We wanted to raise awareness among doctors that seeing pharmaceutical representatives should no longer be considered a‘ routine norm’, a tradition passed down from one medical generation to the next.

We questioned the assumptions that seeing reps makes us better prescribers, constitutes good medical education or is, ultimately, in our patients’ interest.

In terms of raising awareness, No Advertising Please did the job, featuring in around 80 TV, radio and print media reports at the time, and I still receive regular feedback from doctors, medical students and researchers.

It also caused quite a stir, with enthusiastic opposition provided by the AMA, the pharmaceutical lobby and plenty of readers of this GP magazine. A fine stoush.

One of the valid criticisms was that the campaign focused too much on GPs, whereas much of the expensive prescribing( and overprescribing) occurs in hospitals, where reps also

have an influence. Hospitals are particularly fertile ground for the pharmaceutical industry because not only do they contain most of the key influencers of the nation’ s prescriptions, but they also breed the next generation of prescribers.

If a rep can sponsor an education meeting about gastric conditions and convince a few consultants to try out a new, expensive PPI, the flow-on effect throughout the medical community is 100-fold.

And the learned conversation at the meeting is far more likely to steer towards, say, the distinct chemical properties of different PPIs rather than the fact that the entire drug class is overprescribed.

Discussions around deprescribing, cessation, excessive costs and polypharmacy are a trifle embarrassing at sponsored education sessions, and doctors tend to be polite.

However, an article published in the Journal of the American Medical Association last week sheds new light on prescribing by hospital doctors. The study of 16 millions scripts looked at how the introduction of stricter policies on sales reps directly promoting drugs to

DOCTORS’ ATTITUDES ARE OFTEN BASED ON THE BELIEF THAT DRUG INFORMATION FROM INDUSTRY‘ HAS TO BE BALANCED’.

doctors( known as detailing) affected prescribing. 2

It showed that where the strictest policies were introduced, which included banning gifts from salespeople, restricting drug reps’ access to doctors and penalising both reps and physicians for non-compliance, the market share of promoted drugs

fell and there was a rise in the market share of nonpromoted drugs— largely cheaper generics.

At a drug class level, the hospitals with stricter policies saw a fall off in market share for promoted drugs of 5-10 %, which may not seem much, but given the fact that branded drugs cost up to seven times more than generics, it’ s not small bikkies in a nation that will spend half a trillion dollars on pharmaceuticals this year.

The long tradition of industry influence in our hospitals is difficult to shake. Few Australian doctors will have avoided routinely attending sponsored education sessions throughout their training.

But this norm is slowly changing. Last year, I coauthored a Medical Journal

of Australia paper, calling for increased transparency and decreased influence of industry in hospital-based education. 3

One of the biggest barriers to this is the substantial proportion of decision-makers who continue to hold positive attitudes to the market-oriented activities of pharmaceutical and medical device industries.

Even nurses are targeted, with few questioning whether their wound dressing speaker should be an employee of a company that sells the dressings.

Doctors’ attitudes are often based on the belief that drug information from industry‘ has to be balanced’ and, therefore, is likely to be beneficial to patient care.

Yet, a 2010 systematic review effectively excluded the existence of any reliable

evidence that information sourced from pharmaceutical reps improved doctors’ prescribing habits. 4

It is telling that, among all the vociferous opposition to the No Advertising Please campaign, not a single commentator ever managed to cite any evidence supporting this homespun dissent, despite it propping up the sponsorship of hospital education for so many decades.

GPs sometimes mount the argument that the drug rep is the expert in their new product, so who better to provide education? I consider this a dubious argument even in general practice, but no tertiary institution could possibly use the same justification.

Hospitals are hotbeds of expertise, overflowing with consultant specialists, pharmacists and medical educators.

The only remaining argument for sponsored educational meetings is made by hospital bean counters, who might otherwise have to provide sandwiches. Did someone say something about a free lunch? ●

Dr Coleman is a GP.

References

1. No Advertising Please: bit. ly / 1qVROLl 2. JAMA 2017; online. 3. MJA 2016; 204:20-22. 4. PLOS Medicine 2010; online: bit. ly / 2p3JPSJ