One practice’s experiment in refusing detail rep visits

Although some cost was incurred to replace pens, clock, staplers, and other branded items, the gifts brought by the detailers were not viewed as a big benefit for the clinic or its staff. The ethics of gifting was raised as a conflict of interest.

Patient and public response
To explain the key reasons behind the change in policy to patients and the community, Madras Medical Group sent press releases to local news outlets, and physicians took time to discuss the issues of samples and gifting with their patients.

We submitted a press release to the Madras Pioneer [local weekly newspaper] and Bend Bulletin [regional daily newspaper]. I think patients get this issue a whole lot better than doctors do. Doctors think they’re uninfluenced. They’re wrong. The general public knows and thinks they are. If you look at public surveys and patient surveys, it will very clearly tell you that patients take a dim view of this financial entanglement.—(Clinic MD)

Anecdotal patient feedback to the policy was generally positive. Although the practice conducted no formal survey, physicians and nurses received little negative feedback from patients regarding the policy or the lack of available drug samples. Clinic members believe the policy has resulted in improved patient care and moral clarity.

The feedback I got back from patients was generally very positive…and I got a hand-written thank you note that said, “Way to take a stand.” …It seemed to me that a lot of the people who had the fewest resources and least education were the ones who seemed to understand it the most.—(Clinic MD)

Discussion

This qualitative case study contributes to the discussion about the ethics and potential negative clinical effects of the doctor-pharmaceutical industry relationship.^2,13-20 Leading ethicists have long weighed in on the subject.¹⁵ Medical and nonmedical media outlets are replete with articles outlining the practice of drug detailing and questioning its practice.^21-24

Many academic medical centers have adopted policies regulating the interaction of the pharmaceutical industry with students, residents, and faculty.²⁵ In 2008, the Association of American Medical Colleges’ (AAMC) Task Force on Industry Funding of Medical Education released a report that included “developing principles, recommendations, and guidelines to assist members in refashioning industry relationships to better conform to high standards of medical professionalism.”²⁶ However, of the approximately 800,000 physicians in the United States, only 22% practice full time at academic medical centers that would adopt the AAMC policies.²⁷

While Campbell et al reported that more than 90% of physicians interact with pharmaceutical representatives, little is known about how private practice professionals and office staff perceive this interaction, its impact on office culture and workflow, and strategies or policies for managing this interaction.¹ Our qualitative study provides insight into how a small private primary care practice views working in an environment free from direct pharmaceutical detailing.

The policy change evaluated in this study did not occur overnight. What began as a theoretical and abstract discussion of the potential conflicts of interest in the doctor-pharmaceutical company relationship evolved into a more thorough look at this practice’s habits. Practice staff recorded the number of visits and lunches sponsored by drug companies and were surprised by the high frequency of these contacts. In response, the practice set limits on the number of such lunches and, later, on the number of detailing visits. Some doctors in the practice demanded that, during these visits, only peer-reviewed literature be cited by the representatives. After the rofecoxib (Vioxx) situation hit the press, the practice’s physicians became convinced that these limited interventions were not strong enough and developed the stringent policy change.

Before implementing the policy, the physicians discussed their rationale with the staff. Staff feedback was incorporated into the policy and, to date, there has been no staff turnover either related or unrelated to the policy. Recognizing the need for timely and accurate medication information, the practice began a structured and participatory monthly educational meeting using unbiased, evidence-based materials that were previously available to the doctors but reviewed with varying frequency by different providers.

Pharmaceutical gifts were acknowledged as valuable to the staff (lunches, pens, samples, etc.) and lunches in particular offered important social time. Overcoming the pushback from staff on the elimination of sponsored lunches was remedied by providing a monthly lunch with protected time for staff socialization. Interruptions in the busy clinical day decreased after the policy implementation, thereby improving patient flow. Without the frequent detailing visits, the nurses related that they were better able to focus on their clinical responsibilities. Additionally, the practice’s physicians and nurses observed that sample medications were often taken for personal use. The use of prescription drug samples by clinic staff has been documented elsewhere.²⁸