Does your doc have your best interests in mind?

[StormRichards]

I just don't trust the pharmaceutical field very much due to what I've seen, and how you never know which drug will be the next one that turns out to be life altering/threatening and they didn't know it until it was too late. I'm very cautious with what I take.

I'm with you on this one.

For many years my oldest brother did not drive so I often took him to his doctor's appointments. I remember one time when he came out of the doctor's office with a little bag of free samples. VIOXX. We had the same doctor and I specifically remember the doctor using a VIOXX clipboard and notepad. I wondered at the time what else he had in his office free from the pharmaceutical company.

Thankfully my brother wasn't on that medicine long before it was taken off the market.

[disneysteve]

I specifically remember the doctor using a VIOXX clipboard and notepad. I wondered at the time what else he had in his office free from the pharmaceutical company.

I feel obligated to address this point.

Back when pharma companies were still allowed to promote their products to physicians, which ended in 2008, we used to debate this a lot. One day at work, I was discussing it with someone and just out of curiosity, I brought them into my office. We looked around and in clear site (without going into drawers or cabinets), we found 9 items from drug companies: pens, notepads, a stapler, etc. All 9 of them were advertising medications that I never prescribe. They were just useful items that I got for free so why not use them?

My prescribing decisions are not determined by someone giving me a 5-cent pen or a 10-cent notepad. More often than not, my decisions are driven by what med is covered by your insurance plan at a cost that you can afford.

Were there promotional abuses? Yes. Were some doctors influenced by that? Yes. But I think stopping it entirely only punished doctors and made it that much harder to run a profitable business.

The other thing to keep in mind is that as marketing drugs directly to doctors ended, selling them to the public skyrocketed. Direct to consumer marketing was a $5.4 billion business last year, a 19% increase from the year before. This causes far more problems because now patients come in demanding the drug they saw on TV. There are even ads for really high end and costly drugs like chemotherapy agents and medical devices like specific joint replacements. Advertising those to the public makes no sense at all.

[StormRichards]

I feel obligated to address this point.

Back when pharma companies were still allowed to promote their products to physicians, which ended in 2008, we used to debate this a lot. One day at work, I was discussing it with someone and just out of curiosity, I brought them into my office. We looked around and in clear site (without going into drawers or cabinets), we found 9 items from drug companies: pens, notepads, a stapler, etc. All 9 of them were advertising medications that I never prescribe. They were just useful items that I got for free so why not use them?

My prescribing decisions are not determined by someone giving me a 5-cent pen or a 10-cent notepad. More often than not, my decisions are driven by what med is covered by your insurance plan at a cost that you can afford.

Were there promotional abuses? Yes. Were some doctors influenced by that? Yes. But I think stopping it entirely only punished doctors and made it that much harder to run a profitable business.

The other thing to keep in mind is that as marketing drugs directly to doctors ended, selling them to the public skyrocketed. Direct to consumer marketing was a $5.4 billion business last year, a 19% increase from the year before. This causes far more problems because now patients come in demanding the drug they saw on TV. There are even ads for really high end and costly drugs like chemotherapy agents and medical devices like specific joint replacements. Advertising those to the public makes no sense at all.

Not sure how, but your reply quoted CaptainSteve instead of me.

I understand and respect your opinion on this.

The problem doesn't have to be widespread for the perception to be widespread. Not stating that the doctor based his prescriptions on anything unethical, but when you do see all of the freebies you are left to wonder. And that is not a good thing.

[GoodSteward]

Not sure how, but your reply quoted CaptainSteve instead of me.

I understand and respect your opinion on this.

The problem doesn't have to be widespread for the perception to be widespread. Not stating that the doctor based his prescriptions on anything unethical, but when you do see all of the freebies you are left to wonder. And that is not a good thing.

Thanks to the bad eggs, as usual, there is a stigma left behind because of how things have been, and possibly still are. Obviously, Steve only got cheap stuff to allow free advertisement in his office for that company, but from the view of a patient it appeared as if he was promoting it/paid by them to push it; or some other incentive to prescribe it more. Sadly, you can be the most honest guy in the business and still be seen as a bad guy due to all the stigmas out there. Just in like the finance world for advisers and agents. I think removing the names from things helps the patient feel like the doctor is looking out more for the patient and not trying to pocket more with some back door deal they have with a drug company.

[disneysteve]

Not sure how, but your reply quoted CaptainSteve instead of me. I fixed that.

I understand and respect your opinion on this.

The problem doesn't have to be widespread for the perception to be widespread. Not stating that the doctor based his prescriptions on anything unethical, but when you do see all of the freebies you are left to wonder. And that is not a good thing.

Exactly. They were forced to change an age-old practice due to public perception. Most doctors find that really insulting - the perception that we went to 4 years of college, 4 years of medical school, 3 or more years of internship and residency only to base our treatment decisions on who gave us a nicer pen.

As I said, we really have relatively little control over what we prescribe. We prescribe what's covered, and we prescribe generics whenever possible.

[disneysteve]

I think removing the names from things helps the patient feel like the doctor is looking out more for the patient and not trying to pocket more with some back door deal they have with a drug company.

I understand the perception issue.

It just really annoys me that essentially what replaced marketing to the doctors who actually make the decisions is marketing directly to the patients. "Ask your doctor about...." How many times a day do you hear that while watching TV?

[GoodSteward]

I understand the perception issue.

It just really annoys me that essentially what replaced marketing to the doctors who actually make the decisions is marketing directly to the patients. "Ask your doctor about...." How many times a day do you hear that while watching TV?

The next move they want is to not have to list the side effects in the commercials. That will make this even worse.

[StormRichards]

Exactly. They were forced to change an age-old practice due to public perception. Most doctors find that really insulting - the perception that we went to 4 years of college, 4 years of medical school, 3 or more years of internship and residency only to base our treatment decisions on who gave us a nicer pen.

As I said, we really have relatively little control over what we prescribe. We prescribe what's covered, and we prescribe generics whenever possible.

Your frustration is understandable but bad eggs ruin it for the good in many professions. And of course the bad eggs get more press coverage.

[StormRichards]

"Ask your doctor about...." How many times a day do you hear that while watching TV?

The next move they want is to not have to list the side effects in the commercials. That will make this even worse.

Steve, do you actually get a lot of patients come in and ask? Thankfully I do not have any illness that requires medication, but for many of the commercials the side effects sound worse than the condition mentioned in the commercial.

I think to myself "heartburn or anal leakage" and immediately think I would rather suffer from the heartburn. Or many of the other ailments they have commercials for.

[disneysteve]

Steve, do you actually get a lot of patients come in and ask? Thankfully I do not have any illness that requires medication, but for many of the commercials the side effects sound worse than the condition mentioned in the commercial.

I think to myself "heartburn or anal leakage" and immediately think I would rather suffer from the heartburn. Or many of the other ailments they have commercials for.

I don't get a lot but enough to be annoying. It puts the doctor in the defensive position of having to explain to the patient who is convinced that they need drug XYZ why that isn't actually what they need. And I really love the commercials that say, "Ask your doctor for a free sample." Then they come in and are upset when I tell them that I have no free samples.

As for side effects, there are pros and cons to that. Numerous times I've had patients refuse to take a medicine that I recommended because of something they heard (or thought they heard) on a commercial.

The bottom line is that I'm 100% opposed to direct to consumer marketing. It's just one more way that treatment decisions are taken out of the doctors' hands and influenced by outside forces that rarely have the patients' best interests in mind.

[LivingAlmostLarge]

I hate to point out but you are bringing up antedotal evidence. There isn't supporting proof that one person gets the flu shot = flu. It's like my cousin got herpes from licking a spoon someone who had herpes did. Second, we keep picking on the flu shot. That's not the outbreaks nor what most people are avoiding. Flu shots are common and annual, but let's talk about the real outbreaks and what people are avoiding. Flu shots are best guess what strain is going to happen. It's not easy and it mutates. Also scaling up isn't always easy either.

But what is easy? Whooping cough. Polio. Mumps, measles, small pox etc. We have proven vaccines for them. But parents now are choosing to not vaccinate their kids because they feel that the herd immunity is protecting them. What they don't realize? It's not. Herd immunity only works when the majority immunize. Why do you think the outbreaks happen?

We pick on flu shots, great don't get it. But you want to pass on the rest of the vaccines? I hate the fake news. I can't stand the fact people keep quoting the fake study proving it doesn't cause autism yet people keep perpetuating the myth. It was disproven. Not only that when you point out that opinions about it, not STUDIES, not proven evidence people don't want to listen. Because it sounds better to say that vaccines are the problem.

On this very board we talk about how the FDA makes the costs of drugs so expensive because it's so stringent on rules. The same rules apply to vaccines yet people don't say "oh yes they went through trials as well."

And I don't know that drs aren't influence by pharma companies. I think part of the influence comes that some companies push their reps to sit and explain why their drug is better for longer to a dr. Also once a dr starts using a drug and sees effect perhaps lack of time and previous experience pushes the dr to prescribe the drug again instead of switching. And only switching when a patient doesn't see the result expected or has an adverse reaction.

Actually, I've personally not seen this around me. I work with people who get flu shots, and they often still get the flu. My grandmother took the flu shot yearly and yearly got the flu. She finally just quit taking it and she quit getting the flu. Again, observation is all I am giving here. I've personally not gotten the flu shot, ever I guess, and I can't remember the last time I got the flu. Cold/Crud...every year. But never the flu. One explination I was given by someone is that since there are many strands of the flu they take a guess at which will be the worst each year, and give shots for those. They can't get them all. I don't know how true that is, but that does make sense.



I agree with your post. While it is hard to OD on some vitamins, it can be done on others. Minerals can definitely be OD'd on. You have to be careful. I just don't trust the pharmaceutical field very much due to what I've seen, and how you never know which drug will be the next one that turns out to be life altering/threatening and they didn't know it until it was too late. I'm very cautious with what I take.

[disneysteve]

And I don't know that drs aren't influence by pharma companies. I think part of the influence comes that some companies push their reps to sit and explain why their drug is better for longer to a dr. Also once a dr starts using a drug and sees effect perhaps lack of time and previous experience pushes the dr to prescribe the drug again instead of switching. And only switching when a patient doesn't see the result expected or has an adverse reaction.

This happens to some degree but as I've said, the single biggest factor influencing what I prescribe is formulary coverage and cost. You can come in and tell me about your new product and it can be the greatest drug in the world but if it isn't covered by the insurance companies, I'm not going to write it for my patients. Many doctors also work in healthcare systems that have targets for generic drug usage and they get penalized, or at least miss out on incentives, if they don't reach those targets. Most docs have very little freedom to prescribe whatever they want to.

[FLA]

I worked in a Radiation Oncology practice with 3 docs. Because of the effects of some radiation on erectile function, we were heavily visited by reps from cialis, viagra and levitra. They brought us funny ED pens and lunch. The 3 reps each got about 5 mins with the docs every couple of months. We were heavily sampled with the drugs. Yet the docs prescribed what would work best for each individual patient, they really weren't swayed by the reps, much to their consternation. Now those days are gone, no more free lunch and golf outings that they never went to. A respectable doctor isn't swayed by that kind of stuff.

[FLA]

But what is easy? Whooping cough. Polio. Mumps, measles, small pox etc. We have proven vaccines for them. But parents now are choosing to not vaccinate their kids because they feel that the herd immunity is protecting them. What they don't realize? It's not. Herd immunity only works when the majority immunize. Why do you think the outbreaks happen?

We pick on flu shots, great don't get it. But you want to pass on the rest of the vaccines? I hate the fake news. I can't stand the fact people keep quoting the fake study proving it doesn't cause autism yet people keep perpetuating the myth. It was disproven. Not only that when you point out that opinions about it, not STUDIES, not proven evidence people don't want to listen. Because it sounds better to say that vaccines are the problem.

On this very board we talk about how the FDA makes the costs of drugs so expensive because it's so stringent on rules. The same rules apply to vaccines yet people don't say "oh yes they went through trials as well."

ITA with you, all of it

[disneysteve]

Yet the docs prescribed what would work best for each individual patient, they really weren't swayed by the reps, much to their consternation.

A respectable doctor isn't swayed by that kind of stuff.

I will say that the reps do have an influence, but not really in the way people think. Your example is a perfect one. Viagra, Cialis, and Levitra all do the same thing. And they all cost about the same amount (and typically aren't covered by insurance). If one rep is particularly nice or provides extra good service, maybe I'll preferentially prescribe that product over the others, but it's choosing between 3 equal drugs. It's not like I'm choosing the fancy expensive drug over the cheap generic drug.

The other way that reps have an influence is that they educate us about new products. If the new product truly offers significant benefits over the older products, I certainly may use them in select patients who haven't gotten an adequate response to the existing options.

A bigger factor, though, which the public never really hears about, is how the manufacturers negotiate with the insurance companies to get on their formulary. We will see the effect of this in a few weeks after January 1. All of a sudden, drugs that have been covered will get replaced by other drugs and I'll be stuck changing meds for a bunch of my patients. I really have no choice because if I don't make the changes, the patient will no longer be able to afford their medicine.