the Natural Condition

The Public Library of Science seems, to my nerdy eye, to be the ‘open source’ repository of the publishing community. Last week, PLoS Medicine hosted an article that provided a fascinating, and chilling, look into the mind of a ‘drug rep.’ Drug reps are the suave pawns of the pharmaceutical companies who market the newest therapeutic agents. They meet with physicians, prepared with a convincing heap of data supporting their products, and most importantly, armed with a smile and a checkbook. Drug reps often treat physicians to fine dinners that create a convenient forum to discuss family life and, should it come up, cycloxyprxanimibidodizole, or whatever the drug of the week is.

In the article, the authors discuss some of the thought processes of the reps. The main ‘informant’ is a former drug representative for the pharmaceutical company Eli Lilly. If you read anything from the original piece, make sure to peruse Table 1, “Tactics for Manipulating Physicians.” The table describes various ways to market a product based on the type of physician, from the “high-prescribers” to the “acquiescent docs” to the “aloof and skeptical.” The article covers many common practices in the field, such as clever script tracking schemes and the value of giving out samples. While the article is professional and rigorous in its evaluation, it also offers several personal quotes from the front lines of the business:

While it’s the doctors’ job to treat patients and not to justify their actions, it’s my job to constantly sway the doctors. It’s a job I’m paid and trained to do. Doctors are neither trained nor paid to negotiate. Most of the time they don’t even realize that’s what they’re doing…

and

During training, I was told, when you’re out to dinner with a doctor, ‘The physician is eating with a friend. You are eating with a client.’

Even I, a lowly research assistant (but future physician!), was once chatted up by a smooth-talking, curiously-pretty-for-her-age drug rep. I happen to work in a cubicle next to a fellowship program director, who in turn organizes the lives of the actual doctors in the fellowship program, who, finally, are the young, clinical minds who wield the malleable prescription pads. She was, naturally, of an exceptionally amiable nature, but I found the true aim of her banter to be quite obvious: get in good with the right people and, indirectly, the favors and face-time will come. A wry smile came across my face as I thought to myself, “I don’t even know the names of the fellows … you’re wasting your time, miss.”

Despite my obvious skepticism, from an economical perspective, I believe these salespeople are probably integral parts to the progress of modern medicine. When all is said and done, the main thing that drives innovation — and I speak in generalities — is the bottom line. Pharmaceutical companies are firms that sell a product, who are accountable to shareholders. The only way they can attract the brightest minds to develop the breakthrough drugs is by competitive compensation, which stems from a great market share. This is not to say that pharmaceutical companies are purely money-making machines; they probably rely on high volume products (Viagra) to subsidize research efforts for meds that are cost sinks because of either low disease prevalence, or an inability to pay among the afflicted population (poverty). In any case, foolish beneficence on the part of the drug company would be bad for everyone. Drug companies need to sell their products or else no one gets better, and physicians happen to be the retailers — or, at least, the gatekeepers.

So long as the drug reps are not presenting falsified or incomplete information, then schmoozing a doc to prescribe your pill seems just business as usual. I, however, will remain “aloof and skeptical” as long as I can.

References:
(1) Following the Script: How Drug Reps Make Friends and Influence Doctors. Fugh-Berman A, Ahari S. PLoS Medicine Vol. 4, No. 4, e150 doi:10.1371/journal.pmed.0040150

One need not search far to palpate a growing dissatisfaction among physicians about the current state of the practice of medicine. Complaints include longer hours, waning compensation, the hassle of insurance providers, direct-to-consumer drug advertisement, skyrocketing malpractice premiums due to growing fears of injury litigation, and a general disintegration of the prestige and respect long given to the title “MD.” While all these claims are valid, a vociferous elite in the published medical community dwell ad nauseum on the shortcomings of modern practice, while often neglecting the timeless virtues of the physician. Medical Economics recently published an opinion piece by a pediatrician who claims that the he has not, in fact, been overcome with the disenchantment that reverberates in the commentary of many practitioners. “Hard to believe, but it’s been almost 20 years, and I still feel the same way,” writes Dr. Lawrence Rifkin. “Being a doctor can be a hassle. But it’s still a joy and a privilege.”¹

Although Dr. Rifkin’s essay is a mere 700 words long, he uses the term “wonder” five times.² The word has many applications, but “wonder” may be most aptly ascribed to the sentiment of aspiring doctors. Medical students and prospective medical students gaze upon the field with a starry-eyed perspective; we mean to do good, and to make humanity healthier. And good for us. For, just as the crabby, nostalgic docs warned Dr. Rifkin 20 years ago, our opinions will likely change. But I say, you have to set out at level 10 on the “wonder” scale in order to accommodate the proposed drop to a disillusioned level 4. Were students to enter medicine already jaded, they might fall off the charts altogether and find themselves practicing, well … plastics.³ But Dr. Rifkin says that his sense of wonder has not left him. It is “reawakened by stepping back and taking a second or two now and again to look at the big picture.”¹ His point of view is thoroughly refreshing and encouraging to the newest generation of medical students entering a cynical world.

When I pause and really think about what our profession has accomplished, the sense of wonder rushes in. Since the mid-1800s, life expectancy in much of the world has doubled. It’s as if modern medicine and public health have given each of us a second lifetime. Who among us doesn’t have a relative who was saved by modern science—heart bypass surgery, perhaps, breast cancer treatment, or a C-section? My role may be small, but it still feels good to be a part of such a positive change.¹

I hope to thrive off the wonder of being part of a positive change for as long as I can when I officially begin my medical career this summer. And regardless of what truth may lie beneath the seemingly glossy finish, I am sure that cynical diatribes accomplish very little to affect real change, whether in the practice of medicine, or in any profession. But optimism … now there’s a start.

Footnotes:
(1) Still a privilege to be a doctor. Medical Economics. 2008.
(2) Forgive the literary deconstruction of this piece. My undergraduate training involved a good deal of textual analysis, and I cannot help but to count words and to distill meaning where meaning may not actually exist. Nonetheless, I do believe that an author may pen words that arise from a deeper part of their consciousness of which they may not even be aware; the repetition of “wonder” is then seen as an inadvertent, and important, theme.
(3) This comment is, admittedly, a cheap shot. My apologies to the plastic surgeons out there who really do correct horrible disfigurement, such as lifting those dreaded wrinkles that come from the unnatural process of “aging.”

The New England Journal of Medicine recently conducted a panel discussion on the issue of Physicians and Execution. The panel members consisted of a general surgeon as the moderator (Dr. Atul Gawande from the Brigham and Women’s Hospital in Boston, a notable author)¹, a law professor (Deborah W. Denno, Ph.D., J.D.), and two anesthesiologists (Dr. Robert Truog and Dr. David Waisel). As individuals who know the science and have researched the ethics behind the topic of execution, one should duly consider their opinions.

Dr. Waisel outlined that the typical lethal concoction consists of 3 drugs. The first drug, sodium thiopental, is a barbituate whose aim is “to put you to sleep, create amnesia and anesthesia.” The second drug, pancuronium bromide, causes muscle paralysis. While anesthesiologists often use both of these drugs to sedate patients in the operating room, the lethal injection doses are necessarily much larger. The third and final drug, however, is not part of a doctor’s toolbox. Potassium chloride … (Read the rest of this article »)