Two investigators then performed computer word searches on the infobases of the 2 previously selected practices using the codebook. All relevant passages were tagged and printed, and the information retrieved was compared with data identified from an earlier in-depth reading of the transcripts from the 2 practices we initially studied. The word search technique and template organizing style was used to identify relevant portions of 4 more practices for secondary data analysis.29
Finally, segments of the selected field notes and patient encounter notes that described drug samples and pharmaceutical representatives were identified and organized into preliminary tables or matrices.30 After constructing matrices for the 6 selected practices we held discussions and further refined the organization and categories within the matrices. Once the matrices were refined they were used to organize relevant data identified by word searches for the rest of the 18 practices in the sample. The matrices served as the framework for data analysis, allowed the visualization of emergent patterns, and facilitated comparisons across physicians and practices.
Results
Individual clinicians and their practices displayed noticeable variation in their approaches to pharmaceutical representatives and the use of samples. Our analysis revealed patterns with respect to the types of contact they have with the pharmaceutical representatives, their use of sample medication, and the relative benefits obtained from the interactions.
Contact with the Pharmaceutical Representatives
All 18 practices had some form of contact with the pharmaceutical industry. This contact ranged from scheduled and well-organized meeting times to random interactions. Formal strategies and policies regarding drug representative interactions and the use of samples were in place in 8 of the 18 practices (44%). One other practice voiced a concern regarding the need for such a policy.
Most of the 8 clinics that had a formal plan or policy preferred a specific time (such as the lunch hour) during which the physicians and staff could meet with the representative. Some practices determined which days and times would be most convenient for their staff. One clinic made the clinician’s schedule available, thus allowing the representatives to schedule visits accordingly. One rural physician even allotted 30-minute patient appointment times to each representative to optimize the quality of these interactions. These lengthy visits facilitated more extensive drug detailing and CME, and generated an ample supply of samples, which were used to serve the needs of this particular rural community. A receptionist in another clinic was found to simply use a chalkboard to notify the staff whenever a representative had set up a presentation in the office. All of these measures appeared to be effective in minimizing confusion, distraction, and schedule disruption.
The remaining 10 practices displayed more haphazard dealings with drug representatives. These included brief hallway meetings that happened when clinicians were confronted by a representative as they exited the examination room. Other pharmaceutical representatives waited in medication sample rooms, hoping to catch the physicians as they searched for samples. These casual relationships were, at times, counterproductive. In one practice the physicians seemed oblivious to when “drug lunches” were scheduled, leading to frustration on the part of the pharmaceutical representatives; in another, the physician found herself rudely interrupted by an imposing representative during her own lunch.
Usage and Storage of Sample Medication
In the 18 practices, medication samples were used in 19.8% of the 1588 observed patient encounters. Multiple drugs were dispensed in 14.6% of the encounters in which samples were used. In only 5.1% of cases was a medication dispensed as a result of a patient’s specific request; the clinician usually initiated the distribution of samples. Drug samples were also offered to additional family members in 3.5% of encounters, sometimes even when these individuals were not accompanying the patient to the given appointment. This appeared to be particularly common in certain rural practices where the clinicians seemed sensitive to the needs of their patients and their families.
A review of the types of medication dispensed revealed noticeable trends and pointed to a prevalence of certain medication categories [Table 1]. The top 4 categories included asthma and allergy remedies, anti-infective agents, analgesics and anti-inflammatory medications, and antihypertensive drugs. These major categories accounted for more than 63% of all drugs dispensed.
The duration for which these medication samples were given varied from starter dosages (lasting 1-3 days) to complete courses of treatments (eg, a course of antibiotics) to amounts sufficient to supply the patients’ needs for several months (eg, antidepressants). The analysis of the clinician’s intent when dispensing samples identified that some were using samples to test for efficacy and tolerability while others were attempting to offer temporary relief or convenience to the patient. Also, certain physicians were clearly concerned about cost savings for their patients. The use of medication samples could be seen to represent tangible benefits to the individual patient.