UA to loosen drug reps' grip at UMC

These banquets aren't for sick patients, though. They go to doctors, interns, students and staff, courtesy of medical drug and device companies trying to sell their products.

There is nothing unique about the scene. The free lunches, and all kinds of other perks, go to hospitals, doctors' offices and clinics all over the city and throughout the country on a daily basis, and have for years.

The very effective marketing tactic is blamed for influencing doctors to prescribe expensive drugs their patients may not even need — and thus for raising the cost of our already very expensive health-care system.

But what is unique about UMC is that it's the only hospital in Tucson — and one of the first in the country — that is trying to control, even eliminate, the all-too-cozy connections between the healers and the sellers.

A new policy has been drafted that would stop the free meals, gifts, trips and payments at the University of Arizona College of Medicine.

If the policy passes, it will be no less than a "paradigm shift" at UMC, in the words of one doctor there, and will cost the already financially pinched medical college major money.

But it's time, maybe past time, for it, say those working on the policy and preparing to pre-sent it to the UA medical faculty, where it's expected to meet no small amount of resistance.

"The real issue is, do things the drug industry does for physicians influence how they prescribe medications, and there is lots of evidence to show that it does," said Dr. T. Philip Malan, vice dean of academic affairs in the College of Medicine.

"We have got to be thoughtful about the message we are giving to our students through our role-modeling. But I think it's going to be controversial. To be honest, influence is very difficult to recognize sometimes. Physicians are intelligent and educated, and many of us feel we can see through these things. But the evidence suggests we are not as good as we think we are."

Pharmaceutical companies spend up to $18 billion a year — more than $13,000 per doctor — persuading doctors to prescribe their drugs, with overwhelming emphasis on the newest and costliest. This pays for some 60 million visits a year by salespeople — known as "drug reps" — laden with all manner of food, gifts, sponsorships and other tokens.

They do it because it works. Study after study shows that while doctors deny any influence from all the wooing, it does significantly increase the likelihood that they'll prescribe the drugs being pushed, even if evidence shows they may not be the best or most cost-effective.

"Prescribing nonrationally" is what the American Medical Association calls the effect. It's why the AMA, along with the American Medical Student Association, is strongly pushing medical schools across the country to stop it.

A handful of medical schools — notably Stanford, Yale, Georgetown, the University of Pennsylvania and the University of California-Davis — recently adopted policies that effectively kicked the drug and device reps, and most of their goodies, off campus. The policy drafted for UA is closely modeled after Stanford's.

"The UA is getting out ahead of the curve, but this is slowly happening all over the country," said Dr. Raymond Woosley, the former UA vice president of health sciences who tried — and failed — to get just such a policy passed here five years ago.

"There was a lot of resistance then, but things are changing," he said. "The public is more aware of what's going on. I really hope it succeeds this time. It is absolutely essential."

To be fair, things aren't as bad as they were just a few years ago. Under threat from federal regulators alarmed by a dramatic rise in drug spending, the pharmaceutical industry — known as "Big Pharma" — quickly passed some new rules in 2002, putting a voluntary halt to the most egregious stuff — free cruises, resort trips, golf outings, expensive gifts, and lavish dinners for doctors and their entourages, most with no educational value at all, save for information about the drugs being peddled.

Today, the most common practice slated for elimination at UMC is the free lunch — the meals catered by the drug and device reps in hospital clinics and at noon medical conferences on various subjects that go on all over the hospital.

The drug companies provide the food, then make themselves, their drug or devices, information, and small gifts available for the doctors, students and staff attending. On any given day, as many as 20 sales reps are checking into UMC for these and other appearances.

"What would change is the drug reps would no longer be given full and complete access to the medical staff and students at these conferences," said Dr. Kevin Moynahan, a UA internist and vice dean for curriculum.

"There would be no catered lunches, no gifts, no interaction between the doctors and the reps. That's the hope — to disconnect the drug companies and the doctors."

Even though the gifts that go with these events are now small and cheap — pens and coffee mugs instead of the golf clubs and golf bags of yore — studies analyzed by the Journal of the American Medical Association repeatedly show they still influence prescribing habits.

"Most physicians are not aware of how even small gifts have an effect," Moynahan said. "These are dedicated and caring people, and it's truly a shock to think they might react this way."

But losing this perk is not going to go down easy. Doctors and medical students are busy people, and grabbing something to eat while at a lunchtime seminar saves precious time. Plus, many say information about a new drug is valuable.

"This is a tough one," said Dr. Sanjay Ramakumar, a urologic surgeon who recently left UA to go into private practice here.

"There are real benefits, when the industry sponsors educational endeavors, textbooks, things like that, at a time when money is tight for all academic institutions," he said. "But anyone who says this has no influence is not there. We can't fool ourselves. We are all influenced by their presence."

Noting that he is just as exposed to drug reps in private practice as he was at the UA, Ramakumar thinks that rather than ban them in teaching hospitals, they should be used to teach students how they are affected.

"They're going to see this when they open their practices," he said. "They should be ready for it."

Stopping this practice will indeed cost the UA money. UC-Davis now has to foot a $70,000 annual bill for doctor/staff event meals that drug companies used to provide.

Even more problematic will be the loss of the free drug samples generously provided to doctors. They use these to test patient responses to new drugs before making them pay for a month's supply. The benefit to low-income patients is obvious.

A drug rep may drop 20 boxes of Viagra samples at the urology clinic weekly — about a $500 value — said John Flores, president of the Arizona Medical Representatives Association, the industry group for Arizona drug reps.

By far the highest of their physician marketing costs, the samples pay off, big time.

"You get one patient on a chronic medicine for life by starting them on a sample, that's the big return. That more than makes up for the cost of the samples," Flores said.

Some of the reps, who closely track physician prescribing records, call those they think aren't prescribing enough of a certain drug, said Steve Nash, executive director of the Pima County Medical Society.

"The doctors hate that," he said.

That's precisely why this kind of one-on-one, hands-on, face-to-face contact has to stop, said Dr. Sanford Newmark, a pediatric integrative medicine specialist who trained at the UA and now is in private practice.

"We're very concerned about the overuse of prescription drugs, and seeing the drug reps get in with the medical students at the very beginning of training is just not a good idea," he said. "The information they get is not accurate or, at the very least, biased. But it's all over the hospital, and it's even worse in private offices.

"It's absolutely great the university is looking at this."

The new UA policy would allow drug companies to send in free samples — for the benefit of low-income patients — but they would be delivered and stocked in a central location, with no presence of drug reps, much less their food and gifts.

Caught by surprise that UMC may become a "no-see" hospital, Flores — who represents drug reps throughout Southern Arizona — said he was "shocked and disappointed."

"We provide a tremendous amount of resources and the best available therapies to this institution," he said. "To break that partnership would be detrimental to the quality of patient care, and the eduction of residents and medical staff."

He said he doubts the policy will pass, and if it does, predicts that it won't last long.

"The doctors absolutely will not support it," he said. "The majority understand our value."

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