Drug Sale Practices : Is Medicine Infected by Marketing?

Few of the millions of Americans who make the U.S. the largest consumer of prescription drugs in the world have heard of people like Shellie Rothstein.

Rothstein, a pharmaceutical sales representative whose well-traveled turf is doctor-dense Beverly Hills, is a foot soldier in a highly competitive drug industry army dedicated to shaping physicians’ decisions about drugs.

The industry’s weaponry is a mix of pedagogy and propaganda--scientific papers, symposiums, research grants, stethoscopes, free samples, frequent-flier miles, resort weekends, lavish dinners, $500 honorariums and innumerable logo-imprinted pads and pens.

Pharmaceutical marketing permeates American medicine to a degree few consumers understand. It plays a powerful and controversial role in the complex process by which prescription drugs travel from the laboratory to the patient’s bedside table.

Stakes Are Higher

The techniques are not unlike those used by other businesses. They help sell everything from breakfast cereal to cars. The difference here is that the stakes are far higher and the choice of which drugs patients will take is made by a middleman--the physician.

For many doctors, drug industry marketing is their prime source of information about drugs, according to numerous studies. Some medical policy researchers believe that its influence eclipses that of professional societies, scientific journals and medical school education.

As some physicians and drug industry experts see it, industry marketing is indispensable in keeping doctors up to date in a rapidly evolving field. With well over 8,000 prescription drugs on the market, they say the industry is essential to ensuring that drugs are properly used.

But critics, including professors of medicine, hospital pharmacists and some consumer advocates, see a more insidious influence. They say the industry cultivates a taste for more drugs, the latest drugs, the most expensive drugs. The price of the industry’s largess, they say, is paid by patients in the spiraling costs of prescription drugs.

“It has become a much more flagrant problem” in the last 20 years, said Dr. Roger Rosenblatt, a professor of family medicine at the University of Washington School of Medicine. “It infects medicine in a very deep way and there’s much less public debate about it.

“There’s almost a conspiracy of silence in medicine that we will not discuss this hidden subsidy, this kind of hidden transfer from patients to pharmaceutical companies to doctors that occurs on a day-to-day basis,” Rosenblatt asserted.

A few recent examples:

- Ayerst Laboratories offered physicians a round-trip ticket to any city served by American Airlines if they would prescribe the company’s hypertension drug Inderal LA to 50 patients and send in details on specially provided, personalized prescription pads.

- Merck Sharp & Dohme invited health care managers and their spouses to an expenses-paid weekend at the Newporter Resort Hotel in Newport Beach. The subject of the symposium, managing patients with high cholesterol, was discussed for less than four hours.

- Pfizer Laboratories picked up the tab for a weekend symposium at the Sheraton Scottsdale Resort in Arizona on the subject of “Cost Containment and Arthritis Therapy.” Spouses or guests also received free accommodations--but had to pay their own air fare.

- The Veterans Administration this year disciplined 32 employees for accepting honorariums and “gratuities” from drug firms seeking to sell drugs to the VA. According to records obtained through the Freedom of Information Act, one physician had accepted nearly $50,000 from a single firm.

- Ortho Pharmaceutical invited physicians to participate in a drawing for a personalized Cross pen and pencil. In return, the doctors were to prescribe Ortho’s birth-control pills and write on the order “Do not substitute” to prevent replacement with a cheaper equivalent.

- Jelly beans, grooming sets, opportunities to be photographed with Captain America, umbrellas, playing cards and cappuccino were among the gimmicks used to attract doctors to sales booths at the recent convention of the American Academy of Family Physicians.

Doctors at the meeting waited in line for up to an hour to have models shine their shoes.

The U.S. market for prescription drugs is the world’s largest, valued at $30 billion. Drugstores dispensed 1.61 billion prescriptions in 1987. By some estimates, two out of every three times an American visits a doctor, a drug is prescribed.

The industry that feeds that demand is highly competitive. No single pharmaceutical firm dominates the field. The four largest account for just 25% of industry sales, and no major company holds more than a 7% share of the market.

‘Me-Too’ Drugs

Every year, the industry brings several dozen new drugs to market. All but a handful are so-called “me-too” drugs. That is, they represent little or no advance over what is already available, in regulators’ opinions. But they present a marketing challenge.

There are at least 22 different penicillins available in the U.S. There are seven different beta blockers, for heart conditions, and 15 versions of the antibiotic cephalosporin. A new chemical entity is approved for human use on an average of every two to three weeks.

But prescription drugs cannot be peddled like other products. Federal regulations prohibit advertising them directly to consumers. Instead, firms must target their promotions to doctors, who make choices on behalf of consumers, who in turn pay the price.

The proliferation of new drugs is a challenge to physicians as well as salesmen. About 70% of all drugs on the market were not around 15 years ago. Doctors find themselves forced to choose among products that did not exist when they were being trained.

That rapid evolution intensifies the need for continuing medical education. The pharmaceutical industry, in cooperation with universities and professional groups, has stepped in with an abundance of symposiums and seminars to help fill that need.

“I think that’s a socially responsible role for us to take,” said Grant Denison, president of U.S. operations for G. D. Searle & Co. “Science has become so complex, the number of products so vast. Physicians have a crying need to keep up.”

Others, however, doubt that the influence is entirely benign.

Result of System

“The education of American physicians about drugs . . . has (been) relegated to drug companies by default,” charged Dr. Jerry Avorn, an associate professor at Harvard Medical School who has studied the influence of pharmaceutical marketing. “As a result, pharmacological solutions are thought of first, rather than nonpharmacological approaches that could be just as effective and safer.”

The cornerstone of the marketing and promotion process is so-called detailing, a practice one physician likened to lobbying: In face-to-face encounters with physicians and pharmacists in offices and hospital corridors, sales reps sing the virtues of their products.

As the industry and many doctors tell it, the aim is educational--to supply practitioners with information about new drugs and refresh their memories about old ones. Sales people work closely with the profession to ensure optimal use of drugs, industry officials say.

But as critics tell it, the aim is propaganda--to bombard doctors with often selectively compiled data, reinforcing the message through relentless repeat visits and ubiquitous “reminder items” such as pens, coffee cups and lunch.

Detailing, which is almost entirely unregulated, is widely believed to be the most effective of all industry strategies.

“A lot of the company hinges on that sales representative,” said Jim Shamp, manager of media relations for Glaxo Inc., the nation’s third-largest drug company in prescription drug sales. “That’s where the rubber hits the road.”

Shellie Rothstein is Glaxo’s top representative in the Western region, a 33-year-old pharmacist who left a job with the drug information service at the University of Chicago for what she calls “real-world medicine.” She is one of 1,600 Glaxo representatives nationwide; the company hopes to increase that number to 2,000 by the year 1993.

Rothstein’s territory includes 500 physicians and pharmacists, to whom she promotes four Glaxo products. Her success or failure is reflected in her annual earnings--a salary plus a commission based on sales in the ZIP codes she traverses.

On a recent morning, her itinerary began with a visit to a gastroenterologist at Cedars-Sinai Medical Center. He had recently returned from speaking at a medical conference, with Glaxo’s help. Glaxo had covered the costs of his air fare, hotel and honorarium.

Later came an infectious-disease specialist who lectures on antibiotics, including Glaxo’s, at local hospitals, sometimes with a Glaxo honorarium. Rothstein also stopped in at three pharmacies, two hospitals and the office of a Beverly Hills internist.

Along the way, she dispensed information and a few freebies--Glaxo pens, pads, note-pad holders, pill-counting trays, pamphlets and books. In each doctor’s office, she checked the free-sample cabinet and replenished the supply of Glaxo drugs at the physician’s request.

All her clients described Rothstein and Glaxo as highly ethical. They described their dealings with the company as mutually beneficial. One crusty pharmacist, however, described detailing with some ambivalence, saying it was useful but he disliked the “gimmicks.”

“This is what we call brainwashing . . . to remember the drug,” cracked Max Stollman, who runs the Family Pharmacy on the fringe of Beverly Hills. He was pondering a black Glaxo pill-counting tray and two Glaxo pens and scratch pads he had just received.

Rothstein looked incredulous.

“Do you really believe that, Max?” she asked.

“Oh yeah, sure. Getting the name across is the name of the game.”

Why didn’t he reject the offer? a reporter asked Stollman.

“I really didn’t want to refuse it,” he said. “That’s rude.”

Drug companies’ generosity extends far beyond counting trays.

Sales representatives buy lunches for a physicians’ office staff--to “make their day a little nicer,” as Rothstein put it. Some cater lunches to coincide with meetings of entire medical center departments, or sponsor lunches with speakers.

Firms invite physicians to dinner at well-known hotels and restaurants, serving up a free meal and a speaker on a topic of interest. In addition to picking up the tab, firms often reimburse the dining doctors “for their time.”

Dr. Calvin Kunin, a professor at Ohio State University, said he recently turned down a drug company representative’s invitation to attend a dinner at a hotel in downtown Columbus, listen to an after-dinner talk and receive $100 for his efforts.

Large Grants

Drug companies also give large grants to physicians working in academic medical centers to study the companies’ products. In some cases, they pay the researchers by the patient--up to several thousand dollars per patient enrolled, some researchers say.

Supporters of the practice say it is reasonable: Who better to study a new drug objectively than academic researchers? But some critics suspect that firms use some grants to win coveted spots on the hospital’s formulary, the list of drugs approved for regular use.

Many large companies sponsor symposiums at resort cities. The topic is less likely to be the company’s product than some condition it treats. The firms foot the bill for not only the speakers but often for the carefully selected “thought leaders” flown in to attend.

Dr. Stephen Goldfinger recalls an invitation sent several years ago to directors of gastroenterology training programs; each was invited to designate one young trainee to a two-day symposium in Florida, all expenses paid by the sponsoring drug company.

Goldfinger, associate dean for continuing education and associate professor of medicine at Harvard Medical School, calls such arrangements “manipulative pedagogy.”

“No person attending such a conference should have any doubt about either the fundamental motives of its sponsor or the high quality of the market research that determines how doctors can be influenced,” he wrote in The New England Journal of Medicine.

“The assumption that one can accept the blandishments without any risk of being compromised is incredibly naive, but even if it were true, would that make it right?” Goldfinger asked. “Indeed, isn’t it a bit sleazy to take the corsage without at least yielding its sender a place on one’s dance card?”

Attitudes toward pharmaceutical promotions vary widely.

Most physicians accept and welcome the activities, according to both the industry and research on the subject. Those physicians say the information and funding helps them and their patients. They say they are capable of judging critically anything the industry offers.

One physician, responding to Goldfinger, charged in a letter that Goldfinger’s criticisms in the journal article “smacked of holier-than-thou moralism that harks back to a bygone era.” The industry is not the Evil Empire, the doctor argued; it is an equal partner.

“I see absolutely nothing wrong with providing a physician medical-education events. They are busy people,” said Denison of G. D. Searle & Co. “I think that’s a very, very appropriate role for us to take as a pharmaceutical company.”

“Good will is certainly a part of it, with no apologies,” said Shamp of Glaxo. “But it’s a whole lot more complex than giving someone a cigar or buying favor with a pen. You’re selling to a highly ethical, highly skeptical middle-person who would not ever be swayed.”

Others, however, find the practices distasteful. Kunin, of the University of Ohio, has a policy of seeing no sales representatives. He calls paid dinners “payola.” He says he keeps himself up to date by reading the medical journals and attending scientific meetings.

“A physician is responsible to keep up and should devote the time to that,” said Kunin, who has examined the relationship between researchers and the pharmaceutical industry. “That’s what they went to medical school for and this is a service profession.”

There appears to be little doubt that drug promotion is highly effective.

In one study on the subject, Avorn of Harvard Medical School examined physicians’ perceptions of two heavily advertised prescription drugs. Both drugs had been shown in scientific studies to differ little from the non-prescription versions.

According to Avorn’s published report, he found that the perceptions of many of the physicians were shaped by advertising rather than scientific literature. Yet they were unaware, or unwilling to admit, that they had been influenced by non-scientific sources.

The danger, Avorn and others argue, is “irrational prescribing”--the use of inappropriate drugs or inappropriate doses. Such practices may contribute to what some researchers believe, and some studies suggest, is a significant problem of physician-induced illness.

Physicians are prescribing sleeping pills for problems that could be cured through diet and life style, Avorn contends. Expensive new anti-depressants and drugs for hypertension and cholesterol are being used where older drugs, or no drug, would suffice, he says.

Resistant Strains

Excessive use of antibiotics to treat trivial infections is contributing to resistant strains of micro-organisms, Kunin argues. Money is being spent on developing, and purchasing, new generations of antibiotics to fight new resistant strains.

Nevertheless, pharmaceutical detailing is almost entirely unregulated.

The Food and Drug Administration has no authority over the practice, according to Kenneth Feather, acting director of the division of drug advertising and labeling. In his 17 years with the office, Feather can recall no action ever taken against detailing.

A few institutions and individuals have begun exploring ways of controlling the influence of pharmaceutical promotions--without, some of them say, excessively restricting an industry that has made many important contributions to medical care.

Unbiased Information

One approach entails a practice sometimes called “public interest detailing” or “counter-detailing.” Pharmacists or other health professionals use the techniques of the drug companies to promulgate what they contend is unbiased drug information.

In a pilot program, Avorn and other researchers found that public-interest detailing accomplished a 14% reduction in prescribing of the drugs being studied. An expanded program could save government health insurance programs millions of dollars, Avorn estimates.

Kaiser Permanente, with 2 million members in Southern California, has quietly implemented a program in which pharmacists and physicians work together to evaluate drugs, taking into account both their therapeutic benefits and their cost-effectiveness.

At the University of Connecticut, a new seminar series for doctors in training examines pharmaceutical marketing in hopes of turning out new physicians capable of critically evaluating information provided by drug companies.

In England, the Royal College of Physicians has suggested that gifts be accepted only if they will not impair judgment. The size of any gift should be such that the physician would be willing to have the arrangement known publicly.

A few skeptics, however, wonder whether moderation is possible.

“Perhaps some middle ground can be found that will resolve the ethical morass in which we find ourselves,” Rosenblatt wrote recently. “However, I suspect that as in many types of addictive behavior, only one therapy will ultimately be effective--abstinence.”