Instructions accompanied the dispensing of samples in 150 (47.8%) of the cases and were predominantly verbal in nature. Dosing appeared to be the main focus, and little to no attention was given to more detailed information, such as whether the medication should be taken with meals. Drug interactions were not routinely discussed.
The majority of dispensing was done by physicians, physician assistants, and nurse practitioners. In some clinics, office staff had access to samples and were asked to consult with the physician before using these samples. Personal use of samples was documented in at least 4 practices, and in 2 of these the nurses were described as “helping themselves.” One particular clinic even voiced concerns about patients having unsupervised access and mentioned the need to develop a drug policy.
Dispensing patterns varied significantly among the clinics. Certain practices, especially those in rural, underserved communities, were found to dispense more liberally than others. These clinics appeared to be particularly sensitive to the needs of the individual patients and those of the greater community. In one practice, medication was handed out in 39.2% of encounters. On one occasion the physician waited until after the pharmaceutical representative had delivered an adequate supply of the necessary medication to give it to the patient. In contrast, clinicians in a particular suburban clinic only dispensed drugs 4.4% of the time.
However, even within a given practice, vast individual variances existed for each clinician in their approach to samples. In one clinic, 2 of the partners displayed disparate habits: One physician used samples regularly (in 41.9% of observed encounters), and the other only did so on rare occasions (in 3.2% of observed encounters). Of all the 18 sites, the physician who dispensed samples most frequently did so in 56.7% of observed encounters; the physician, however, at the other end of the spectrum dispensed medications in 2.4% of the observed patient encounters.
Of the 18 practices, 9 made use of specific closets or rooms for the storage of medication samples. One particular practice boasted an extraordinary and meticulously organized shelving system, complete with labeled bins and demarcated sections. The medical assistant in whose office these medications were stored was responsible for dispensing the ordered medications. In contrast to this efficient system, most clinics displayed very little structure in the organization and dispensing of samples. One clinic was described as having an overfilled, disorganized stack of shelves where medications were placed alongside vitamin supplements and herbal products. In this clinic staff spent vast amounts of time searching for the appropriate samples.
Only one clinic kept the sample room locked; another office had placed a notice on the door to keep it shut. It is important to note, however, that these storage places did not contain narcotics or similarly scheduled medications. In spite of Health Care Financing Administration regulations, we did not find any documentation to support which samples with which serial numbers had been distributed to patients, making effective recalls almost impossible. Stocks were most often replenished during routine drug representative visits. In one of the sites the head nurse kept in contact with the representatives and notified them when additional stocks were needed.
Benefits of These Interactions
We found that physicians and patients gained some advantage from their dealings with drug companies. The benefits the practices obtained from their contact with the pharmaceutical industry varied substantially. Other than medication samples, the most commonly observed benefits included the provision of meals, treats, and patient education materials [Table 2].
Patients also profited in a spectrum of ways. While samples represented tangible cost savings, immediate relief, and convenience to the individual patient (and occasionally to their family members), patient education materials facilitated further understanding of their diagnosis, potentially leading to a higher degree of satisfaction with their health care.
Discussion
Our study suggests that the relationship between the pharmaceutical industry and clinicians is symbiotic. It is a complex relationship that deserves objective analysis regarding its virtues and pitfalls.
Although it is essential to acknowledge the extent of the pharmaceutical industry’s influence, it is equally important to recognize and enhance the opportunities that clinicians have to direct this relationship. Our data suggest that clinics with existing policies for interactions with drug companies appear to derive more satisfaction and less frustration from their encounters. Formal meeting times eliminated unwanted interruptions and distractions from patient care and made the interactions more meaningful. Physicians who negotiated extensive and structured contact with drug representatives often received regular visits and generous supplies of both samples and patient education materials. Drug representative briefings, even though these needed to be viewed with healthy skepticism, also constituted a welcome form of CME for certain physicians.31