impact of the policy on patients, physicians, nursing staff, and clinic operations
- perceived influence of pharmaceutical representatives and drug samples on the practice
- lessons learned to share with other family medicine practices contemplating implementation of a policy excluding pharmaceutical representatives and drug samples.
On a single day about 2 years after the policy change, an out-of-town neutral interviewer (GA) unaffiliated with the practice interviewed physicians and nurses. The interviewer asked the predetermined questions of each study participant and was free to ask related questions depending on the answers. The team taped the interviews and had them transcribed. Two study investigators and a senior research associate, none of whom were associated with the practice, read each transcript and independently identified common themes, concordance, theme saturation, and unique perspectives. The study was approved by the Oregon Health & Science University Institutional Review Board.
Six clinic personnel participated in the interviews: 3 family physicians with an average of 8 years of practice, and 3 nurses with an average of 20 years of service. (The other 2 practice physicians were not in the office on the day interviews were conducted.) The interviewees agreed that the practice was free of pharmaceutical representatives, sample medicines, and marketing paraphernalia (pens, note pads, etc.). Each interviewee understood and supported the policy.