BACKGROUND: Interactions between the pharmaceutical industry and physicians have been discussed in numerous publications; however, most articles are limited to surveys and self-report data and often focus on academic or training contexts. We describe the role of pharmaceutical representatives and the use of samples in community-based family practices, using data obtained by directly observing clinical encounters.
METHODS: We collected detailed descriptive field notes of the direct observations of 53 primary care clinicians and 1588 patient encounters in 18 purposefully selected Nebraska family practices. We used a comparative case study design, that used depth interviews of clinicians and office staff, and included details of the interactions with pharmaceutical representatives and the use of samples in clinical encounters.
RESULTS: Individual providers and practices displayed noticeable variation in their approaches to drug representatives and samples. We found formal strategies and policies in a minority of practices. Generally there was little structure in the organization and distribution of sample medications at the office level, and detailed patient education regarding these drugs was rarely observed in patient encounters. Nevertheless, samples were used in almost 20% of observed encounters, at times as starter dosages, but often as complete courses of treatment. The benefits derived from contact with the pharmaceutical industry varied substantially, but most often included free medication samples, meals, and patient education materials.
CONCLUSIONS: Clinicians have a complex symbiosis with the pharmaceutical industry and need to critically evaluate their handling of samples and their contact with pharmaceutical representatives to optimize this relationship and ensure quality patient care. Clinics with specific policies for interactions with drug companies appear to derive more satisfaction from their encounters.
The world of medicine is permeated by the influence of the pharmaceutical industry, which spends an estimated $10 billion (more than $13,000 per physician) each year on drug promotion.1 This industry’s influence extends from medical education to clinical research and patient care.2 For example, medical journals and medical conferences are supported by pharmaceutical advertising or depend on financial contributions from pharmaceutical companies to offer their programs. Pharmaceutical companies grant a variety of scholarships and subsidies. The pharmaceutical industry also reinvests a portion of its profits to support new research and development, including hundreds of clinical trials reported each year in the scientific literature.3 Up-to-date drug detailing and continuing medical education (CME) is offered to clinicians, and patient education materials are frequently made available to practices. Patients, especially those with a lower income, benefit from receiving free medication samples donated by pharmaceutical companies.
Pharmaceutical companies, health care providers, and patients represent unique interests that may at times overlap. How the interactions between physicians and pharmaceutical representatives influence prescribing habits, decision making, and physician behavior in general is a contestable topic that has not been well studied or thoroughly understood. In the last several years, medical organizations in the United States and Canada have released discussion papers and policy statements about the relationship between the medical profession and the pharmaceutical industry.3 Whether the influence of the pharmaceutical industry is ultimately beneficial or detrimental remains a contentious and complex topic shrouded in much controversy.4-15
The interactions between the pharmaceutical industry and physicians have been discussed in a plethora of publications. Several of these articles have focused on the ethical implications of these interactions and the potential for exploitation; however, they have commonly been based on surveys and self-reporting and have often been limited to providers in academic or residency training contexts.3,16-21 Brotzman and Mark16 encourage the development of more comprehensive policies for residency training purposes. Kelcher and coworkers19 promote the concept of a structured educational program to prepare residents for future contact with the pharmaceutical industry. Lexchin9 discusses the need for critical comparison when evaluating drug information received from pharmaceutical representatives.
So how do family practice clinicians approach this challenging relationship? Through direct observation of these interactions within the private practice context, we attempted to add a new and vital dimension to the assessment of this rather complex symbiosis. We describe the approaches and reactions of individual family physicians and their practices to pharmaceutical representatives.
Methods
The Prevention and Competing Demands in Primary Care Practice study was designed to examine the organizational contexts that support or inhibit the delivery of preventive services in family medicine practices. Eighteen practices were studied using a multimethod ethnographic design that involved extensive observational field notes of the office system and the clinical encounters. These notes were collected by a researcher who spent at least 4 weeks in each practice. A total of 44 physicians and 9 other clinicians were shadowed, and approximately 1600 patient encounters were directly observed. Individual depth interviews were conducted with each clinician and many of the practice staff to obtain their perceptions.