Drug Reps 'R Us

Now five months in to my third year medicine clerkship, I'm pleasantly surprised about how little interaction with pharmaceutical company representatives I've had. As I get deeper into it, I am realizing just how tenuous the dynamic between pharmaceutical innovation and controlling costs in health care.

I am pleased to report that I still feel uncomfortable in the setting of drug company schwag or it's provider. Sometimes I feel the same squeamishness I've felt witnessing (illegal) drug transfers. Is it a coincidence? In doctors' offices: Who's the pusher? Who's the dealer? And what does that make the patients? Are they stuck in a crossfire?

Here are a few personal vignettes about my encounters with (legal) drug dealers.

Before my clerkships, I often attended the University of Washington's Chairman's Rounds each Tuesday. That food was provided by a rotating ensemble of drug company reps. They asked for attendees to sign in, and would actively seek eye contact of the audience as we filed in. If I were dressed less formally (PhD casual), I would occasionally be interrogated about which department I was with. (My answer was always pathology.) Most times, I clipped on my medical school ID badge kept my eyes focused on the food or floor and walked past them without noting the company or drug. After all, I was there to keep up my clinical mind. I did take the food, however. Some other students and residents (but never faculty) brought or bought their own lunches...

My first rotation at Seattle's Children's Hospital was pharm-free. The free food at the daily noon conference was provided by the residency program rather than drug companies. Monday's World Wraps and Wednesday's fish burritos were my favorites. Then as an outpatient in the pediatrics clinic, I discovered that the patientmedicine samples were provided by Children's Hospital, not by drug reps. In fact, some of the residents placed the absence of "pharm food" as a positive attribute for that program.

The next stop on my magical medical mystery tour was a family practice office in Anacortes, WA. They had kicked the drug reps out years before in favor of samples provided by Group Health. The idea being that enough of the practice's patients are insured by Group Health that it will pay off to get docs in the practice of handing out and prescribing the generic meds on GH's formulary that it will benefit the insurer even if the docs give the samples to non-Group Health patients.

For the last 7 weeks, I've been in Spokane, WA for my medicine clerkship. The only evidence of pharmaceuticals at the hospital where I worked were in the ubiquitous pens and post-it notes on the floor. Not until my outpatient experience have I had direct contact with drug reps. In the endocrinology (diabetes, thyroid and hormone problems) and dermatology (rashes and acne) clinics, I've encountered piles of free handouts, cabinets full of samples, company provided patient handouts, occasional lunches and the well-dressed woman with a clipboard. "Who is this attractive lurking specter?" I wondered the first time in the endocrine clinic? She was just waiting patiently for the doc to sign a clipboard acknowledging receipt of the samples. She got in one sentence before my preceptor informed her that she had more patients to see.

I am being gradually exposed to the tight grip of pharmaceutical companies on medical practice. Fortunately, I am also experiencing some of the push-back that entities as different as private practice and world-class health care institutions are giving. Whether its the cold shoulder given by docs as they sign the receipt or the broad resistance of entire hospitals, there is certainly a tension that was not there 10 years ago. The consequences of doctors giving free samples of brand-name drugs is not always obvious to patients or doctors. But I'd like to think that the next generation of physicians is ready to approach health care in a less expensive, more sustainable manner.

We shall see.