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VIEWS & REVIEWS: Kinesh Patel Why I love a free lunch BMJ 2008; 336: 962-a [Full text]

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Rapid Responses published:

Why we did away with the free lunch

Mick A Leach   (25 April 2008)

Free lunches are not the answer

Brett D Montgomery   (26 April 2008)

In Defence of "Free" Lunches

Michael A James   (26 April 2008)

Junior Doctor's Salary and CPD

Mohammad S Rahman   (26 April 2008)

Free lunch - shurely shome mistake

Jack Beattie   (26 April 2008)

Not so angry from Glasgow

Des Spence   (26 April 2008)

that McEnroe moment

Clare E Wilkie   (27 April 2008)

Free Lunch

Suresh Kumar Pathak   (28 April 2008)

Let's get the message right. Intellectual and not Gastronomical indulgence!

Osborn A. Viegas, Claire M Viegas   (28 April 2008)

Hungering for answers

Anna Shore   (28 April 2008)

You must be joking

Adrian H Sie   (29 April 2008)

The Ethical Price (to physicians and patients) of Promotional Lunches

Anthony N Fleg   (1 May 2008)

Free Stuff? Yes, Please.

Annemarie Jutel   (1 May 2008)

There ain’t no such thing as a free lunch

Jim C Moonie   (1 May 2008)

Who sups with the devil must needs a long spoon

Roger K.A. . Allen   (1 May 2008)

Lunch Free for whom?

Muthukrishnan Jayaraman, KVS Harikumar, A Verma, KD Modi   (1 May 2008)

not simple, is it?

Declan P Fox   (1 May 2008)

What about the NPC?

Peter D Burrill   (1 May 2008)

Lunch from a high horse?

John A Wilson   (1 May 2008)

Best interests and vested interests: the NHS, medical education, and drug information

Patricia McGettigan   (30 May 2008)

Why we did away with the free lunch 25 April 2008
Mick A Leach, GP Harrogate, HG1 5JP Send response to journal: Re: Why we did away with the free lunch	We have a weekly clinical meeting for our whole (clinical) primary health care team. The food used to be provided by a pharmaceutical company, who then after our discussions made a presentation. We became very fed up with presentations of very variable standards about drugs that were not usually new at all; and where the drugs were new, the presentations were clearly in fact promotional rather than well balanced reviews of all the evidence concerning their use and role, compared to existing options. So we decided to pay for our own food. Now, once a quarter, we have a meeting to which we invite one of our senior PCT pharmacists, at which we discuss all new drugs (possibly relevant to primary care) licensed since our previous such meeting, and look at evidence surrounding them. Within in our PCT we used to prescribe an average quantity of new drugs; we are now bottom in the list of prescriptions issued for new drugs. We're happy to pay for our food. Competing interests: None declared
Free lunches are not the answer 26 April 2008
Brett D Montgomery, Clinical Senior Lecturer Discipline of General Practice, SPARHC, University of Western Australia Send response to journal: Re: Free lunches are not the answer	I share Dr Patel’s concerns about doctors’ continuing education and the quality of hospital food.1 However, I disagree that "free" lunches are the best solution to either of these issues. No clinician can reasonably be expected to follow the progress of experimental drugs in hundreds of journals. That is why we have independent sources of information about drugs, which aim to distil an often complex evidence base into accessible guidance for busy clinicians. Examples of these publications include the Drug and Therapeutics Bulletin, NPS Radar, and Prescrire International. The latter publication published a review of ivabradine last year, deeming it "best avoided".2 According to the Prescrire abstract, concerns include a lack of evidence of superiority to standard anti-anginal medications, and evidence of increased adverse cardiac events in patients taking ivabradine compared to patients taking atenolol or amlodipine.2 Did Dr Patel hear these messages from his smiling drug rep? I found this information via a PubMed search in about the time it would have taken Dr Patel to eat his lunch. Contact with drug reps is positively associated with prescribing of new drugs, prescribing costs, and nonrational prescribing.3 Industry-paid meals are associated with formulary addition requests.3 New drugs are not necessarily safe; how many patients may have been harmed by free lunches promoting rofecoxib? And "free" lunches are not really free: they are paid for with sales of medications. It would be wise to improve investment in doctors’ prescribing education, but let us not deceive ourselves that free lunches are a substitute for this. References 1. Patel K. Why I love a free lunch. BMJ 2008; 336: 962. 2. Anonymous. Ivabradine: new drug. Best avoided in stable angina. Prescrire Int 2007; 16: 53-6. 3. Wazana A. Physicians and the pharmaceutical industry: is a gift ever just a gift? JAMA 2000; 283: 373-80. Competing interests: BM is a member of Healthy Skepticism, an organisation that aims to reduce harm from inappropriate pharmaceutical promotion.
In Defence of "Free" Lunches 26 April 2008
Michael A James, Consultant Taunton & Somerset Hospital, Taunton TA1 5DU Send response to journal: Re: In Defence of "Free" Lunches	Dear Sir Re: Why I love a free lunch. K Patel BMJ, 2008; 336: 962 How refreshing to find the journal publishing an article with a modicum of common sense and treating us to a brief visit to some down to earth reality rather than the normal diet of continuous force-fed PC drivel to which we are normally subjected. It is really quite a surprise that such a dangerous reactionary made it through the editorial process, it remains to be seen whether such a slovenly lapse would be allowed twice. I am not quite sure how all this furore about “free lunches” first started, presumably from someone who needed to raise their profile with a few easy publications on a topic that was bound to be lapped up by the modern fraternity with its fad for self-deprecating disparagement mainly promulgated by those who have escaped the humdrum need to actually deliver reality and prefer the cosy comforts of the armchair (or should that be committee room chair) critic. The fact is that no one but the dimmest wits imaginable (sadly the sort of people who take on our managerial roles) ever thought that there was any such thing as a free lunch. Everybody knows what a drug lunch is and if they did not it is quite obvious from the moment they arrive and start reading posters and receiving articles and promotional material, strangely all about the same thing that this must be part of an advertising program! Congratulations! the PC brigade have spotted this cunningly disguised trick. Just in case there was anyone left out there who did not realise this, I am sorry to have disillusioned you, however now that we have established that a drug lunch is an advertising opportunity - what is wrong with that? Has advertising suddenly become illegal, is it contaminatory or infectious. We had better let the rest of the world know since the entire world runs on the economy of advertising, not least our own BMJ who fund the journal with page after page of this disgusting effluent. Yes I know that this too has been the subject of PC debate, but the fact is that the advertising funds the publication – who would pay for it if it were not for the advertising? The fact is that advertising offers not just doctors but the whole world a service. No its not a free service but who offers anything worthwhile free? Advertising offers us all a service and it is a service that occurs at many levels. There is the funding of events (ever heard of the Olympic Games), the funding of research and yes the funding of education. However, to take it back to its most fundamental and basic level it is essential to the whole process of communication. As Dr Patel said, who would have ever have heard of Ivabridine if the manufacturer had not notified us of its existence who would have heard of Live Aid if it had never been advertised? The OED defines advertising as the process by which something is made publicly known. This is clearly an essential service. Advertsing, only becomes sinister when it is done covertly or in a way that is not open – nothing is more open than a drug lunch. It is a lamentable fact that Governments around the world are not prepared to fund the essential postgraduate education of their medical work forces. Without drug company support I would not be able to fulfil my minimum CME requirements and neither would the vast majority of British Doctors. Personally, I agree that it would be preferable that my education was paid for out of the public purse, but I do not think I would be prepared to accept the cuts that would be necessitated elsewhere in public services to pay for it. Even if all education was publicly funded a certain amount of advertising would still be necessary to bring new developments to public awareness, so shall we just all grow up and accept that advertising is part of life, part of our education is learning how to assimilate and process advertising so that we can use its benefits and discard the packaging. Competing interests: None declared
Junior Doctor's Salary and CPD 26 April 2008
Mohammad S Rahman, Speciality Registrar Year 3 In Psychiatry Mersey Regional Psychiatric Training Programme Send response to journal: Re: Junior Doctor's Salary and CPD	It’s rather sad and alarming that a junior doctor doesn’t feel any pang conscience when he attends drug industry sponsored free lunch (1) , since there are ample evidences that these free gifts affect the doctor’s prescribing behaviour (2) and drive the cost up for the patients (3). Instead of reading two general journals, author may want to include some evidence based medical journal into his reading list. But this article raises more fundamental question about how doctors’ are expected to pay for their continuing professional development. I see a parallel between this and the recent uproar surrounding the Members of Parliaments’ (MPs) expenditure (4). It’s unreasonable to expect MPs’ to pay for all their official duties out of their own pocket and there have been calls to increase the basic salary and concomitant clarity in their expense account management (5). With European Working Time Directive (EWTD) and decrease in pay supplement, the salaries of the junior doctors are set to get lower. Recent below inflation pay rise (6) and removal of free accommodation (7) mean some very hard financial times for newly qualified doctors in UK. Primary beneficiary of the knowledgeable doctor are the patient. If the society wants more independent and impartial doctors who will be acting on their benefits only, then NHS should substantially increase the education budget and ring fence it. Till that happens, there will be conflicting interests among junior (and senior) doctors which will drive them towards ‘free Marks and Spencer lunch’ provided by the pharmaceutical representatives. References 1. Patel, K; Why I love a free lunch BMJ 2008;336:962 2. Chren MM, Landefeld CS. Physicians' behaviour and their interaction with drug companies. JAMA. 1994;271:684-689. 3. Caudill, TS, Johnson, MS, Rich EC, McKinney, WP. Physicians, pharmaceutical sales representatives, and the cost of prescribing. Arch of Fam Med. 1996;5:201-206. 4. http://news.bbc.co.uk/1/hi/uk/3763440.stm 5. http://news.bbc.co.uk/1/hi/uk_politics/7286328.stm 6. http://www.nhsemployers.org/pay-conditions/pay-conditions-3612.cfm 7. http://www.bma.org.uk/ap.nsf/Content/fhoaccom1207 Competing interests: I have not attended any pharmaceutical company funded free lunch or received any free gifts (e.g. pens, writing pads) over last 3 years. I have attended an examination preparation course which was partially subsidised by Novartis. I occasionally see pharmaceutical company representatives who provide me with literatures related to their product.
Free lunch - shurely shome mistake 26 April 2008
Jack Beattie, Paediatrician Royal Hospital for Sick Children, Glasgow G3 8SJ Send response to journal: Re: Free lunch - shurely shome mistake	I assume this is some kind of editorial prank? Here, on the same page of the esteemed journal we have young Dr Patel extolling the value of drug company food bribery to educate us about their products, while pictured above is BMJ writing colleague Dr Spence, evangelist for the ‘no free lunch’ cause (http://www.nofreelunch-uk.org). Doubtless a Glasgow kiss of peace will reflect their mutual respect when they next meet for a mentoring session. I hope Des Spence has calmed down. Competing interests: Dr Spence & I may share care of some patients, free at the point of delivery.
Not so angry from Glasgow 26 April 2008
Des Spence, GP G20 9DR Send response to journal: Re: Not so angry from Glasgow	I am grateful to Kinesh for raising such an important issue. He speaks for the silent majority of doctors who still enjoy the hospitality of Pharma Companies valuing the education and support. Believing that if they are influence by Pharma education this is largely for the good and in the interests of patients. But respectfully I must disagree In reality there are scant new drugs ( perhaps one a year in most specialist areas) with most new BNF entries mere reformulations or “me too” medications. Also never suggest Pharma marketing material is education – it isn’t. But consider prescribing new drugs presents risks. Some 30 000 patients are currently seeking compensation for heart attacks and strokes as a direct consequence on widespread prescribing of Vioxx. Vioxx is a long line of new drug disasters and subsequent withdrawals. Rapid uptake of new drugs often puts patients at risk. More generally , however, Pharma Marketing has distorted of the medical agenda and made us disproportionately dependence of therapeutics. The recent revelations on the efficacy of antidepressants a case in point. We have seen the development of a miserable and medicalisation of society. For too long doctors have pointed to the Pharma industry (like Rick in The Young Ones) saying “it wasn’t me it was them” but this isn’t true. Indeed the industry are at least currently trying to address marketing issues. The problems of medicalisation and excessive hospitality is our responsibility. The GMC has been complacent and reluctant to specific guidance to doctors. So the whole issue has been allowed to drift. We are public servants with our £200 000 our University education paid for by the state. Our NHS offers unrivalled service and care to all in society irrespective of their ability to pay. Doctors in the UK are motivated by vocation and not by profit . I am very proud to be a UK doctor. It might seem political correct but I make no apologise. I have taken, a sworn oath to but the needs of patients first and these are not served by the current dependence and contact with the Pharmaceutical industry. There is a need to silent majority to speak in out this debate. Competing interests: Nofreelunch , Mother wore a cheese cloth shirt, smoked cannabis at University , holding left wing views but trapped in middle class suburbs
that McEnroe moment 27 April 2008
Clare E Wilkie, GP Northfield/Mastrick Medical Practice, Aberdeen AB16 5UU Send response to journal: Re: that McEnroe moment	As the man said, Dr Patel, you cannot be serious. You cannot maintain that promotional material from a drug rep equates to education. The reps visit, bearing salmon and rocket roll or whatever, to persuade you to prescribe their drugs. They are not there to engage you in a discussion of the relative merits of different drugs or treatments (or of refraining from prescribing completely), which is what an educational session or educational publication would ideally do. It can't be that onerous to read the Drug and Therapeutics Bulletin, or to consult the BNF or your pharmacy advisor when you need to know about a new medication. The messaage you get may be more complex and less starry eyed than the reps' message, but it will certainly be more independent. I might add that drug advertising to doctors differs in an important way from advertising of, for example, consumer goods: we do not pay the bills - the NHS does. Is that an excessively PC point to make? Competing interests: None declared
Free Lunch 28 April 2008
Suresh Kumar Pathak, Retired GP Retired Send response to journal: Re: Free Lunch	It is nice to read the confession of Dr. Patel about the free lunch. But Free is a not the correct description. The cost of entertaining and providing the food and some goodies at the medical representatives stall adds up to the cost of the drug, and ultimately the tax payer bears the cost of Salmon roll. Only recently there was an Editorial in BMJ about the drug compnies incentive offers (or is it bribery?) to the prescribing doctors. Fortunately I have never enjoyed these luxuries during my working for more than 30yrs as a GP, I am proud of this. Competing interests: None declared
Let's get the message right. Intellectual and not Gastronomical indulgence! 28 April 2008
Osborn A. Viegas, Professor of Reproductive Health Tan Sri Jeffrey Cheah School of Medicine, Monash University, JKR 1235, Bukit Azah, 80100 Johor Bahru, Claire M Viegas Send response to journal: Re: Let's get the message right. Intellectual and not Gastronomical indulgence!	The retrospectroscope is a wonderful biomedical tool! As I approach the end of a career that has spanned four continents (Africa, Europe, Australia and Asia) I like to think I have seen it all but am sensible enough to realise that this is not possible. The profit motives of any pharmaceutical company can hardly be disputed. Even worse, such “educational” interaction between doctors and the industry may be more sinister than immediately apparent. For example, there is a well-known association between such interactions and the change of the prescribing habits of younger (particularly) doctors and to spiralling medical costs with no evidence of commensurate improvement in patient satisfaction. So, why does the medical fraternity continue to foster such "intellectual binges"? When I was Practicing in the UK in the early 70s, such methods of education were frowned on. There was either a cap placed on the level of entertainment provided or sometimes, a ban on the use of any given product name that was being touted at the time. How things have changed since then! Salmon and rocket rolls are no longer the benchmark. Lavish indulgence over many days in exquisite surroundings sometimes many miles away from home now seem to be commonplace so that even the stongest-willed doctors find such invitations difficult to resist. When I was in academic Practice in S.E Asia, I suggested that the Companies interested in advertising their products should provide the equivalent of a year's subscription towards a medical journal of their choice for the Department library in lieu of a generous meal at a venue we would otherwise have found economically prohibitive. I would even accept subscription towards other less onerous lifestyle literature but remained adamant that any gastronomical extravagance was quite unnecessary. My argument was naturally that this method was cheaper and had a much more useful impact on education - the old Chinese adage of "give the man a fish and you will feed him for a day. Teach the man to fish and you will feed him for life". Predictably, this noble idea received little positive response. I was given short shrift and we were back to elaborate banquets in the most salubrious surroundings. I also recall the troubles we had with Pharmaceutical or Biomedical Engineering Agencies that provided much sought after research funding - what was to be published and what was not. In Australia, I remember a colleague spending an extended weekend on the Gold Coast - thanks to the advent of Proton Pump Inhibitors. Where will such generosity stop? Can such funding not be better placed? Must this association between industry and doctors be laced with such ulterior intent? These are serious issues that require serious attention at a time when the tenets of research integrity are being questioned 1. In the light of present day methods of communication - the internet, teleconferences, videoconferences, must we accept the temptation of a salmon roll with rocket and balsamic vinegar chips? I suggest we detract from such liberties and stay focussed on the business of providing good medical care at affordable cost. 1. Smith R. Most cases of research misconduct go undetected, conference told. BMJ 2008;336:913 (26 April), doi:10.1136/bmj.39556.698646.DB Professor Osborn Viegas AM, MD(Birm), FRCOG, FRANZCOG, DA email:profviegas@hotmail.com Competing interests: None declared
Hungering for answers 28 April 2008
Anna Shore, Foundation Year House Officer St James's Hospital, Leeds, LS9 7TF Send response to journal: Re: Hungering for answers	Has Kinesh Patel met Des Spence - fellow BMJ columnist and UK spokesperson for the No Free Lunch group? Perhaps he should buy him a sandwich and chew over this debate. Having heard Des's well-informed, evidence based responses to many of the questions Kinesh poses, I have no doubt who'd be left with a bad taste in his mouth. Competing interests: None declared
You must be joking 29 April 2008
Adrian H Sie, SpR Paediatrics Crosshouse Hospital KA2 0BE Send response to journal: Re: You must be joking	Nearly spilled my homemade cheese sandwich over my BMJ reading this. How are doctors supposed to get new information? Perhaps by reading during your lunch break, rather than listening half heartedly while munching on your M&S wrap. Or even, maybe, a journal club? Drug lunches are socially uncomfortable, and consume time that could have been used a) to chat with your colleagues (team building) b) to learn about something that might change your actual practice, or might be evidence based, not just speculative c) to catch up on the news - which is what you're talking about, a mildly interesting fact or 2 that probably has no direct bearing on your life, personally or professionally "The NHS is unwelling to devote serious capital to fund educational activities"? The free lunch does not contribute to education, indeed, I can afford my own lunch and would rather the money be used for patients. What helps education is having protected time. Not money. Or free food. Competing interests: None declared
The Ethical Price (to physicians and patients) of Promotional Lunches 1 May 2008
Anthony N Fleg, PharmFree Coordinator, American Medical Student Association North Carolina, 27516 Send response to journal: Re: The Ethical Price (to physicians and patients) of Promotional Lunches	The unexamined drug is not worth giving -Socrates, in a little-known, hard-hitting lecture to the neurologists of ancient Greece Humor aside, would we, as patients, want our physician prescribing us medicine simply based on an attractive rep that brought an even more attractive spread of food, "educating" the doctor on the drug? We do our patients a grave dis-service when we rely on promotional lunches (nothing is free, and drug lunches come an incredibly high ethical price) to provide us with "information." If the information in the published literature is not there to support a drug's use, then we should wait for the evidence to appear, and not use the ethically problematic short-cut, which assumes that getting our "educational" sales pitch from sales representatives is equivalent to having an evidence-based, un-biased view on the drug. Luckily, waiting is not going to hurt our patients, as the vast majority of new drugs are not medical breakthroughs, and do not offer substantial benefits when compared to their cheaper, safer, older, un-advertised generic counterparts. I would give one analogy to those, like Dr. Patel, who continue to see promotional lunches as a source of "education". If you wanted to buy a new car, would you go to the Mercedes dealer, asking them for "education" on the best cars on the market - the most stylish, the best values, the safest, etc? And, furthermore, would you walk away from such a meeting thinking that you now had a great, unbiased "education" on the issue, such that you would buy a car based solely on that advice? I do hope Dr. Patel does not plan to teach in any U.S. medical school, as the AAMC, the accrediting body of U.S. medical schools, yesterday released a report calling called on a 100% ban on gifts and lunches at U.S. medical schools. In health, Anthony www.pharmfree.org Competing interests: None declared
Free Stuff? Yes, Please. 1 May 2008
Annemarie Jutel, Associate Professor Otago Polytechnic, Dunedin, NZ Send response to journal: Re: Free Stuff? Yes, Please.	Drug lunches do more than just educate doctors (poorly) through advertising. They provide a moment of spontaneous pampering and unexpected pleasure, as Kinesh Patel has pointed out. It’s a bit like getting a French manicure or a head massage: for a few moments, the cacophony of the wards disappears, replaced by an enjoyable kinaesthetic the likes of which one wouldn’t even get at home. One of the respondents in our yet-to-be published survey on nursing and the pharmaceutical industry reported that free “stuff” was a bit like a toy in the kiddies’ meal at the fast food joint: a little smidgen of unexpected d fun that, ridiculously, she admitted, she looked forward to. Good employers should know how powerful such interludes and meaningless trinkets can be for generating loyalty and happiness (the pharmaceutical industry does, after all). Should hospitals look after their docs and allied health professionals to make sure they get occasional treats and expressions of appreciation? Other corporate employers do. To counter the pharmaceutical industry’s powerful tools of persuasion, we need alternate sources of information, but we also need alternate sources of positive reinforcement and distraction. Hospital managers, take heed! Competing interests: I am a member of Healthy Skepticism, a non-profit organisation with an interest in improving health by reducing harm from misleading drug promotion.
There ain’t no such thing as a free lunch 1 May 2008
Jim C Moonie, F2 Surgery Timaru Hospital, New Zealand Send response to journal: Re: There ain’t no such thing as a free lunch	Anyone reading this is obviously the sort of person who likes to stay on top of the game by keeping up to date with all the latest news, research and advances in medicine and will, therefore, no doubt be familiar with that other bastion of such information, Wikipedia, used increasingly by juniors and consultants alike as a first port of call for guidance on a topic with which they are unfamiliar. It was indeed there that I discovered the origins of the phrase after which this piece is titled and it will be no surprise to many of you avid Wikipedia readers to learn that it was ‘popularized by science fiction writer Robert A. Heinlein in his 1966 novel The Moon Is a Harsh Mistress, which discusses the problems caused by not considering the eventual outcome of an unbalanced economy’. What this means, the article continues, is best explained in the words of American marcroeconomist Greg Mankiw. Namely ‘to get one thing that we like, we usually have to give up another thing that we like. Making decisions requires trading off one goal against another’. This is, of course, true and with drug companies the trade off is one of ethics, morals, bias and coercion, but it is not absolutely, necessarily, strictly true in a purely relative sense. For example. I am currently working as an F2 in New Zealand. The days are often long, with an on call day running from eight in the morning until eleven at night. Weekends are the same and night shifts as the only doctor in the hospital are more than a touch stressful. On top of this the pay, compared to what I could earn at home, is poor. So, aside from the obvious benefit of New Zealand being a Utopian version of the UK, the Pacific Ocean just outside the ICU and the southern alps visible from the surgical ward, skiing at weekends and kayaking after work, Sydney and the South Pacific Islands just a bus ride away, why else am I here? Well, the lunch is free for one thing. The rationale lies in the fact that if you are carrying a pager then a true lunch break, in the sense that you are freed of the constraints of work is not possible. You are always, in this sense, at work and the least the hospital can do, so the rationale goes, is pay for your lunch. It doesn’t just go for lunch. Tea and coffee are free, so is fruit and cakes and mineral water and smoothies and apple juice…I could go on, but the point is made. In England I rarely had time to eat lunch and the least my employer could have done was give me free food to eat, even if they wouldn’t give me the time to eat it. And if lunch is free anyway, then gone is the persuasive power of the free drug company lunch and gone too is the ethical dilemma. Several weeks ago now I received a phone call from my consultant’s secretary. She was ringing to inform me that a drug company was sponsoring a free lunch. I trotted happily up the stairs to the meeting room and sat down to enjoy my lunch. I couldn’t tell you what the drug was and it wasn’t until I was half way through my third sandwich that I realised my stupidity. That was the last drug company lunch I attended and while they may go on from time to time, you’ll find me in the canteen eating my free lunch, or perhaps even brousing Wikipedia for the latest updates in medical science or maybe even reading the BMJ. References Wikipedia Competing interests: None declared
Who sups with the devil must needs a long spoon 1 May 2008
Roger K.A. . Allen, Senior Consultant Thoracic and Sleep Physician Wesley Hospital, Auchenflower, Brisbane, Australia Send response to journal: Re: Who sups with the devil must needs a long spoon	Lest we suffer ennui as this topic has been discussed in this forum before, here's my two bob's worth (perhaps 20 cents now): Although in full-time private practice as a thoracic and sleep doc, I rarely see drug "reps" as we call them here in Oz, and have noted that I often come across patients on drugs prescribed by GP's that are clearly the result of the latest "visit" by a drug rep bearing gold like the Maggi, with a "free" pen and pad, "samples" or a some other "lure" with which to hook the unsuspecting MD. If you wait long enough, you will find out that basic antibiotics and other drugs, long since off patent, are sufficient and if you read the journals, your prescribing habits will be more dictated by common sense than by the "lure". I observe recently and once again, that a pretty young "rep" had the top buttons undone of her gaping blouse but as a hardened sceptic, I was a wake up to her ample provisions. If I on rare occasions agree to see a "rep" (my staff only do this on my instructions) I do so to ask them embarrassing and searching questions about the drug and things like, wasn't it your company that made the gas that was used in NAZI concentration camps? I hasten to add that the Greek for "drug" is "pharmakon" which is the same word for poison. If they ever offer me a lure such as a free pen, a sextant (I am a sailor), or a bottle of wine, I open my second drawer where I have a full box of biros (paid for by me) and offer them one. They look aghast. I also tell them that I have enough money to buy countless boxes of pens and that I am in no need of pens with names on them, paper pads or any other such junk that is aimed at my subconscious mind, let alone unbuttoned blouses. Drug reps also keep a dosier on all doctors they visit and this includes your "response" eg "friend" or "foe" or in my case, "troublemaker". We now have an Xray machine at our front door to check for bombs when drug reps visit. He who sups with the devil.... Competing interests: None declared
Lunch Free for whom? 1 May 2008
Muthukrishnan Jayaraman, Senior Resident, Endocrinology Medwin Hospital, Hyderabad, India-500001, KVS Harikumar, A Verma, KD Modi Send response to journal: Re: Lunch Free for whom?	The practice of hosting free lunches (dinners usually)is a rapidly increasing trend in India too, what with so many companies launching numerous new products. While I agree that it is one of the ways to learn about a new drug for most of the busy practitioners and residents, it may not be the right way. Most of the information given out by these companies is biased and often exaggerated. The other side of the story is rarely put forth. The better source of such balanced information would be a well- written editorial in a reputed journal. However, such lunches maybe a good time for the harried physician to relax and recuperate for a hectic day ahead. That's all there is to it, and thats how it should be taken. Drug companies should realise that such freebies do not impact prescription practice of a balanced, well-informed physician. Competing interests: None declared
not simple, is it? 1 May 2008
Declan P Fox, Freelance physician Based in Newtownstewart. BT784NP Send response to journal: Re: not simple, is it?	I used to run a lot of meetings for GPs with pharma sponsorship. Subject matter was controlled by me and it wasn't exactly difficult to ban overt promotion. Some of those meetings were very good educationally and would not have happened without pharma money. The NHS is indeed parsimonious with CME funding, whether it be cutting study leave for junior doctors or putting umpteen millions into GP appraisal when it could be used far better for educational programs. I have seen nationalised drug manufacturing and frankly folks, it sucks. Big Pharma has plenty of faults but is probably the least bad alternative. I agree with Des Spence that it does need watching and I think that the cosy relationship with government could usefully be abolished. As for useful info from reps, well I was reminded yesterday that Rabeprazole is a relatively clean drug. Which is nice, considering that I tend to prescribe it when doing locums in Canada because it is the cheapest! I have serious doubts about the quality of information available from prescribing advisers and have had more useful exchanges with hospital and retail pharmacists. Who actually deal with patients. Finally, why on earth are we flagellating ourselves over prescribing costs etc etc here in the UK when we are so cheap compared to most other countries??!!! Yours etc Declan Fox Competing interests: I continue to hassle pharma reps for money to help with CBT training.
What about the NPC? 1 May 2008
Peter D Burrill, Specialist Pharmaceutical Adviser for Public Health Derbyshire County PCT, Chesterfield, S41 7PF Send response to journal: Re: What about the NPC?	Has Dr Patel not heard about the National Prescribing Centre, an NHS organisation that provides information and education about drugs, prescribing and medicines management (www.npc.co.uk)? They even have a new medicines section and you can sign up for e-mail alerts. Or try the new initiative NPCi (www.npci.org.uk) with its blogs and podcasts about new drugs and the latest clinical trials. Perhaps his trust would consider commissioning some therapeutic workshops from NPC Plus, rather than inviting in drug companies to promote their products, which are usually of unknown safety and effectiveness. Drop me an e-mail and I will add you to the distribution list of my newsletter (peter.burrill@derbyshirecountypct.nhs.uk). Know where to find the information and how to use it - that's the secret of success (Einstein). With best wishes Competing interests: I am an NPC Plus trainer and on the DTB editorial board.
Lunch from a high horse? 1 May 2008
John A Wilson, Consultant Physician Victoria Hospital, Kirkcaldy KY2 5AH Send response to journal: Re: Lunch from a high horse?	Goodness me. I never thought so many of my colleagues - some apparently on the cusp of retirment - could show such alacrity and agility in leaping onto their high horses while leading the charge of the nofreelunch brigade. Yes, for sure, it would be foolish to rely on information traded during a pharmaceutical-sponsored and product-driven lunch (or even a week on the Australian Gold Coast)as the main source for one's ongoing medical education. But does the poor man need to be quite so roundly lambasted? I have to say I am more uncomfortable with the righteous denouncements of some of my medical brethern than the confession which they sem so worked up over. So, Dr Patel, good for you for raising the topic. I am sure there are occasions when you buy your own salmon and rocket roll to munch while perusing PubMed, BNF or whatever. Competing interests: Regular puchase of lunch from WRVS canteen
Best interests and vested interests: the NHS, medical education, and drug information 30 May 2008
Patricia McGettigan, Senior Lecturer in Medicine Hull York Medical School HU6 7RX Send response to journal: Re: Best interests and vested interests: the NHS, medical education, and drug information	In the same issue that persuasively set out six healthcare themes for ‘making a difference’ (1), a viewpoint was published entitled ‘Why I love a free lunch’(2). If it is representative of younger doctors’ insights about medical education and ongoing learning, it chills hopes of achieving the ‘making a difference’ aspirations. The author describes his first encounter with one new drug and asks, ‘how is the average doctor supposed to find out about new drugs that may potentially benefit their (sic) patients?’ He continues, ‘the NHS seems unwilling to devote serious capital to fund most educational activities (although you would think a better educated workforce would be something to strive for), so it’s left to the drug companies to fill the gap’. A more constructive, evidence-based viewpoint is that the NHS makes considerable investment in medical education and as recipients of that public investment doctors have responsibility (aside from moral duty) to ensure that their contributions to healthcare, including their use of medicines, are grounded in high quality, non-conflicted evidence. Taking the question of NHS support for educational activities: ‘NHS’ arouses varying emotions and opinions from stakeholders, but, to assert that it does not support educational activities is unfair and untrue. As a government agency, the NHS spends considerable public money on medical education. In the broadest sense, that includes medical, dental, and nursing training, and training in the related professions. Concentrating on undergraduate medical education, funding is provided by the Higher Education Funding Council for England (HEFCE) and the National Health Service (NHS). ‘Broadly, HEFCE funding is used to support the direct costs of medical education in university medical schools and the NHS funding, (via the Department of Health and Strategic Health Authorities) provides the service facilities to support that teaching’(3). Service Increment for Teaching (SIFT) funding is provided to hospitals by the Department of Health to compensate for excess costs arising from the additional workload of medical student education. As the British Medical Association 2007 report shows, the sums involved are substantial(3). It is apparent that Trusts need to be explicit about how they spend their SIFT funding but the bottom line is that the money is paid to support medical education. Any doctor whose medical education was undertaken in the UK has been the beneficiary of educational funding from the NHS. On the question of finding out about new drugs, the view that doctors have the choice of ‘being educated through advertising, with all its pitfalls, or remaining ignorant of many new drugs altogether’ reflects a moral and intellectual laziness that sits uneasily with ‘making a difference’ aspirations. In particular, the hopes of Avorn et al for safer prescribing may fall on stony ground. Learning to use drugs wisely, safely, and in patients’ best interests is difficult. Medical schools only initiate that learning process but no doctor needs to depend on pharmaceutical company-provided information about new drugs. Advertising may alert doctors about a new drug but pharmaceutical companies are not objective providers of information and cannot be considered reliable educational resources. The companies seek to sell drugs, as they should, but there is no free lunch. Patients whose doctors rely on such information are arguably better off if their doctors remain ignorant of those drugs (4-7). Medical journals are useful sources of information though not without pitfalls (8,9). Most medical schools teach their students basic skills in critical evaluation, providing capacity to assess evidence, wherever it is read or heard. Specific to drugs, independent information sources are plentiful; to name a few, they include in the UK the National Prescribing Centre, the Drugs and Therapeutics Bulletin, the British National Formulary, and the National Institute for Clinical Excellence. All are available online (from NHS provided hospital computers) and several provide timely, balanced advice about the clinical place of newly marketed drugs. Some are even funded at arms’ length by government/NHS. There is no earthly reason for doctors to go looking for a free lunch; lunch yes, but not free. From Day 1 of employment, remuneration is adequate to permit them to buy their own lunches, Marks & Spencer or otherwise. The attraction of ‘free’, even for smart people not in need of ‘free’ anything, illustrates pharmaceutical companies’ understanding of human behaviour and their capacity to exploit it(10). It is way past time doctors separated themselves from vested interests and acted in the best interests of their patients and society at large. New doctors, with all their potential to make a difference to the quality of healthcare, are serving no-one by trotting out the same tired old justifications of a past generation. References 1. BMJ Group: Making a difference. Running the gauntlet to improve patient care. BMJ 2008;336:947-959. 2. Patel K. Why I love a free lunch BMJ 2008; 336: 962. 3. British Medical Association. Health Policy and Research Unit. Medical Service Increment for Teaching (SIFT) report. May 2007. http://www.bma.org.uk/ap.nsf/AttachmentsByTitle/PDFSIFTfunding/$FILE/Siftreport.pdf. Accessed 30 April2008. 4. Psaty BM, Kronmal RA. Reporting mortality findings in trials of rofecoxib for Alzheimer Disease or cognitive impairment: a case study based on documents from rofecoxib litigation. JAMA. 2008;299(15):1813-1817 5. Angell M. The truth about drug companies. 2004. Publ: Random House. ISBN 0-375-50846-5. 6. Avorn J. Powerful medicines: the benefits, risks, and costs of prescription drugs. 2004. Publ: Alfred A Knopf. ISBN 0-375-41483-5. 7. Brownlee S. Overtreated: why too much medicine is making us sicker and poorer. 2007. Publ: Bloomsbury. ISBN-10: 1-58234-580-5. 8. Sismondo S. Ghost management: how much of the medical literature is shaped behind the scenes by the pharmaceutical industry? PLoS Medicine 2007; 4(9)e286 doi:10.1371. 9. Ross JS et al. Guest authorship and ghostwriting in publications related to rofecoxib: A case study of industry documents from rofecoxib litigation. JAMA. 2008;299(15):1800-1812. 10. Ariely D. Predictably irrational: the hidden forces that shape our decisions. 2008. Publ: HarperCollins. ISBN 978-0-06-135323-9. Competing interests: None declared