Eight years ago, David Evans was one of five physicians running a practice in rural Oregon and noticed that pharmaceutical sales reps were frequent visitors, so frequent, in fact, they had appeared 199 times during a six-month period. And during a 10-month stretch, he found that drugmakers had sponsored 23 so-called ‘in-clinic’ lunches for physicians and office staff.
So Evans, who describes the number of visits as “staggering,“ and one of his partners championed the idea of showing reps the door – for good. And given that the steps taken proved to be not only effective but easy, he documented the approach in an essay that has just been published in the Journal of the American Board of Family Medicine in hopes of inspiring other physicians to do the same thing.
“Many docs find the concept challenging,” says Evans, who is now with the Department of Family Medicine at the University of Washington. “Cultural change is hard.” This remains especially true for the vast majority of physicians who do not practice at large academic medical centers, which have taken the lead in recent years in formulating new policies about interactions with the pharmaceutical industry.
Basically, the essay offers a primer on how such a practice can limit industry interaction along with a rundown on the lessons that were learned. But it was not always easy. As he notes, once the sales reps were no longer welcome, the shelves in the sample closet grew bare, his partners could no longer rely on free journal reprints to keep up on medical literature and staffers had to buy their own lunch.
To overcome reluctance, the practice took what were called “small, interim steps,” which included limiting the number of lunches to just once a month and asking reps to distribute only peer-reviewed materials. But not only did Evans and his colleagues deliberately eschew a cold turkey approach, they systematically went about a re-education process to explore the effects of industry marketing.
For instance, the physicians held monthly morning meetings to discuss peer-reviewed literature about the influence of detailing and sampling on prescribing patterns, drug costs and the ethics of receiving gifts. And like a friendly book club, they read and discussed ‘The Truth About The Drug Companies,’ by Marcia Angell, a former editor of The New England Journal of Medicine and industry critic.
They also explored the equivalent of a case study – the withdrawal of the Vioxx painkiller once sold by Merck (MRK) and the fallout on cardiac health. And they researched and discussed the subsequent Congressional investigation into the controversy over clinical data and marketing. Once they finished this informal crash course, the ‘pharma-free’ policy went into effect on January 1, 2006.
To gain staff buy in, Evans and his colleague quizzed them on ways to improve the practice. And they instituted monthly “all-clinic” lunches that cost between $60 and $80, which were protected time for the staff. But there was no effort to replace gifts and tchotchkes from reps. Meanwhile, branded office supplies were tossed and new items were bought at local businesses for less than $200.
There was also a benefit for patients, who received notices about the change. An inventory was taken of the sample closet and they found “very few” first-line medicines for common illnesses. Yet the estimated average monthly price for the brand-name drugs was $90. The practice then identified less-expensive options for 38 of 46 sampled drugs and these cost, on average, just $22 a month.
This proved particularly important, because the data helped Evans and his colleague – who had advocated the policy change – to convince their colleagues that there were valid reasons for turning their backs on detailers. “This data also allowed the clinic providers to put the results of the discussed peer-reviewed literature into the context of their everyday clinical experience,” the essay notes.
As for the physicians, they identified sources of information about medicines that did not come from the pharmaceutical industry and held monthly meetings. Finally, press releases were issued, generating coverage in the local media, which not only helped reinforce the message to patients but also alerted others in the surrounding medical community to the concept (here is the study).
“This study demonstrates that a shift in practice culture from a highly detailed practice to a pharma-free clinic is achievable,” the essay concludes. “Barriers to success can be identified and overcome when attention is given to careful information gathering, inclusion of staff input, and both clinic and patient education.”
In an earlier study published two years ago in The Journal of Family Practice, which more specifically examined physician and nurse attitudes toward the shift, Evans notes that the policy change improved both staff attitudes and patient flow. “The policy is still in place and I don’t think anyone will change it,” he tells us. “It has been a big success.”
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