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.

Hahahahhahahahahahahahahahahahahaha!

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