Letters

Reasons for not seeing drug representatives

They should be seen because they are a good resource

But doctors do see them: "freebies" seem disproportionately important

Companies have to encourage doctors to prescribe their products

Drug representatives have much to offer

Summary of electronic responses

They should be seen because they are a good resource

EDITORThe role of drug company representatives is changing, but Griffith's advice not to see them would deprive general practitioners of a good resource, which would be costly to replace.¹ They offer many useful services that may not be easily accessible from other sources in the wider NHS, including up to date information on products and the provision of papers relating to a particular product or disease.

As primary care groups develop, this contact with individual doctors is likely to diminish, but the representatives' role in helping with the development of a formulary in each primary care group could be vital. Their ability to supply up to date information about particular products is also of great benefit to hospital pharmacists in NHS hospital trusts, who are often responsible for maintaining the hospital formulary under the guidance of the drug and therapeutics committee.

Pharmaceutical representatives are frequently a vital financial resource in the provision of sponsorship for meetings as part of continuing professional development. Indeed, half of general practitioners' postgraduate education is sponsored by the pharmaceutical industry, and much of that sponsorship is initiated by the representatives. The standard of continuing professional development is unlikely to be maintained without that sponsorship.

Griffith suggests that doctors feel obliged to see representatives and that junior doctors need education on the pitfalls of doing so. There is no evidence for these statements. Indeed, younger doctors frequently have better skills in critical appraisal and are thus more likely to question the representative hard. If he or she does not have evidence based knowledge of the product then younger doctors are unlikely to use it. Doctors could, though, usefully be given education about the Association of the British Pharmaceutical Industry's code of practice, which spells out what doctors may and may not expect from representatives as well as the penalties for doctors who try to induce representatives to break the code.

Pharmaceutical representatives are well trained and obliged to pass an examination within two years of beginning work. They can be a valuable resource in the provision of information and papers. Rather than stop seeing representatives as Griffith advocates, doctors should turn the representatives' visit into a positive occasion, ask questions, demand information, and make use of them.

Richard Tiner, medical director. 
Association of the British Pharmaceutical Industry, London SW1A 2DY JJack{at}abpi.org.uk

But doctors do see them: "freebies" seem disproportionately important

EDITORGriffith has given several reasons for not seeing drug representatives.¹ Many of the responses to his editorial on the BMJ's website mention the role of "freebies" in bribing doctors to see drug representatives.² An interesting psychological phenomenon is at work here, which is worthy of further study.

I recently had the fascinating experience of working on a drug company's stand at a psychiatry conference, where one of my functions was to give out pens and alarm clocks to delegates after they had filled in questionnaires. I was amazed at the lengths to which people would go to get one of these worthless trinkets. Many delegates stole them when my attention was distracted. One psychiatrist even got his 10 year old son to fill in a questionnaire on how he treated his schizophrenic patients in the hope that this would qualify him for an extra alarm clock.

The perceived value of these goods in the psychiatrists' minds was clearly far higher than their real value. This raises various questions. Does the phenomenon apply only to psychiatrists, or is it universal? Is it peculiar to medical conferences? If the phenomenon is more general, we could hypothesise that general practitioners are driven to see drug representatives by an irrational and irresistible urge to collect their freebies.

Adam Jacobs, director. 
Dianthus Medical, Mitcham, Surrey CR4 3BA ajacobs{at}dianthus.co.uk

Companies have to encourage doctors to prescribe their products

EDITORDespite Griffith's conclusions that seeing drug company representative increases workload and costs,¹ not having contact with the representatives would present problems.

On the whole, drug companies aim to make most of the profit that can be gained by a new drug during the first few years, when it remains under patent. It is therefore vital to the company that widespread use of the drug starts during that period. For this to happen, doctors' awareness of a new product needs to be established. Much time, effort, and money are devoted to the promotion and marketing of the drug, and drug company representatives are a cornerstone of this process.

Without this marketing strategy the likelihood of a successful product launch is greatly diminished. As a result, there will be little profit gain and so no incentive for the drug companies to continue their research programmes to find newer and better drugs for the future.

The training that doctors receive should allow them to assess the information they are given by the representative. Is the drug truly new? Does the evidence prove that it is more effective than others? What are the side effects? The general public is often less well equipped to assess this information and vulnerable to promises of a cure. Consider what happened recently when the company that made a non-steroidal anti-inflammatory drug targeted patients rather than general practitioners with its marketing.

Blanket bans on new drugs, or a blinkered approach to innovative new treatments, not only deny existing patients the benefits of new drugs but damage the opportunities available to future patients. The NHS's response to sildenafil (Viagra), interferon beta, and, in our own specialty, ondansetron, propofol, and sevoflurane is counterproductive to patients' treatment today and damages future drug research.

Doctors are accustomed to working in teams. The pharmaceutical industry is part of that team, in the same way as nurses, physiotherapists, and hospital management are. We don't always see eye to eye with each other, but we spite ourselves and our patients if we won't even talk to each other. Without drug representatives' pens most NHS doctors couldn't write any notes, without their mugs we couldn't drink our coffee, and without their drugs we couldn't cure our patients.

P Dodd, senior house officer in anaesthetics. 
docdodd{at}hotmail.com

T Dexter, consultant in anaesthetics and intensive care. 
Department of Anaesthetics, Wycombe General Hospital, High Wycombe, Buckinghamshire HP11 2TT

Drug representatives have much to offer

EDITORTimes are changing, and doctors' workload is increasing in many ways. Griffith suggests that pharmaceutical representatives are contributing to this workload and ignores many positive aspects to the representatives' existence.¹ He makes an assumption that only new products are promoted, that the information obtained can be accessed from different sources, and that promotion necessarily leads to waste. He is wrong.

Changes in established products are discussed as well as new products. Much information is passed on about therapeutic areas and disease as well as products for all areas. The representative is often the conduit between the health professional and the company's medical information department, the value of which is shown by the 26 000 telephone inquiries and 6000 written inquiries that SmithKline Beecham Pharmaceuticals received last year from the medical profession.

As an example of increased cost attributable to contact with representatives Griffith cites the use of selective serotonin reuptake inhibitors. These drugs provide benefit to many millions of patients and are efficacious, cost effective, well tolerated, and safer in overdose than other treatments. Much more money is wasted on alternatives used at doses so low that they are tolerated but ineffective.

As we approach the new millennium a constructive, not an adversarial, approach between industry and health professionals is needed. Pharmaceutical representatives and the pharmaceutical industry have much to offer. We provide information and education, fund most research in the NHS, and provide altruistic support. In partnership with health professionals we can meet our common goal, improving the health of patients.

A G Benbow, medical director. 
Clinical Research and Development and Medical Affairs, UK, SmithKline Beecham Pharmaceuticals, Welwyn Garden City, Hertfordshire AL7 1EY Alastair_G_Benbow{at}sbphrd.com

Summary of electronic responses

Deciding whether to see or not to see drug representatives is difficult. Of the 20 electronic responses that we received to this editorial, 10 were explicitly in favour (nine of them being from doctors) and seven were against it.¹ The main reasons for seeing drug representatives are free gifts, free meals, free travel, but also "educational support, ... research grants, ... [and] ... drug company sponsored trials" (C Booth).

Drug representatives also "tend to be more pleasant, respectful, and caring to doctors as a whole, or at least on the surface, than the general population" (P Ting).

Do drug representatives influence prescribing patterns? "I hope that most intelligent doctors are able to separate the `wheat from the chaff' ... and not be too influenced by the free pens, scales, note pads, appointment slips, sphygmomanometers, otoscopes, stethoscopes, etc that aid our work greatly, not to mention meals, weekends, and other trips that can make life so much more pleasant" (J Senior).

But then "would companies spend so much if these efforts didn't work?" (S Reidbord).

There is also evidence "that the prescribing behaviour of French primary care physicians is influenced by drug promotion. Firm fidelity was associated with more dangerous prescribing, consistent with the finding that drug promotional information generally omits safety information" (J Coste).