LETTERS * CORRESPONDANCE
We will consider for publication only letters submitted in duplicate, printed in letterquality type without proportional spacing and not exceeding 450 words. All the authors must sign a covering letter transferring copyright. Letters must not duplicate material being submitted elsewhere or already published. We routinely correspond only with authors of accepted letters. Rejected letters are destroyed. Accepted letters are subject to editing and abridgement.
Seules peuvent etre retenues pour publications les lettres recues en double dont la longueur n'exce'de pas 450 mots. Elles doivent etre m&canographiees en qualite "correspondance" sans espacement proportionnel. Tous les auteurs doivent signer une lettre d'accompagnement portant cession du copyright. Les lettres ne doivent rien contenir qui ait ete presente ailleurs pour publication ou deja& paru. En principe, la redaction correspond uniquement avec les auteurs des lettres retenues pour publication. Les lettres refusees sont ddtruites. Les lettres retenues peuvent etre abrdg&es ou faire l'objet de modifications d'ordre redactionnel.
Physicians and pharmaceutical companies D ~ r. Robert F. Woollard's description in "Snake oil and Caesar salad: the ethics of physician and pharmaceutical relationships" (Can Med Assoc J 1991; 145: 931-933) of the murky relationship between physicians and pharmaceutical companies is on the mark. So, too, is his
description of physicians' extraordinary defensiveness when challenged on the propriety of accepting the meals, fishing trips and other perks that accompany this cosy arrangement. The ability of physicians to deny that they can be influenced by all of this has long fascinated me. Perhaps it is pertinent to -
For prescribing information see page 401
point out explicitly what may be going on here. The motivation of the company ("educator") is obviously to sell drugs by influencing physicians. There is nothing intrinsically wrong with this: some drugs are life-saving, others extremely helpful to patients. However, some are of dubious merit except as revenue producers. Advertisers make little distinction between them for obvious reasons. The strategies designed to seduce physicians are aimed at several levels, including the emotional. Drug house dinners ("educational meetings"), for example, try to influence the practitioner somewhere deep inside - probably between the heart and the gastrointestinal tract - so that the company's name (or logo or representative) evokes a warm feeling that can't quite be identified but just seems to be good. The second purpose of these educational activities is to lead the physician into a belief that pharmacotherapy is logically the first approach to a problem. The third (on an ascending scale of specificity) is to persuade the physician that company A is ethical, is devoted to research and education, and generally represents a pretty nice group of people. The fourth goal is to suggest that a particular class of drugs may be helpful for the problem (and certainly has been proven elsewhere to be safe and effective) and, with a little luck, to suggest that brand X of this class is superior to brand Y sold by another firm. Finally, all this promotion is designed to remind the physician that the representative would be pleased to help him or her with samples, educational visits to the
office and any other continuing medical education (CME) event. Physicians are inclined to attest that a company product "was not even mentioned." Clearly not all promotional aims can be achieved in one event: it is the cumulative package being presented that counts. Not to recognize that one is being influenced is evidence of the subtlety and effectiveness of the process. The overall effect of these activities encourages unquestioning pharmacotherapy with all its attendant hazards. We have a responsibility to our patients, if not to ourselves, to be a little more aware of the process. Our compliance with the sales person's blandishments will not be tolerated by the patient if he or she comes to believe that we should have known better. Arthur J. Macgregor, MD 1026 Cook St. Victoria, BC
Although I admire Dr. Woollard's writing ability I question his purpose and the cause for such an article. I agree that physicians are not immune to criticism from without or, as in this case, from within the profession. During the past few years there has been considerable discussion and controversy on the relationship between the pharmaceutical industry and physicians. Much of this appears to be generated by physicians more active in academia than in clinical practice. Woollard states that he has been met by a defensive response from colleagues on this issue. I cannot help but ask whether everyone is out of step except Woollard and his committee. Few would disagree that new CAN MED ASSOC J 1992; 146 (3)
327
drugs have profoundly benefitted modern medicine and have assisted physicians to treat disease and reduce suffering. Much of the opposition seems to focus on the cost of pharmaceutical therapy and the assumption that new products increase medical costs; in fact, they frequently reduce the cost of therapy. The introduction of cimetidine reduced the cost of peptic ulcer therapy from $721 to $221 per patient,' resulting in overall savings to the health care system of millions of dollars. In Britain Teeling-Smith and Wells2 attributed the reduction in hospital costs from 1957 to 1982 of £447 million to new drugs. It is estimated that the introduction of brand name d-blockers such as timolol to prevent a second heart attack resulted in a net saving of between $1.6 and $3 billion.3 A second concern of Woollard is that the interaction between physicians and the industry may result in inappropriate therapy. Woollard quotes a number of opinions on this issue but fails to provide any data to substantiate that there is a problem. Although some of the advertising practices of a few pharmaceutical companies may be in poor taste I resent the implication that physicians are influenced by the industry to inappropriately treat their patients. I consider this insinuation a slur and an insult to the intelligence of physicians and to the integrity of physicians and the industry. As physicians we should review our activities on a regular basis, but it is inappropriate for the CMA or other bodies to make accusations based merely on assumptions. In the interests of our patients and good medicine physicians and drug companies should work as partners rather than as antagonists. Only then will we be able to provide the most efficient and economic care. This controversy has been taken out of perspective; it iS h¢igh timf
We will consider for publication only letters submitted in duplicate, printed in letterquality type without proportional spacing and not exceeding 450 words. All the authors must sign a covering letter transferring copyright. Letters must not duplicate material being submitted elsewhere or already published. We routinely correspond only with authors of accepted letters. Rejected letters are destroyed. Accepted letters are subject to editing and abridgement.
Seules peuvent etre retenues pour publications les lettres recues en double dont la longueur n'exce'de pas 450 mots. Elles doivent etre m&canographiees en qualite "correspondance" sans espacement proportionnel. Tous les auteurs doivent signer une lettre d'accompagnement portant cession du copyright. Les lettres ne doivent rien contenir qui ait ete presente ailleurs pour publication ou deja& paru. En principe, la redaction correspond uniquement avec les auteurs des lettres retenues pour publication. Les lettres refusees sont ddtruites. Les lettres retenues peuvent etre abrdg&es ou faire l'objet de modifications d'ordre redactionnel.
Physicians and pharmaceutical companies D ~ r. Robert F. Woollard's description in "Snake oil and Caesar salad: the ethics of physician and pharmaceutical relationships" (Can Med Assoc J 1991; 145: 931-933) of the murky relationship between physicians and pharmaceutical companies is on the mark. So, too, is his
description of physicians' extraordinary defensiveness when challenged on the propriety of accepting the meals, fishing trips and other perks that accompany this cosy arrangement. The ability of physicians to deny that they can be influenced by all of this has long fascinated me. Perhaps it is pertinent to -
For prescribing information see page 401
point out explicitly what may be going on here. The motivation of the company ("educator") is obviously to sell drugs by influencing physicians. There is nothing intrinsically wrong with this: some drugs are life-saving, others extremely helpful to patients. However, some are of dubious merit except as revenue producers. Advertisers make little distinction between them for obvious reasons. The strategies designed to seduce physicians are aimed at several levels, including the emotional. Drug house dinners ("educational meetings"), for example, try to influence the practitioner somewhere deep inside - probably between the heart and the gastrointestinal tract - so that the company's name (or logo or representative) evokes a warm feeling that can't quite be identified but just seems to be good. The second purpose of these educational activities is to lead the physician into a belief that pharmacotherapy is logically the first approach to a problem. The third (on an ascending scale of specificity) is to persuade the physician that company A is ethical, is devoted to research and education, and generally represents a pretty nice group of people. The fourth goal is to suggest that a particular class of drugs may be helpful for the problem (and certainly has been proven elsewhere to be safe and effective) and, with a little luck, to suggest that brand X of this class is superior to brand Y sold by another firm. Finally, all this promotion is designed to remind the physician that the representative would be pleased to help him or her with samples, educational visits to the
office and any other continuing medical education (CME) event. Physicians are inclined to attest that a company product "was not even mentioned." Clearly not all promotional aims can be achieved in one event: it is the cumulative package being presented that counts. Not to recognize that one is being influenced is evidence of the subtlety and effectiveness of the process. The overall effect of these activities encourages unquestioning pharmacotherapy with all its attendant hazards. We have a responsibility to our patients, if not to ourselves, to be a little more aware of the process. Our compliance with the sales person's blandishments will not be tolerated by the patient if he or she comes to believe that we should have known better. Arthur J. Macgregor, MD 1026 Cook St. Victoria, BC
Although I admire Dr. Woollard's writing ability I question his purpose and the cause for such an article. I agree that physicians are not immune to criticism from without or, as in this case, from within the profession. During the past few years there has been considerable discussion and controversy on the relationship between the pharmaceutical industry and physicians. Much of this appears to be generated by physicians more active in academia than in clinical practice. Woollard states that he has been met by a defensive response from colleagues on this issue. I cannot help but ask whether everyone is out of step except Woollard and his committee. Few would disagree that new CAN MED ASSOC J 1992; 146 (3)
327
drugs have profoundly benefitted modern medicine and have assisted physicians to treat disease and reduce suffering. Much of the opposition seems to focus on the cost of pharmaceutical therapy and the assumption that new products increase medical costs; in fact, they frequently reduce the cost of therapy. The introduction of cimetidine reduced the cost of peptic ulcer therapy from $721 to $221 per patient,' resulting in overall savings to the health care system of millions of dollars. In Britain Teeling-Smith and Wells2 attributed the reduction in hospital costs from 1957 to 1982 of £447 million to new drugs. It is estimated that the introduction of brand name d-blockers such as timolol to prevent a second heart attack resulted in a net saving of between $1.6 and $3 billion.3 A second concern of Woollard is that the interaction between physicians and the industry may result in inappropriate therapy. Woollard quotes a number of opinions on this issue but fails to provide any data to substantiate that there is a problem. Although some of the advertising practices of a few pharmaceutical companies may be in poor taste I resent the implication that physicians are influenced by the industry to inappropriately treat their patients. I consider this insinuation a slur and an insult to the intelligence of physicians and to the integrity of physicians and the industry. As physicians we should review our activities on a regular basis, but it is inappropriate for the CMA or other bodies to make accusations based merely on assumptions. In the interests of our patients and good medicine physicians and drug companies should work as partners rather than as antagonists. Only then will we be able to provide the most efficient and economic care. This controversy has been taken out of perspective; it iS h¢igh timf
