Thursday, April 20, 2006

Free At Last

Yesterday, I emancipated myself.

I'd been thinking about doing it for years and years and yesterday, something snapped and I did it.

I decided I am no longer seeing drug reps in clinic.

A small thing? Yes. Will it annoy our staff? Probably. Especially because yesterday they scheduled 3 lunches with this one rep, the one in the camel coat. The one I've caught in a blatant lie. You could say he was the straw who broke this camel's back.

All this goes to the way-back days of training. Initially, in med school, I loved them and their free pens and occasional stethoscope clip-on label, as they stood at the lunch table before each day's noon conference. Plates and cups and napkins blazoned with the drug-du-jour. Sometimes, there'd be a full blown conference that the campus would hold and many, many reps would come. This is where they really shone. Each set up a booth to 'educate' us on the latest and greatest. Each booth had all sorts of freebees like beach towels, vinyl tote bags, and flip-flops, all with the drug name. Always there were vats of candy and stacks of shiny pamphlets. Sometimes there is something of real educational use, such as a pocket reference manual. They are always friendly and immaculately dressed, and make me feel dowdier. Most look rather plastic, but some seem like real people when in their roles. To a person, they act like they 'love' us. They make us feel learned and important and so very, very cool. Sort of like I imagine it is with groupies. Honestly, this has always creeped me out.

As I am a greedy being at heart, I loved the free plastic models of drippy noses and handfuls of tootsie rolls (which I don't even like) and, best of all, those mugs adorned with the names of antihypertensive meds, or better yet, something 'naughty', like an erectile dysfunction drug. I especially loved them when we were impoverished students and residents. Those advertising mugs went in our cupboards in our crappy apartments, we sipped our morning coffee from them.

I'm not stupid. I know the impact of advertising. It is everywhere, even in our most respected journals, I'd guess at least 1/2 of the pages are glossy ad pages.

I'd soothe my soul: "I read the literature and base all my prescribing choices on The Evidence," I'd say. I'd try to do this, but when you're running flat out, trying to care for as many as possible, and trying hard not to A) kill anyone and B) not to miss anything, thumbing through the literature isn't always handy. So you pick the drug from the class of drugs you want to use, that you are most familiar with. I'd be lying if the word staring at me from my coffee mug that morning didn't have a bit of influence on what brand was at the front of my mind.

Now, we come to the sample closet. Pretty much all offices have them, they were even in the resident's clinic of the program where I trained, the program, I might add, led by the guy (that's him in the picture to the right) who was so concerned with the influence of drug companies on our forming psyche and on the prescribing practices of his colleagues, that he'd banned all drug company sponsored resident lunches (the program provided lunch if you showed up to daily noon conference, and we all showed up, by God.) and ridiculed you if you showed up with a drug-name blazoned bag or watch. Being one of the Really Big infectious disease gurus in, well, the world, his opinion did matter. (Ask any provider if they know what the Sanford Guide is and chances are they'll pull it out of their pocket.)

So, under his influence, I started to question my acceptance of the goodies. After residency, now in private practice (and after that disastrous year in horrible Bellingham), I was lucky enough to stay on with a group under the Providence umbrella, attached to the hospital where I trained. As managed care was, well, ubiquitous, keeping drug costs down was key. Generics are cheaper. Generics, by nature of being around longer, (hence the loss of the patent and the ability of other companies to make these drugs cheaper), are also generally more of a known quantity. I like this in a drug. I don't like surprises, like finding the Great New Thing is actually linked to an excess of nose hair, loss of toenails, or death. Especially death. I'm also extremely concerned about the over use of what are termed 'broad spectrum' antibiotics (the really expensive ones that kill pretty much everything) when a nice, narrow spectrum drug will do, and do it better and cheaper, even if not sexier.

The sample closet contains all the samples that the reps drop off, by the rolling suitcase-full, for us to dispense, for free. They are never generic. They are almost exclusively costly. They are usually very, very new. Sounds great, right? Free drugs. Free drugs for your patients, especially the ones with no prescription coverage. The downside? This gets you used to using these drugs when you pull out your prescription pad and choose which drug to write for. Plus, there's no pharmacist checking for problems with drug interactions or forgotten allergies, so there's a small bit of extra risk. Still, seemed worth it for the free drugs. As I was leaving to come out here, our clinic was exploring using stock supplies of generics in our sample closets for our patients, in place of the expensive, new samples, so we'd grab a course of $2 amoxicillin in place of a not-more-effective but $100 more expensive med. I don't know what became of it, but Buffaloons would. She and I went through all this together, pretty much from med school until I moved out here. She's still with the clinic.

Where I am, now, in the glamorous strip-mall, I've found that many of the drug reps passed us by, as we are a few miles away from the main hospital campus and we don't do continuity care. My samples dwindled. I was very concerned for quite a while, and we would even call the reps and ask them to come by, preferably on a day that J, our nurse practitioner was there. He didn't mind chatting with the reps and I've always hated it; feeling like a whore. Then, I realized last week, that I wasn't wasting as much time running to the sample closet and bagging drugs for patients to take. I was writing for generics whenever possible, even if the expensive sample was there, as I had gotten out of the habit.

It was like waking up and finding the small, annoying, but what you thought was an inevitable chain around your finger was gone, and, by God, it felt so liberating!

So, yesterday, when the camel-coat drug rep whom I despise was here, wanting to talk to me, I decided that the only one who was making me do that was me! And, by gum, I'd not be doing that anymore! I turned down his samples (one an antibiotic that is now a much cheaper generic, and one, another horrendously expensive antibiotic with a very broad spectrum that has a very small place in my practice) and vowed I'd never go back.

I sent a message out to our entire staff and practice director that I was no longer seeing any reps, ever. I would be using essentially nothing from the sample closet. I threw out every pen and note pad in my office and on my person. I even ripped the drug names off the notes on my bulletin board and threw out the mouse pad with the constipation drug on it. Actually, one of the nurses, sensing the importance of this moment, cut the name off the pad, so I'd at least have a bit of a mouse pad, but then I decided that the technicolor flower would ever be associated with the drug name, and I got rid of the whole thing. Plus, the mouse works fine without the pad.

This weekend, I'll splurge on a stack of notepads and a new mouse pad, for around $4.79.

I think I can afford it.

See, that's the thing. The money that is spent on getting us to prescribe these drugs is phenomenal and I just don't want to be part of it anymore.

Finally, Colin would like to share a joke with you-all:

Why didn't the cow go to the party?

She wasn't in the mooooood.


Ahhhhhhhhh, guess you had to be there. Can you tell we live in cow-country?



Anonymous Anonymous said...

good for you! any sales rep coming into a business is a big stress. I had to put a no soliciting sign on the office door, but apparently none of these reps can read.

LOL about the joke. funny!!

11:33 AM  
Blogger moegirl said...

You go sister!!

Sorry you will be missing out on the free swag, but I think your decision is worth it. Especially with camel coat guy- sometimes even having casual contact with that kind person leaves you feeling kinda yucky. Why even be exposed to their bad mojo?

Love the cow joke!

11:49 AM  
Blogger Diana said...

Amy- I think our staff actually like them coming as they bring lots of stuff for them, too, like lunch and mugs and interesting pens. Is there the equivalent in the legal profession?

Stacy- Thanks. I should have done it long, long ago.

2:31 PM  
Anonymous christie said...

I'm not as radical as you (yet...give me time...but Ohhhhh how I like this gel pen resting so comfortably in my hand and the little clock on my stethescope, and the calendar, and the stapler, and the clock on the wall, and the tissue, and the, well, I guess you know - have I mentioned I'm in my office???) but I am starting to have issues with this whole thing. My equivalent of the camel coat guy is a little prissy blonde (skinny, naturally, bitch) who asked me a couple months ago if she could count on me for 2 new prescriptions a month for her HTN med.... Umm, well, no, you can't, because, well, it never seems to work for me, go figure. I WANT TO POKE HER IN THE EYE.

But I'm ranting...anyway YOU GO GIRL!!!!!!! I am oh so proud of you and your stance. (now pull your britches back up, your balls are showing and none of us really wanna look at that)

2:43 PM  
Blogger Karen said...

Congrats on your Liberation!

And thank you for the education.

I'm now wondering what it's like for doctors in Canada.... wow.

3:00 PM  
Anonymous Gerah said...


Great post, by the way.

3:00 PM  
Anonymous Leigh-Ann said...

My only insight on this is from a patient's perspective. Those free samples really saved my life a few years ago, as I was able to take Effexor (and Effexor XR) for three years without having to pay out-of-pocket. The smallest dose of Effexor was going to cost me $3 per day at the time, and the dose I eventually settled on would have cost $9 per day, so I absolutely relied on my doctor's free samples. I guess anti-depressants are a rare example of when only one specific drug may do, unlike antibiotics, as I'd already tried Celexa, Wellbutrin, Prozac, and Paxil. I was actually in the clinical trials for Celexa prior to its approval, that's how desperate I was to be on some sort of anti-depressant. I'll confess that when my gf and I relocated to Las Vegas, I chose a new doctor based on his willingness to give me free Effexor from his "drug closet". With Nancy on disability at the time, and me an illegal immigrant basketcase, I absolutely credit Effexor for saving my sanity.

Anyway, I know I'm an unusual example, and that you might not live in an area where you see the "no income" community :) However, as a patient, I wanted to speak up and say that some of us really need those free drugs. While I see that it's an evil for some doctors, perhaps it's not the same evil for others. Would a lack of reps and swag cause drug prices to go down (via reduced advertising costs)? Do Average Joe's health insurance costs reflect the costs of giving out free samples to others? I don't know the answer to that.

By the way, I did try to apply to Wyeth's "free drugs for low income people" program, and I didn't qualify because I wasn't a citizen. Also, they took months and months to approve applications, and as you know, Effexor isn't something a person can just "cold turkey" while they wait for a decision to be made.

I hope this comment doesn't come across as a criticism, because it isn't -- you know what's best for your practice. It's just a comment from someone who benefited from the freebies.

3:32 PM  
Blogger Diana said...

Christie- It's so insidious, isn't it? Those gel pens are nice, as are the cookies the one nice rep brought in. I think I'm really pissing off several people by doing this. That's why I wrote this, so I can't chicken out and back down. I think I know the skinny little blonde rep. She has a couple of twin sisters up here, too.

Karen- I really DO wonder that. As I understand, Canada has cut some deals with the drug companies, so that's why many of their drugs are much cheaper. The Veterans Health Care System here (for military vets that qualify) does a similar thing, which makes sense.

Gerah- Thanks. I thought it came across as preachy or something but I don't write very well when I'm fired up.

Leigh-Ann- I LOVE that you wrote this. This is precisely why I took all those samples and meetings with reps all those years. Yes. The depression meds have several in their classes that don't have alternate cheaper generics that work for many people. I've come across many, many, many people similar situations. If I were in primary care, I don't think I'd have made this decision just because many of my patients relied on me for their meds. It's a horribly common problem. I don't have a 'one person acting alone' answer. And, no, you can't just cut Effexor cold turkey. (Sadly, I work in a VERY poor town. The students have an over 60% free and reduced lunch rate for the schools, meaning that over 60% of the kids in town are at or below the poverty level. Yikes.) Mental health care is horribly strained. The group that runs the low income clinic is pulling out, so we're not sure what will happen at the end of June. When I practiced in Portland, it was on the low income side of town. A large number of my patients were on public aid or medicare with no drug benefits. Not many had no insurance as those with no insurance don't tend to go to the doctor for things that aren't life threatening. I also do some work for the county health clinic, which, thankfully, has a limited variety of contraceptive pills that we dispense at minimal to no cost, along with condoms and depo shots. Personally, I feel medical care, including necessary prescriptions are a basic human right. Call me a commie pinko.

5:03 PM  
Anonymous Anonymous said...

Drug reps sound a lot like textbook reps. I bit once and got a bunch of free texts for my class and almost had to call security when I decided not to reorder. And I never got any really neat stuff.

You Rock, Kid.

The Ole RF-er

6:25 PM  
Blogger listmaker said...

You are my hero! Now if we can get the drug companies to take their damn ads off televison and out of popular magazines, I'll be a happy camper. I really don't think I should be going to my doctor and asking for drugs I know virtually nothing about but have seen in pretty ads. "Yeah, doc, give some of those purple pills, would ya? I really love their ads."

Now I'm going to go take those pills I paid a $40 co-pay for and which turned me into a head-to-toe itching allergic reaction and flush them down the toilet. They may not work for me, but gosh they have great ads.

8:46 PM  
Anonymous Leigh-Ann said...

Diana, I'm glad you didn't mind what I wrote, as I didn't want to sound "contrary". I just figured there was another side to the equation that could be brought up.

As for drug companies and advertising, I'm torn. On the one hand, I'm sure advertising costs factor into the ultimate price we pay for each pill. On the other hand, advertising makes people aware that medications exist for conditions they might otherwise suffer silently. I was the first one to tell my Mom about Detrol for her bladder problems -- if I hadn't mentioned it, she might have just thought that slight incontinence/urgency was just a problem that "older women had to endure". The same with Viagra when it was first introduced - it gave people the opening to introduce an issue with their doctor (although I think we're now so aware of ED as an issue that the ads could stop).

The fact is, I think a lot of people feel intimidated by going to the doctor, and might not want to seem like whiners. If a person sees an ad for Celebrex and it makes them aware that they could have a better quality of life, I think it's a good thing. I'm not sure how to strike a balance between education and overkill, though.

10:02 PM  
Anonymous Flippy said...

I like the freebies too. I wish I could've gotten a sample of Oxytrol, instead of spending $80+ on a prescription, using one patch and finding out it didn't work. Some Lyrica samples would've been nice too. They worked at first, but I think they caused weight gain. Ugh, like I need more of that.

Today, Leigh-Ann came with me to my pre-op appointment and we got a cool new drug pen. Some kind of Lidocaine patch or somethin'.

I understand not wanting to get a bunch of a expensive antibiotics, but as a patient, I likey the samples.

For a very brief period of time, I sold industrial chemicals. We didn't give out chemical freebies, but we did give out candy, cool toys, pens, etc. Conversational openers, I guess. And luckily, we didn't have to be as good looking as the pharm reps. I always thought it was funny when Leigh-Ann & I were in the awful & dumpy waiting room for one of our doctors (decent doctor, terrible office management, 3-4 hour waits) and the really hot drug reps would stop by. They always looked so out of place. Brightened up my wait a little though.

Sorry this is so long - I'm on drugs. :)

10:39 PM  
Blogger Teri said...

You are so totally my hero! thankyou thankyou thankyou thankyou thankyou! I can't even begin to express how disgusted I have been with drug company reps and for how long. Nor the study I read about that showed that most physicians get the majority of their onfo on new drugs from the reps - who, of course, have incentive to SELL, not tell the truth about efficacy, side effects. blah, blah. blah.

I have a firend, well, really an ex-coworker - who had a b.s. in chemistry, with some sort of emphasis on pharmacology - did a short stint as a drug rep, and he was absolutely miserable. The drug companies put the squeeze on their reps. Those lavish lunches? Straight out of the reps commission checks (at least that was the case for my ex-coworker). And, around here, at least, most offices won't even see the rep unless (s)he comes bearing goodies...
In anycase - I'm cheering you on! Go, Diana, Go!

10:40 PM  
Blogger Teri said...

p.s. A joke or two for Colin:

Q: What did the cow do on her day off school?
A:She went to the Moooooooooooovies.

Q:What's the cow's favorite flavor of ice cream?
A: Blue Moooooooooon

Q: Why did the cow rent a truck?
A: Because she was mooooooooooving.

(It must be the age - the cow jokes are clearly big at our house, too.)

10:43 PM  
Anonymous Kismet said...

Thorny issue. I can see both sides. But I have to say, I think you made the right decision. I want my Dr. to read this. He is so cool


11:08 PM  
Blogger Mridula said...

I came here through Teri's blog and what a post it is! By any chance you have read a book called 'No Logo'? Though it does not deal with medical advertising and reps but it is an interesting take on advertising. Once again, lovely post.

12:46 AM  
Blogger Diana said...

Dad- You'd think you'd at least warrant a sparkly gold bookmark or a pen. Maybe a stale cookie shaped like a book?

Listie- $40. Ouch! (Of course this would be an argument for your doc to have given you a sample, if one were availiable.) I actually don't hate the direct-to-consumer ads as much as most of my colleagues do. Most who ask me about them are just curious what the drugs are for as the ads aren't quite clear. The obligatory side effects disclaimer turns some off.

Leigh-Ann- I've seen the numbers spent for marketing these drugs but don't recall them and don't feel like Googling them now. The statistic I saw most recently that sticks in my mind was that $10,000 was spent per year per physician by drug companies on getting us to prescribe their drugs. I don't know if this is accurate or what it covers. If true, well, Yikes!

I agree that something that gets people more comfortable talking to their docs about their concerns is a good thing. (On an aside, there's an alternative to Detrol, a generic sister, called ditropan. You have to take it twice a day, but is much cheaper and essentially identical.)

Flippy!- Hi! I feel I know you, already, from Leigh-Ann. Some of those pens are pretty cool. Yeah. Lyrica and many of its cohorts cause weight gain. Very disappointing. I love the thought of you giving out samples of chemicals, in decorative vials that were far bigger than the aloquot. (Like one small pill in each hand-sized brightly colored box.) I don't have any problem with other sales reps in other fields giving freebees, I just think medicine needs to be held to a higher standard. Idealistic? Yup. Will it ever happen? Probably not. Hope all goes well with your surgery.

Teri- No shit! Really? Out of their own pockets? Good thing I didn't know this before or I'd have felt even more indebted for the clinic lunches and whatnot, and felt that I should reciprocate, say by prescribing only their drug for a month. (Colin LOVED the jokes. They are probably making the rounds at school as we speak.)

Kismet- That's just it. Pros and cons no matter how you look at it.

Mridula- Welcome! I recognize you from Teri's. You're from India, if I am remembering correctly. Do you know how such things are done there? I've got many colleagues from India, now practicing here. I need to ask them, too. I haven't read 'No Logo' but it sounds very interesting. I am intrigued by the influence of marketing on all of us, especially the insidious sort. Thanks for the recommendation, I'll look for it.

9:23 AM  
Anonymous Anonymous said...

oh yeah, there's an equivalent in the world of legalese. they come from IT places (for computer tech support) office supply places, hotels (for promotional stuff and if you need areas for conferences), local restaurants (which I welcome with open arms...gotta love free salad and breadsticks from Olive Garden!), and office equipment people trying to get you to lease copy machines, faxes, printers, etc.

My absolute favorite are the morons who call from out of state peddling toner cartridges. yea...I'm really gonna do business with someone who sends me, with 1 printer, 8 toner cartridges for $1800.00. nope sorry!

10:11 AM  
Blogger brooksba said...

First of all, that is a cute joke! Colin is such a sweetheart to want to share it with everyone.

I am in awe of you. You rock. Even though my medical insurance only makes me pay $10 of the prescription, I appreciate great doctors looking out for patients in cost AND top-notch care. You truly rock.

2:59 PM  
Blogger Cagey said...

YOU ROCK, DOC. Seriously!!

Just this week, I was sitting in my doc's office with Arun, waiting for his appointment, trying to keep him entertained, watching rep after rep go in AHEAD of me.

I really like my doctor, but I would consider changing if I found a doctor who didn't accept reps.

11:56 PM  
Blogger Diana said...

Amy- I had no idea! I love it that the hospitality industry hits on you. Definite perks. Maybe you could intice a place in The Bahamas to do a free sample trip?

Beth- Thanks, sweetie. You're blessed with only a $10 copay. The thing I try to stress to those lucky to have kick-ass insurance (few and far between, these days) is that the insurance companies won't be losing money. What you spend will eventually be paid for in higher rates and less coverage as your employer won't be able to afford the cost of the higher premiums. It is in your favor to keep your costs down, to the best of your ability, without compromising care, so your boss can continue to afford to cover you at a high level.

Cagey- OUCH! That looks bad. In your doc's defense, I hope he wasn't spending time with them, just 20 seconds for a quick signature and have the nurse or assistant or someone stash the drugs. While (s)he attends to the business at hand: seeing the patients. Unfortunately, it is easy for that 20 seconds to turn into a few minutes or more as the sales pitch winds up.

8:27 AM  
Blogger Lisa P said...

Wow - I've missed a lot... was at the Providnece "Practical Advances in Internal Medicine" course last week - so just catching up.
Yep - we have LOTS of generics in our sample cupboard now. We also have some name brands too, but anything has to go thru the pharmacy committe. So we DO have effexor XR, but alos have generic prozac, and couple others. We have (when we're not out) Prilosec, but also otc and generic pepcid.
Diana - we CAN'T (as in, are NOT allowed to) have any pens, etc w/ drug names on them. Office manager came thru and threw them ALL away. Now only PMG or just plain "bic" pens.
Occassionally the drug reps require a "witnessed signature" adn I am the designated clinic signee - however, I ALWAYS look extremely busy and NEVER make direct eye contact. Signature only. NO chit chat. And definitely NO detailing... The way it should be.

4:05 PM  
Blogger Diana said...

Lisa (Hi Honey!)- (See, you really need that blog, in all your spare time, of course.) Thanks oodles for the update on what is happening on the sampling. I thought it was a marvelous idea at the time. I'm giggling at the image of you as designated sample signer. No eye contact, no nuttin'.

4:42 PM  
Blogger Cagey said...

Hey - my doc is a woman. :-) I've never gone to a male doc and plan never to do that, either.

My doc is a no nonsense kinda gal, so I can't imagine her being super impressed with them taking her time. It just pissed me off that they were ushered on back and there were several in a row. It was probably the "several in a row" that did it.

9:11 PM  
Blogger Rozanne said...

Good for you! What's really scary is all the subconsious marketing that goes with all those freebie pens and mugs. Why can't I think of the name for that phenomenon? I remember learning it in junior high.

I like that you included the detail about the mousepad with the name of a constipation med on it and that it also includes a technicolor flower. Funny!

4:35 PM  
Anonymous Anonymous said...

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9:10 PM  

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