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.

Organizing Students: Schwag

So, you've got an organization together, and it's held a few events. There is a little bit of buzz about the group, but you want it to go a little further. One way to keep your group on the minds of your audience is with free handouts. Any college student these days knows about schwag. You missed out? Check this page for a comprehensive history of "Stuff We All Get." They say,

the term schwag refers to all manner of logoed stuff given away by companies to get people to remember them, feel good about them, have their phone number and website at hand and generally make them think about them before any of their competitors.

My group didn't have any competitors and we don't sell a product, but we definitely want folks to think well of us. Anytime we ask folks to fill out a survey, we give them a free pen with our website on it. And I'd rather carry around a FOSEP pen than some pen hawking the latest statin or ED drug.

The pens have come in handy for other reasons. Just the other day, I was asked about FOSEP by a prospective member. After we talked, I gave him one of my FOSEP pens and referred him to our new members sign up site. Sure, pens are cheap, but that we have and give them out says that the group has its act together. I incorporate the pen pass into my pitch about FOSEP.

I can't think of a better tool to jot down my ideas about the Office of Technology Assessment or responses to young earth creationism than my FOSEP pen!

Here are the obligatory links to FOSEP and my other tips for student organizations.

Organizing Students: Food

This one is almost a no-brainer: In order to get students to participate in a group, it is always helpful to provide food. Keep in mind that there are two types of food: free food and cheap food. Both are important.

Let's talk about free food first. Free food gets people in the door. In weighing the cost-benefit of catching an early bus home or stopping by for a light dinner at an evening members' meeting, the free food always tips the scales in the same direction. Graduate students are notorious vultures: some of us keep close track of all of the seminars that provide food. For me, it is cardiovascular breakfast club Tuesday morning, medicine grand grounds Tuesday noon, pathology presents Wednesday afternoon and South Lake Union tapas seminar Thursday late afternoon. And those are only the seminars that pertain to my education! If your student group reliably provides pizza or subs at its evening meetings, you will develop a reputation for being a friendly place. For recruitment meetings, I like to mix it up. Pizza or sandwiches are nice, but something different will elicit positive comments and good feelings. A spread of Trader Joe's hor'd'oeuvres is popular and cheap. It's best if you put the food inside the room where you are meeting - even in the back. This keeps the vultures from flying away! Also, at public events (FOSEP holds monthly seminars), get snacks and coffee and your attendance will increase. And be sure to advertise that there will be snacks provided!

But where does money for this food come from? Securing cash for food is notoriously difficult for campus student groups - especially at public universities. At the University of Washington, the main institutional funding sources say "NO WAY!" for proposals for food. For the Husky readers, this includes the ASUW, the GPSS and the LLC. If you want money for food, you have to raise it yourself. Fundraising is a topic that I will cover at length in the near future, but for the purposes of this post you should know that when you ask for money, make sure you ask for money that can be spent on food. Or, if you ever get a donation of cash or check, be sure to deposit it into an account that can be spent on food. This can be set up through the school's budgeting system.

Free food is one way to get people to feel like your group is there for them. If it works for drug reps, furniture salesmen and job recruitment, it will probably work for your student group. The other important type of food is cheap food. This applies when funds are tight or when some of the group's leaders hold planning meetings. Chipping in $5-7 for gourmet pizza, takeout Indian food or the like provides the opportunity to create a congenial environment to get the work done. There is a reason families try to eat meals together and friends get together for dinner: breaking bread is an age old tradition that unifies individuals. On a more practical side, sometimes the best time slots for students meetings are in the dinner hour, at lunch, or even breakfast. In Seattle, getting coffee can even turn into a working meeting.
Cartoon by Adam York Gregory. Check out his other comics at The Flowfield Unity. This post brought to you by our friends at FOSEP. Other student organization tips can be found here.

Carbon Footprint: Low Flow

This is the sixth entry in my series about reducing your personal carbon footprint. So far, I have suggested that you ride the bus, take the stairs, live in the water-powered Northwest, think differently about air travel and recycle aluminum. I enjoy writing these tips; I hope you enjoy reading them. That this is number six also means that I have been keeping up with my regular blogging for almost two months.

Today I want to share with you information that could reduce your carbon footprint, lower your electricity bill and conserve our watersheds. How much? Well... To start, the Department of Energy estimates that electric water heaters are the second biggest energy sink in homes without natural gas. (I am guessing this is after the fridge.) Where does the warmth in that guilty pleasure of a long hot shower come from? In most homes, gas and coal fired power plants. A utilities sponsored study found that a family of four could save 14,000 gallons of water a year just by switching to an energy efficient shower head. This amounts to 21 cents a day on water and 51 cents a day on electricity bills.

Energy efficient shower heads and faucet aerators work by inserting air into the water stream. The contents come out at the same pressure - there is just less water. Evidently, the water cools faster though. According to one site,

if you are tall, you may notice that the water has cooled a little before it reaches your feet.

Interesting. Hopefully this fact does not convince my wife that we should not switch the head in our household. But speaking of switching, you can get a FREE aerating shower head by calling 206-684-3800 or emailing rescons.scl@seattle.gov. In addition, many Puget Sound residents will soon be mailed forms with which they can receive two FREE faucet aerators and one shower head. You can go to this website and register before the crowds to make sure you get one. There are also numerous additional tips to reduce your water usage at that site.

Ombudsman

Tomorrow I meet with the University of Washington's ombudsman. Don't worry, it's nothing serious, and is of my own prerogative. If it is appropriate, I will certainly post more specifics in the future.

Just out of curiosity, does anyone out there have any experience interacting with ombudsmen?

Universities have come to rely on this person as a resource for personal conflict mediation and for processing claims of scientific misconduct (neither is the reason I am meeting with her). One prominent use of ombudsmen is the James Sherely tenure dispute at MIT. I also bet that legislation like the Whistleblower Protection Enhancement Act (HR 985) probably comes to bear on this office. The nature of ombudsmen's work is usually confidential, so it will be interesting to learn more about what the office does.

I figure that at the least, I will come away from our meeting with a better sense of how the ombudsman can factor into the academic structure. And maybe by the end of this I will be able to pronounce ombudsman without twisting my tongue.

FREE TimesSelect

Were you as upset as I was last year when the New York Times limited its opinion columns and other features to subscribers only? If so, you will be as happy as I am right now that individuals with academic email addresses can receive complimentary subscriptions to the TimesSelect program. Just follow this link and you will have another way to while away those minutes between timepoints or incubations!