Editorials

Reasons for not seeing drug representatives

Lightening workload, cutting costs, and improving quality 

Many doctorsboth hospital doctors¹ and general practitioners²feel that their workloads are increasing. There is a sense that we are being overwhelmed by a multitude of calls on our time, fitting in management and administration, continuing medical education, teaching, audit, and appraisals over and above our basic clinical work. Why then do so many doctors still find time to see drug company representatives?

Most doctors still see them regularly and a few (perhaps about 10%) see them quite often (M Butterfield, personal communication: unpublished data from BMJ readers). Lexchin noted that representatives have traditionally been seen as the most important source of information about new drugs. ^{3 4} There may have been a time when representatives were the easiest source for finding out about pharmaceutical developments, but now there is ready access to a plethora of non-promotional, evidence based information in simple and digestible form on all the major therapeutic advances. Drug information departments additionally supply detailed advice on such matters as new formulations and interactions. There seems little or no need to see representatives in order to keep abreast of drug developments.

Indeed, strong reasons exist for not seeing representatives. Their job is primarily to sell their company's product. They are an important part of the pharmaceutical industry's promotion methods, and they are highly successful in altering doctors' prescribing habits. Work in Northern Ireland showed an increase in prescribing of various drugs that appeared to be greater than could be accounted for by an increase in patients with specific indications for these drugs.⁵ The authors suggested that the profession may not have instituted effective checks to ensure that the promotion of new products did not lead to inappropriate or wasteful use. Not surprisingly, there is also evidence that the more reliant doctors are on commercial sources of information the less rational they are as prescribers.³ This may mirror the circumstance, recently discussed in the BMJ, of conflict of interest in relation to review articles written by people with drug company links.⁶ Such people are more likely to be sympathetic to the drug in question. Similarly, doctors are more likely to be supportive ofand prescribea drug promoted to them by a representative.

Drug companies might point out that their representatives provide information to clinicians faster and at an earlier stage than other sources. This may be true sometimes but does not of itself lead to good practice. Indeed it may have the opposite effect. At the time that new drugs are licensed there are often no published comparisons with existing standard treatments and rarely any economic evaluations. Thus the really useful information is often unavailable at this stage, and by the time it is, the sales force has moved on to talk about other, newer products. Rather than rushing to know the latest on every new drug, we should perhaps be more concerned about why some proved worthwhile treatments are so slow to be taken up, even when the evidence has been widely publicised.

Increased costs of prescribing are likely to be a further consequence of contact with representatives. Selective serotonin reuptake inhibitors are just one example where promotion by drug companies has boosted sales far beyond levels that might have been expected if non-promotional literature had been heeded. Despite a widely available and authoritative review counselling caution in their use⁷a policy subsequently born out by later evidence⁸sales of selective serotonin reuptake inhibitors soared, with consequent increases in spending. As has been pointed out before,⁹ these resources could perhaps have been better used elsewhere. Given the Byzantine nature of drug pricing in the NHS, it is a matter of speculation what effect there might be on drug expenditure nationally if we all stopped seeing representatives, but at local level it would be surprising if such a move did not bring real benefits.

Changing our habits may not necessarily be easy. Many drug company representatives are delightful and estimable individuals. They are friendly, helpful people who treat doctors with respect and value their timenot a reception doctors get from every quarter. Doctors in turn may feel a sense of obligation and may see representatives as a matter of courtesy. Can we really afford to do this? A particular group targeted by pharmaceutical companies are junior doctorsthe prescribers of tomorrow. We should consider how this problem might be managed in hospitals and in general practice training by devising ways of educating new doctors about the pitfalls they may encounter in seeing representatives.

There is potentially much to be gained by changing our ways. We could cut costs, improve our prescribing practicesand save a little time in our crowded schedules. With more new and expensive drugs now hitting the market, this might be an ideal time for change.

David Griffith, Consultant physician for care of older people. 

Mayday Healthcare, Thornton Heath, Surrey CR7 7YE

Footnotes

   BMJ competing interest: The BMJ might possibly benefit financially if doctors were to see fewer drug company representatives because resources saved might be spent on advertising.