Smart ties, black bags and glib tongues. It has been more than four years since Kasturba hospital saw medical representatives on campus. We took this measure to counter the growing perception that interaction between doctors and medical sales representatives was harming our patients’ economic health.
Not an easy decision. Some doctors clearly felt uncomfortable. “Medical representatives brief us about the new products, and explain their indications, adverse effects and efficacy to us. New brands arrive in the market almost every day. How should we keep ourselves updated without medical representatives?” they whispered their concerns. “What is the harm in accepting small gifts such as branded pens, pads, soap dispensers, coffee mugs or calendars? Or percussion hammers, pen drives, paperweights, calculators and the like,” they asked. Samples? We use them to provide medicines to poor patients in wards. So why you don’t want us to see medical representatives?
Oft repeated arguments, these. Almost every piece of information that the doctors want- on drugs and medical devices- is available online. Evidence suggests that promotion visits by medical representatives influences doctor’s prescriptions- doctors often write expensive drugs, irrational drug combinations and start treating non-illnesses after they see a medical representative. Giving a gift to someone creates an expectation of reciprocity- psychologists have warned time and again. “And even small and subtle gifts,” warn ethicists, “can influence decisions.” As for free samples, they often do not find their way to the poor patients or are given in so small a number that they do not suffice the need of even one-week treatment of pneumonia.
Even in our teaching hospital, pharmacists pointed out to me, tonics, elixirs, irrational multivitamins and protein preparations were being prescribed with freighting frequency. Patients with chronic diseases such as diabetes and high blood pressure, were buying only a small proportion of the drugs prescribed and often did not turn up for their monthly refill.
Concerned that the ban on medical representatives could take a serious toll on their career, members of the local association of medical representatives – about 50 of them – met us requesting us to lift the ban. “We derive up to half of our business from your hospital,” they persuasively argued. “We run the risk of being losing our jobs, if we do not actively promote our company products,” they voiced their fear.
“We are not against you,” we explained them. “We want to loosen the grip of the pharmaceutical industry on doctors. The methods you employ to make your products look better than they are triggers irrational prescription of drugs and increase the cost of healthcare,” we said. “Our doctors are writing drugs that cost 5 to 10 times the drugs they mimic, but are not more effective. Your presence in the hospital makes patients pay from their nose for medications for very ordinary drugs,” we pointed out.
Our earlier attempts to allow limited access to medical representatives obviously did not work. Medical representatives were seen to disrupt our medical services during peak hours, seeking out interns and residents on the wards, often chasing them even in their duty rooms. Some colleagues felt that the ban was a superficial measure that might do nothing to curb the nexus between drug companies and doctors. Medical representatives or no medical representatives, the impact of drug industry on medical practice won’t diminish, they felt. “We need reverse marketing”, said my colleague.” He suggested some measures: to actively teach our residents and interns that cheaper brands are available; to display them in our outpatient clinics and in our wards; to ask residents to carry list of cheaper drugs in their apron pockets. “Eventually residents would develop conditioned reflexes, strong enough to drive away expensive brands in our hospital,” he said.
There is a merit in the argument. A well-known multinational drug company sells a 10-tablet strip of Glimepiride (an oral blood glucose lowering drug) for Rs. 102. Another company sells this drug at one-tenth of a price of its more illustrious counterpart. Unfortunately, the drugs marketed by medical representatives penetrate quickly and last longer in our residents’ brains than economics of prescriptions that some of my colleagues teach during their ward rounds. We believe that a campus sans medical representative would lead to more doctors writing less expensive and more effective drugs- prescriptions not distorted by the biases induced by the goodies offered by industry.