Pharmaceutical representativesBMJ 1996; 312 doi: https://doi.org/10.1136/bmj.312.7045.1494 (Published 15 June 1996) Cite this as: BMJ 1996;312:1494
- Allen F Shaughnessy,
- David C Slawson
- Director of research Harrisburg Family Practice Residency Program, Harrisburg, PA 17105-8700, USA
- Associate professor Department of Family Medicine, University of Virginia Health Sciences Center, Charlottesville, VA, USA
Effective if used with caution
Pharmaceutical representatives are the “stealth bombers” of medicine: they swoop in, change physicians' prescribing habits (better than any journal article or formal educator), and disappear again. In the United States there is one drug representative for every 15 practising physicians—a teacher to student ratio that would be the envy of many universities. Though some doctors welcome the free samples and gifts, most dismiss representatives' information as a sales pitch. However, when their advice is actively sought and treated with caution, they can be a valuable source of new information for a busy doctor.
Obtaining information from drug representatives requires minimal effort. As communication experts, drug representatives package their messages into tight bundles, delivering them neatly between patients, often accompanied by a free lunch. Their bottom line message—“prescribe my drug”—is seemingly supported by medical evidence, yet this is frequently intermingled with emotional appeals and logical fallacies.1 Consumers of this information must be constantly vigilant in order to separate the wheat from the chaff.
In this sifting process two factors must always be considered: the relevance and validity of the information presented.2 However easily obtained, if information is irrelevant or invalid it is useless. The standard sales pitch is rife with information on a drug's effect on cellular receptors, its in vitro inhibitory activity, or its effect on serum concentrations. These intermediate outcome measures are a far cry from answering the question that patients would ask: “If I use this drug is it likely to make me live a longer, healthier, more productive, and symptom free life?” Clear thinking is needed to avoid being misled by irrelevant claims of benefit.
The validity of information presented by drug representatives varies with their level of knowledge and their zeal in conveying their message. A recent analysis of the accuracy of information from representatives found that one in 10 statements—all of which favoured their product—were at odds with the company's own literature.3 Unfortunately, only one in four clinicians was aware that the information was incorrect. Scepticism is the key to obtaining valid information.
One useful way to evaluate information from drug representatives is “STEP,”4 an acronym for safety, tolerability, effectiveness, and price. All four attributes should be considered when weighing the purported advantage of one drug over another. Safety applies to the likelihood of long term or serious side effects caused by the drug. Tolerability is best measured by comparing the pooled drop out rates between the new drug and a competitor drug, rather than trying to weigh the relative incidence of side effects. The best way to evaluate effectiveness is to compare the new drug with your current favourite. The necessary information may be hard to come by, especially since research funded by a drug company may not be published if the results show no benefit of its drug over that of its competitor.5 Lastly, the price of the drug should include not only its direct costs but any indirect costs, such as additional monitoring or extra visits to a doctor. So, until your drug representative produces valid data that a drug is at least one STEP better, your current practice need not change.
Information such as this is not the only stock in trade of drug representatives: they also provide gifts, food, and other inducements to convince doctors to prescribe their drugs. Since reciprocity is so much a part of human nature, doctors must guard against a feeling of indebtedness that might overwhelm the rational approach outlined above. An adage well known in the world of marketing is that advertising works best when its audience does not think it is being “sold” anything.
The best way to avoid “stealth” attacks by drug representatives is to put them to work for you, checking for new information about their drug that is both relevant and valid. Use them to identify and to bring you the facts about their drugs that fit into the STEP approach. Tell them what information you need—”patient-oriented evidence that matters”6 not a “mishmash of preclinical data.”7 Do not trust them to precis information into a conclusion; reserve that crucial process for yourself. The primary goal of drug representatives is to promote a product, but an active approach by doctors can transform them into a useful and accurate source of information.