One morning in September ’95, about a month into my first house job on the South Coast of England, I emerged from the ridiculously early ward round on the coronary care unit feeling a bit dazed and therefore headed off for some breakfast to revive myself. As I approached the sanctuary of the doctors’ mess, I came across a young, smartly dressed gentleman in a well-cut suit standing right outside.
I surmised that he couldn’t be one of the junior doctors, as at the time we all wore white coats with a cheese and onion (the green and yellow coloured Oxford Handbook of Clinical Medicine) bulging out of a pocket. Another possibility was that this man was a newly appointed consultant. However, after a double take, I saw he was smiling, and no one from the medical staff contingent ever seemed to smile within the confines of the hospital walls [1]. ‘Strange things are afoot at the Circle K,’ I thought.
It transpired, when he enthusiastically introduced himself in this unusually optimistic twilight zone which I had found myself in, that he was a sales representative for a pharmaceutical company. He was responsible for promoting one of the anti-angina drugs that I spent most of my day prescribing for patients on their drug Kardexes.
As I made myself some tea and toast in the mess, he struck me as a very cheerful and likeable fellow and it made a distinct change to meet someone so positive and upbeat about life. Everyone I had met in the hospital up until then had the demeanour of a Soviet gulag prisoner resigned to their fate, and I was yet to meet the ophthalmology senior house officer who, I was to discover, was the only exception to this rule.
This chap had a proposal for me: go to a local restaurant one evening the following week with a group of the junior doctors and listen to a talk about his anti-angina drug, then have dinner sponsored by the company which he represented. Given that my diet at the time consisted of ‘ding dinner’s ready’ microwave meals from the local Tesco and the occasional communal doctors’ mess Indian takeaway, this offer was clearly a no-brainer and I agreed to attend without hesitation.
"There were armies of people on the battlefield between the pages of my Pharmacology at a Glance textbook and my pen nib, fighting a war for what was prescribed on the Kardex"
When the evening came around, I had been on-call and awake since 7am the previous day. The drug presentation was pretty much a blur and I am not sure that I registered much of the content, if any. During the dinner, I was so exhausted that after the starter and a single glass of red wine acting as a most powerful hypnotic, I passed out with my head resting on the table [2]. Readers will be relieved to know that I was subsequently nudged awake by one of the registrars and managed to complete the meal but was fighting sleep the whole time.
Whilst I was only vaguely conscious for the majority of that evening, it was the first time that I fully registered the importance placed by the pharmaceutical industry on its relationship with doctors. In my naivety, fresh out of medical school, I had not realised that there were armies of people on the battlefield between the pages of my Pharmacology at a Glance [3] textbook and my pen nib, fighting a war for what was prescribed on the Kardex.
Doctors in general tend to fall into two categories: those that don’t engage with the pharmaceutical industry, and those that do, and I don’t pass judgement on either category. Those that don’t have understandable reasons, including a lack of desire or any perceived benefit from the interaction. Some also consider pharma to have the prefix ‘Big Bad’ and believe these companies actively mislead doctors and harm patients. However, I do engage with pharma as I believe a mutually beneficial relationship can exist and I will explain my reasoning, carefully negotiating this minefield, but please don’t shoot me without reading on.
I will begin with the sales reps or key account managers, the first point of call for any doctor’s contact with pharma. Surprisingly, working in the outpatient clinics can actually be quite a solitary existence, as although you are seeing patients, there is little opportunity to debrief and communicate with staff or colleagues. However, the sales reps will patiently wait to speak with you whenever there is a break between patients or at the end of the clinic. Also, as epitomised by the anti-angina fellow mentioned earlier, they tend to have amiable personalities often with interesting stories to tell. From the reps that I currently interact with, one is a keen Celtic Football Club fan; another used to live and work on a sheep farm; one has spent long spells working in Antarctica; whilst another has a shared passion for Grange Hill and has actually met Pogo Patterson [4]! Essentially, for me, they brighten my day.
As time progresses, these relationships with pharma reps can develop more into friendships. “Ooo, thumbs up, fwiends,” I hear, as fans of The Inbetweeners mock me. Drugs come and go over the years with new challengers usurping the old stalwarts, so the reps will move to different companies, but they generally stay within the same medical field. This situation has been compared to the crushed beer can analogy where they will leave one company and then pop up again recycled elsewhere in another one. This is important, however, as it means that these friendships are maintained over long periods of time and often for the duration of one’s career.
So, in this potential symbiotic relationship between pharma and doctor, the company benefits from educating the doctor about their drug, but what does the doctor gain? Well, this is more strictly governed and regulated by the Association of the British Pharmaceutical Industry (ABPI) than ever before. Prior to the ABPI, in days of old, when knights were bold, etc., I understand it was a free for all of golf trips, fine wines and luxury hotels. Now, however, the ABPI’s Code of Practice dictates the circumstances for how even a solitary biro can be handed out: “attendees at pharma events / meetings may only receive one pen or pencil or notepad which must not bear the name of any medicine […] but may bear the name of the company providing them.” Anecdotally, I have noticed a correlation whereby the quality and durability of the free biro is directly proportional to the efficacy of the drug that the company produces. I think there is a research study in that if anyone wants to add me as a co-author.
The ABPI code is strictly enforced and pharma companies can be heavily fined for breaking it. Rival companies will also inform on each other for breaking the code. As an example, scientific conferences can be lonely places if you do not have any friends or colleagues around and a ‘Norman No Mates’ situation can arise. Recently, in one such episode, I sought out a pharma colleague to join me for a beer after lectures. However, he told me that if he was spotted by someone from a rival company he would almost certainly be dobbed in and get into trouble. I replied that I would be happy to be pay for the beers but he said that it didn’t matter, as it was how it would look to others. Either that, or he really didn’t want to go for a beer with me [4,5]. I ended up going to a retro arcade bar to play Galaga on my tod, chasing an elusive high score being a suitable alternative.
Pink Floyd confidently told us in their song Another Brick In The Wall that “we don’t need no education.” Sadly, this is not true, as acquiring a defined number of continual professional development (CPD) education points is essential for the dreaded annual medical appraisal process. Bruce Forsyth in the 80s gameshow Play Your Cards Right cheerfully informed us that “points make prizes,” but I am not sure that enough CPD points to be able to maintain a license to practice counts as a prize. Regardless of this, ongoing education as a clinician is a necessity.
Unfortunately, the NHS study leave budget is almost non-existent for most UK doctors. Therefore, one of the main ways in which a doctor can benefit from pharma is through education. Pharma companies will sponsor training days and meetings and the quality of these events is usually very high as they can afford to pay for the best speakers, often of international calibre. Attending the events will usually involve having to sit through some obligatory promotional content for the company’s drug. However, I see this as a trade-off. It’s a bit like having to sit through the adverts when watching TV [6] – think Inspector Morse, not Love Island. There are very few perks as a doctor working in the NHS and an opportunity for free, good-quality education I can only see as a bonus.
If you can maintain a relationship with pharma and remain impartial regarding your prescribing, thereby keeping your integrity intact, then I believe you have everything to gain and nothing to lose from any interaction. Be aware though that if your contact with pharma does influence your impartiality and creates bias with regards to your prescribing habits then your credibility amongst your peers is at risk, which for most doctors is paramount. You don’t want your reputation to be one of the casualties on the pharma battlefield.
As a final thought, it is always important to keep in the back of your mind that there is no such thing as a free lunch, especially if you fall asleep during it.
References
1. Just beyond the hospital exclusion zone was a pub where the smiles started to appear, especially as it held special debrief ‘lock-ins’ until the early hours of the morning, which were never disturbed by the Plod. One of the few benefits of working at this particular hospital.
2. The glass of wine after a day at work continues to have a powerful soporific effect on me, even more so than a dimly lit lecture theatre during postgraduate teaching. In fact, on arriving home, if I want to have any kind of hope of productivity or indeed sit through longer than ten minutes of a TV series without falling asleep, it is important to refrain. Easier said than done after a day at the NHS coal face.
3. From the textbooks which I optimistically bought at the start of the academic year as a medical student, all the thick tomes such as Rang and Dale’s Pharmacology were rapidly replaced by much more easily digestible, thin volumes like Pharmacology at a Glance as revision week reared its ugly head. If there had been a leaflet entitled Everything you need to know about Pharmacology for sale in Dillons book shop, I would have bought it.
4. If you do maintain relationships with sales reps from rival companies it is important not to ‘run with the hare and hunt with the hounds’ – i.e., don’t pay lip service to them all. If you are not going to use a particular drug, just be up front and say so, as Doja Cat once sang.
5. I also discovered recently that my pharma contacts on LinkedIn are not allowed to ‘like’ or comment on my posts as this in some way may contravene ABPI guidance. Again, either that or they just think my LinkedIn posts are rubbish!
6. If you want to go ‘ad free’, then the only alternative is to pay for one of the many non-pharma sponsored scientific conferences. However, during these challenging financial times, a quick glance at the eye-watering registration fees can persuade many to just put up with the ads.
