BMJ 2010; 340 doi: http://dx.doi.org/10.1136/bmj.c1102 (Published 29 March 2010)
Cite this as: BMJ 2010;340:c1102
Shane O’Hanlon, specialist registrar, geriatric medicine, Mercy University Hospital, Cork
It was switching to decaffeinated coffee that started it all. In a flash of lucidity I realised the dubious ethical basis for drug company representatives’ courtship of doctors. I noticed that my pattern of prescribing was mostly learnt from observing colleagues, many of whom sourced drug information primarily from drug representatives. I decided to take a drug rep holiday to see if I could emancipate myself from this moral quandary. My aim was to avoid contact with reps, promotional material, and sponsored sessions. I wondered how I might unsubscribe from their lists—and how they knew so much about each doctor?
Their calls generally went: “Hi, my name is Alison/Jane from Something-pharma, and I’m just getting to know the new docs. Would you have a few minutes to chat about my product?” The friendly and inviting tone of the first rep during my “holiday” meant I found it difficult to resist at first. But I had scripted my reply: “Sorry, I don’t meet reps.” The brevity of my put-down seemed to stun her. This clearly hadn’t happened before. She floundered momentarily, not having a suitable response, and apologetically bid farewell. I used the same strategy effectively with all subsequent callers. Some recovered well and tried to do a brief plug for their product. Others asked whether they could leave some literature—I said no, but some did anyway.
None of my colleagues seemed to notice. I wasn’t the odd one out, and the strategy actually seemed quite easy. The reps seemed perplexed, and a couple called again some time later, possibly to check whether I had gotten over my principles. But soon the calls almost disappeared.
The next challenge was the weekly departmental meeting—with free lunch. The rep conveniently had a slot on the agenda. In an attempt to keep things simple and civilised, I decided to sit outside during the rep’s presentation, like a conscientious objector. But sometimes I missed the start of the education session or entered too early and had to stay for the promotional speech. Some reps tried to introduce themselves. It was difficult to claim that I don’t meet reps when I just had. So I began to keep my head down and walk past. This seemed brusque, so I decided to say hello but quietly eat my sandwich in the corner while others had hot Indian takeaways. One rep reassured me that he knew I didn’t meet reps but handed me promotional reading material instead. Worse was when it was my turn to present and I was alone with a rep for a few awkward minutes before everyone arrived. I asked colleagues about cutting the reps, but nobody saw the point.
In the hospital corridors I noticed that some reps approached me then veered away at the last minute, having seen my name badge. Had I become blacklisted? I wondered whether they talked about me in the pub, but perhaps that was paranoia.
I attended some external educational meetings that were sponsored by drug companies. Generally these were held in luxury hotels, and at one there was an unfamiliar rep who uncannily knew my name. I walked purposefully past the fresh cream scones and coffee. The speakers were excellent but positioned next to large advertising boards. I couldn’t separate the presentations from the sponsorship, so I stopped going.
Avoiding advertising was impossible—most journals and medical newspapers carried industry promotion. Shunning these educational resources seemed overzealous. Most medical websites are also littered with pharmaceutical advertising, and there are hundreds of sponsored patient information sites. The only objective sites charged fees instead.
Despite my mixed results, I have no regrets. I now research my prescribing choices and have a healthy scepticism about my colleagues’ recommendations. I realise that it is impossible to avoid pharmaceuticals promotion completely, but I can minimise its influence. Unfortunately there remains the possibility of influence by proxy.
A year later I had to decide whether I would return to my old ways or stay “clean.” I had fond memories of the nights out, of being treated on a company expense account. I saw several colleagues have sponsored trips abroad, saving them considerable personal outlay, and I missed many educational meetings with convivial overnight stays.
But I also saw people start to notice what I was doing. They watched, bemused at my persistence in bringing my own lunch when there was a beautiful spread. Some considered doing the same, but generally it didn’t catch on—I wasn’t promoting it as a life choice. Those who questioned mostly wondered why. The arguments for and against reps have been well documented, and the only way to understand the difference is to stop seeing them. Most people are happy with their current interactions. I don’t judge them, but having altered my practice I feel more independent.
Becoming more aware of drug company influence may empower people to decide for themselves how much they wish to engage with it. I don’t intend to force my opinion on people, merely stimulate debate. But my view now, more than ever, is that in the future the current relationship with the industry will be seen as unjustifiable.