1. BINGO! Fun with drug advertising and other teaching tools for evaluating pharmaceutical marketing Steven R. Brown, MD Banner Good Samaritan Family Medicine Residency Phoenix, AZ Society of Teachers of Family Medicine Spring Conference May 2, 2008

2. “If we put horse manure in a capsule, we could sell it to 95% of these doctors.” - Harry Loynd, former president of Parke Davis

3. Advertising 34% of the pages of JAMA and 44% of the pages of American Family Physician are advertisements. 1 In 2004 the pharmaceutical industry spent $500 million on journal drug ads. Journal drug ads increase sales and yield a return on investment for industry of $5 for every $1 spent. 2 Printed ads and detailing from drug representatives are used synergistically in promoting new medicines. 2 1Lohiya S. Pharmaceutical advertisements in medical journals received in a medical clinic. JNMA 2005;97(5):718. 2Fugh-Berman A, Alladin K, Chow J. Advertising in medical journals: should current practice change? PLoS Medicine 2006;3(6):e130.

4. Promotional spending on prescription drugs, 2004 Total spending: $27.7 billion Source: IMS Health

5. Interactions with industry 94% of physicians have some relationship with industry. 1 Family physicians meet with industry representatives an average of 16 times per month. 98% of residents and 97% of third-year medical students have eaten a meal sponsored by industry in the past year. 2,3 1Campbell EG, et al. A national survey of physician-industry relationships. NEJM 2007;356(17):1742. 2Sierles FS, Brodkey AC, Cleary LM, et al. Medical students’ exposure to and attitudes about drug company interactions. JAMA 2005;294:1034-1042. 3Sigworth SK, Cohen GM. Pharmaceutical branding of resident physicians. JAMA 2001;286(9):1024.

6. Interactions with industry Information from drug reps is often false, 1 and recognized by most to be biased. Leads to non-rational prescribing. 2 1Ziegler MG, et al. The accuracy of drug information from pharmaceutical sales representatives. JAMA 1995;273(16). 2Wazana A. Physicians and the pharmaceutical industry: Is a gift ever just a gift? JAMA 2000:283:373.

7. “Effective promotion, heavy promotion, sustained promotion has carried the day. The physicians have been sold. So has the country.” -Economist Seymour Harris, 1963

8. BINGO!

9. (15 ads from the workshop were shown here and discussed but not uploaded to FMDRL. Educators are advised to find and use their own recent advertisements.)

10. “The best defense the physician can muster against (misleading) advertising is a healthy skepticism and a willingness…to do his homework. He must cultivate a flair for spotting the logical loophole, the invalid clinical trial, the unreliable or meaningless testimonial, the unneeded improvement, and the unlikely claim. Above all, he must develop greater resistance to the lure of the fashionable and the new.” - Pierre Garai, pharmaceutical advertising executive, 1964

11. Rational vs. Non-rational reasons to prescribe a medication

12. Shaughnessy AF, Slawson DC, Bennett JM. Separating the wheat from the chaff: Identifying fallacies in pharmaceutical promotion. JGIM 1994;9:543. (cover of article shown during presentation)

13. “Advertising not only provides information but attempts to persuade us by appealing to our emotions, to the vulnerable spots in our egos, and by applying pressure to the tender area of our psyches.”

14. Non-rational appeals – “fallacy of logic”

15. Non-rational prescribing from the Drug Ads Non-scientific graphs New disease or diagnosis Relative risk reduction Disease-oriented evidence Statements supported by “data on file.” Bandwagon Brand name larger than generic name Disease “education” Chart Junk Appeal to authority Appeal to celebrity DTC ad reference Non-medical catchy slogan Cutesy character Appeal to fear “New”,“first and only”, “first” Red herring

16. Non-rational prescribing from a pharmaceutical rep Non-scientific graphs New disease or diagnosis Relative risk reduction Disease-oriented evidence Statements supported by “data on file.” Bandwagon Brand name larger than generic name Disease “education” Chart Junk Appeal to authority Appeal to celebrity DTC ad reference Non-medical catchy slogan Cutesy character Appeal to fear “New”,“first and only”, “first” Red Herring

17. Anderson GM, Juurlink D, Detsky AS. Newly approved does not always mean new and improved. JAMA 2008;299:1598 (Cover of article shown during presentation)

18. Non-rational prescribing from a pharmaceutical rep Gifts, food, relationship building Testimonial Appeal to pity (“pity melts the mind”) Ego gratification Ad hominem attacks on competitor Appeal to curiosity

19. Rational prescribing

20. Rational reasons to prescribe a drug: (“STEPS”) Safety Tolerability Effectiveness Price Simplicity Preskorn SH. Advances in antidepressant therapy: the pharmacologic basis. San Antonio: Dannemiller Memorial Educational Foundation, 1994.

22. Other resources and ideas Allen Shaughnessey and David Slawson’s 2006 STFM presentation “Evaluating information from pharmaceutical representatives,” on FMDRL “Pharmaceutical Representative Feedback Form” –Google “Virginia information mastery” The “STEPS” conference for new medicines

23. Evaluation

24. Discussion “Pharmaceutical representatives should be allowed to interact with physicians and trainees in our patient-centered medical homes.” –Pro vs. Con –The discussion may be as important as the outcome

25. Pharmaceutical representatives should be allowed to interact with physicians and trainees in our patient-centered medical homes (list compiled from the “wisdom of the group” at STFM Baltimore 2008) Pro (yes reps) –Helps prepare learners to interact with reps in future practice. –Money for education (e.g. food) –Samples. –Food for staff. –Point of contact for further funding (e.g. grants). –Social/collegial interaction (especially in isolated/solo practice settings). –Focus for discussion about new medicines. –Prepare for patient requests from DTC advertising. –Educational items (e.g. Inhalers, body models, charts) to help patient care. –Guidance with patient assistance programs. Con (no reps) –Not in the best interest of our patients. –Not a good use of time in busy schedule of practice or education. –Increases cost to patients. –Leads to inappropriate prescribing. –“Information” from reps is biased and often wrong. Just the party line from industry. –Professionalism, conflict of interest. –We lead by example. This “hidden curriculum” is more powerful than what we tell learners. –Samples aren’t really beneficial to patients. –You can’t really teach how to avoid conflict of interest/influence. Industry knows it can influence doctors despite training. –Learners are too “green” to know they are being influenced inappropriately. –Gifts start “branding” process for learners and creates a sense of entitlement.

27. Questions Q#1: Does the residency allow gifts from industry or industry supported food? Q#2: Are drug samples accepted? Q#3: Are industry representatives allowed access to medical students and/or residents at the primary educational site? Q#4: Are any industry-sponsored residency activities allowed? A “Pharma-Free” residency answers “no” to all 4 questions. Pharma-Free Family Medicine Residencies

28. Great Plains FMROklahoma City, OK Trident/MUSC FMRCharleston, SC Smiley's FMRMinneapolis, MN Tuft's University FMR at Cambridge Health AllianceMalden, MA UCSF- San Francisco General Hospital FMRSan Francisco, CA Mercy FMRToledo, OH Valley FMRRenton, WA Maine-Dartmouth FMRAugusta, ME San Jose-O'Connor Hospital FMRSan Jose, CA UPMC Shadyside FMRPittsburgh, PA Banner Good Samaritan FMRPhoenix, AZ Pharma-Free Family Medicine Residencies

30. Discussion/questions