Pharmaceutical representative rounds: teaching resident physician–pharmaceutical representative interactions

Gretta A. Gross, DO, Director of Osteopathic Medical Education, Wyoming Valley Osteopathic Family Medicine Resi- dency Program, 2 Sharpe St., Kingston, PA 18704.

E-mail address: ggross@wvhcs.org.

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In the Unites States, there are 90,000 pharmaceutical representatives, or 1 for every 6.3 physicians.1 Given these numbers, chances are that physicians in training will en- counter a pharmaceutical representative either in medical school or during their residency, regardless of academia’s attempts to avoid them. Interactions with representatives begin in medical school and continue at a rate of about four times per month throughout a physician’s career.2 In 2002, the American Medical Student Association (AMSA) established its PharmaFree Campaign, which advocates for evi- dence-based rather than marketing-based prescribing prac- tices, global access to essential medicines, and the removal of conflict of interest in medicine.3 In 2007, the AMSA released their first “PharmFree Scorecard,” which grades medical schools on the presence or absence of a policy regulating the interactions between their students and fac- ulty and the pharmaceutical and device industries. Even in the unlikely event that a future physician does not directly encounter a pharmaceutical representative, they only have to turn on the television or open a magazine or a medical journal and they are bombarded by advertisements for the next blockbuster medication (Fig. 1). The pharmaceutical industry is one of the most profitable industries in the United States, owing in large part to their ability to success- fully market medications.

Although physicians may believe their prescribing habits are not influenced by marketing, the evidence suggests otherwise.2 Regardless of where a physician stands on in- teractions with the pharmaceutical industry, advertising has a profound effect on the prescribing habits of both practic- ing physicians and residents.2 A review of physicians in training demonstrated that only a minority of trainees felt that their own prescribing habits could be influenced by pharmaceutical representatives, but were more likely to believe that other’s prescribing could be influenced.4 It should not be assumed that all interactions with pharmaceu- tical representatives have a negative effect; physicians who interacted with them demonstrated an improved ability to identify the treatment for complicated illnesses. Pharmaceu- tical representatives are experts on the medications they detail and can provide physicians with information on dos- ages, indications, contraindications, pharmacokinetics, and side effects. However, many believe the negatives influ- ences exceed the benefits. Physicians were less likely to identify wrong claims about medications, more likely to prescribe a new brand-name medication as opposed to a generic, and made more formulary requests for medications that rarely held a clinical advantage over existing ones.2 When interacting with the pharmaceutical representative, it is incumbent upon the physician to remember the reason why they call on you in the first place: to sell their product. They are trained to use effective sales techniques to create an increase in the number of prescriptions for their product.5 Given the ubiquity of pharmaceutical representatives and the potential to influence prescribing, it seems logical that we should train future physicians to interact with them in a professional and ethical manner, much like we train physi- cians to function within the interprofessional health care team. Unfortunately, at this time no standardized curricula exist.

A 2008 systematic review of available curricula that provide training on the relationships between residents and the pharmaceutical industry identified nine published pro- grams addressing resident–pharmaceutical industry interac- tions.6 Because of heterogeneity in program content, appli- cation, and evaluation, the authors were unable to make definitive conclusions about the effectiveness of these interventions. However, the observed trend toward resident attitudes and behaviors being affected by the pharmaceuti- cal representative–physician interaction appears to confirm earlier data.2 The authors feel this review affirms the need for a widespread, standardized approach to teaching resi- dents appropriate interactions.

The American Osteopathic Association (AOA) Code of Ethics may be used to inform such efforts.7 In part, the section relating to interaction of physicians with pharma- ceutical companies states that it is the “Physicians’ respon- sibility is to provide appropriate care to patients. This in- cludes determining the best pharmaceuticals to treat their condition. This requires that physicians educate themselves as to the available alternatives and their appropriateness so they can determine the most appropriate treatment for an individual patient. Appropriate sources of information may include journal articles, continuing medical education pro- grams, and interactions with pharmaceutical representa- tives.”7 Our goal is to arm our residents with the necessary tools to provide the best care for their patients. This method is one such tool for that armamentarium.

Many avenues exist for potential resident–pharmaceuti- cal representative curricula, from reviewing videotaped in- teractions and faculty debates to small group discus- sions.8-10 We would like to share the approach we use to educate our residents. The goal of our educational program is to improve resident ability to interpret the information provided from a pharmaceutical representative. This ap- proach directly speaks to the AOA’s ethics statement that the physician be educated as to how to interpret the infor- mation.7 The following describes our current approach.

‌Program

Each month we schedule a pharmaceutical representative to present during our morning academic time (Fig. 2). The representative is asked to speak for approximately 10 min- utes regarding their product or products, and the audience consists of our family medicine residents, medical and phar- macy students on rotation, and our academic faculty in family medicine and pharmacy. During the scheduling pro- cess, the faculty moderator requests the pharmaceutical rep- resentative give a typical product detail and provides them with an overview of the educational purpose of the program. On the day of the presentation, the pharmaceutical repre- sentative is introduced, welcomed, and given the floor for the detail presentation. Upon completion, they are asked to leave the room and the audience reviews the information presented.

Before starting the detail, attendees are given the Phar- maceutical Representative Feedback Form (Fig. 3).11 This form covers various sales tactics used by pharmaceutical representatives during a typical detail. Participants are asked to complete the form during the presentation to help identify behaviors and tactics that the representative may have used to market the product. This form then serves as the starting point for the faculty-led discussion that occurs once the representative has left the room.

This discussion focuses on two areas: the marketing and promotional techniques used during the presentation and evaluating the pharmacologic information presented. In- creasing practitioner ability to identify marketing and pro- motional techniques and the reasons they are used is an essential skill for physicians to possess when interpreting sales information.5,8 Evaluating the pharmacologic informa- tion presented and reviewing the role of the medication in current practice allows for the participants to educate them- selves on how to interpret the information before them.11 Both of these areas are evaluated on the form.

Promotional techniques that are often used by represen- tatives include humor or personal stories to “break the ice”; repetition of product name or advantages; use of headlines, gifts, or tokens (including food); positive feedback; solici- tation of faculty support; promotion of active learning by asking questions; diminishing medication disadvantages or competitive medications; asking practitioners to give the medication a try; and incentives. By pointing out where and how these techniques were incorporated into the presenta- tion, the participants are better able to identify them for what they are—sales techniques used to increase product identification and place the product in a positive light.5,12

The pharmacologic information is reviewed on the basis of both rational appeals and nonrational appeals. Nonra- tional appeals to consider prescribing a medication are often made to physicians during a detail session and include testimonials, appeal to authority, bandwagon appeal, red herring appeal, false cause, appeals to pity, fear, curiosity, and ego gratification.5 Again, by identifying these types of appeals, we hope to increase participant knowledge of how they may be used to encourage use of the product. To review the rational appeal, we implement the STEPS ap- proach.11 The focus is on Safety, Tolerability, Effective- ness, Price, and Simplicity. The standards for comparison are other medications available in the same class. Safety covers serious adverse effects and interactions compared with similar medications. Tolerability is assessed based on pooled dropout rates from medication trial participants. Ef- fectiveness is evaluated based on intention-to-treat with patient-oriented outcomes. Price is considered when re- viewing the overall cost of the medication compared with comparable agents and the cost of treating the disease. Simplicity covers the ease of use and need to be concerned for interactions. Participants are asked to decide whether they have enough information based on the representative’s presentation to evaluate along these parameters. If it be- comes clear during the discussion that this information was not adequately covered during the detail, a question is then formulated to ask to the pharmaceutical representative once he or she rejoins the discussion to see whether the informa- tion can be obtained.

Pharmaceutical Representative Rounds concludes with the faculty moderator facilitating a summary of the infor- mation presented as the group attempts to identify the role the product will play in current practice. If it is determined that more information is needed to further this discussion, the representative is invited rejoin the group for a short question and answer session. At times, additional evidence- based information is needed to identify the medication’s role. In such instances, residents are encouraged to develop an answerable clinical question, review and critically ap- praise the evidence, and present their findings during our Critical Appraisal Rounds (formerly Journal Club).13-17

‌Discussion

A review of direct-to-consumer pharmaceutical advertising in 2003 revealed that every $1.00 spent on advertising resulted in an increase in prescription sales of $4.20.18 Understanding the role that marketing plays in medication cost and how that contributes to the overall expense of health care is important information for osteopathic family physicians to know. Rather than simply ignoring pharma- ceutical representatives, we encourage the reader to delib- erately evaluate interactions with health care marketing professionals and use an approach that is in line with the AOA Code of Ethics. The goal is to ultimately enhance patient care. Although we have yet to develop a method to measure changes in knowledge, attitude, or skills with the educa- tional program outlined here, we feel that physicians must interpret the marketing information that they encounter on a regular basis. This type of learning is a movement toward a more evidence-based practice of medicine.

‌References

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