A patient of mine recently asked if all doctors are as gullible to the pharmaceutical companies’ marketing tricks as it appears. I was immediately transported to my days working in an academic hospital. At the time, the "drug reps," as they are called, used to have much more leeway to befriend and bribe exhausted and overstressed trainees eager for free food and a friendly smile. The companies knew better than we that our future prescribing practices were at stake. Falsely armed with a lethal combination of arrogance and naïveté, we medical residents assumed that we could toe the line as excellent clinicians while exploiting big pharma largesse. Even our respected mentors encouraged us to at least listen to the pharmaceutical information--advertisements disguised as clinical trials--while eating our free lunch. According to the hospital's motto, we were the "Best of the West" and that meant being fully capable of prescribing all of the newest medications, even if the only supporting data were generated by the drug company itself.
In the ten years that have passed, I have worked primarily in private practice. One of my first decisions was to eliminate all pharmaceutical company influence. I rebuff phone calls from reps every week, occasionally escort the brazen marketer, who appears unsolicited in the waiting room, to the door and regularly ignore invitations to dinners at some of New York's posh restaurants. In the meanwhile, I have also disregarded the bulk of clinical trials studying the newest drugs, even in the prestigious journals, since most of the funding for this research continues to come from the pharmaceutical companies themselves.
During my training, I believed I was simply acting according to my beliefs. Unlike many of my colleagues, I never believed I was immune to these sophisticated marketing techniques, and I wanted to practice apart from from these influences. What has surprised me through this past decade is the transformation of my prescribing practices. First, I have raised my threshold as to whether or not to prescribe medication at all. In an age when medication is supposed to cure all our ills, the default decision of a psychiatrist is to medicate and always medicate. It is liberating to know that prescribing is a clinical decision, not an automatic action. I also take into account variables never mentioned by a pharmaceutical rep: long-term safety data, years of efficacy with substantial independent research, and, finally, price.
Accordingly, I face the challenges of practicing psychiatry in a very different way. I have gravitated to routinely using medications that came on the market over 20 years ago because the safety record is proven and therefore puts patients and me at ease. I avoid new medication combinations and instead choose older, more thoroughly studied options, such as thyroid medication for depression--a treatment which has safety and efficacy data starting from the 1950s. I also weigh price into the equation both for my patient's pocketbook and to measure my small footprint on the explosion of health care costs.
The uneasy marriage between academic medicine and big business has had significant costs to medicine as well as to society at large. Physicians, by nature, are not business people. In recent years, several highly-esteemed physicians have been caught lining their pockets with pharmaceutical payouts while using their reputations to successfully sway doctors' prescribing practices. Clearly, no one is immune to such cutthroat and well-practiced marketing schemes. Left to their own devices, insulated from sales pitches cynically disguised as education, doctors might find alternate ways to differentiate between the true goals of a healing profession and the hidden influences of the marketplace. Protecting young doctors from powerful marketing influences early in their careers could have long-term safety benefits and help rescue the medical profession from the aura of skepticism and distrust that has come to surround it.
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