Ken and Barbie

Influence. Is that a negative or positive word? I guess it depends on who is influencing whom, huh? But when it comes to the relationship between Doctors and Pharma reps I’m watching a huge pendulum swing and it is not a good time in to be a Pharma rep.

So for background on the history of this relationship we need to visit LifeAfterDx University (LADU) for Under the Influence 101.

Once upon a time, not so long ago, but before I was in the industry (damnit), the reps showered the medicine decision makers with box seats, first class junkets to tropical destinations, gold-plated golf tees, and call-girls. Things got so out of hand the Feds stepped in a now any Pharma “gift” must be usable in the office. Thus the ubiquitous Pharma pen. And sticky notes. Sometimes clocks, business card holders, and anatomical models (my personal favorite, now that there are no call-girls). It’s fun to watch them try to think outside the box but inside the law. The first place award goes to Novo for their NovoLog “cheetah” computer wrist rest. It’s an orange cheetah-shaped gel-filled critter with little miniature flex pens floating around inside of it.

But a new trend is sweeping the industry. Pharma-free. Many practices are closing their doors to the Ken and Bardies.

I actually had a rep break down in tears in my office as she told me how rudely, no…cruelly, she had been treated up in Taos—our state’s epicenter for the anti-pharma movement. Signs in the lobby proudly proclaimed the practice to be free of all influence. The receptionist threatened to call the cops on the rep. But please drop off some samples while the door hits you in the ass.

Ban or don’t ban. But it seems unfair to try to play it both ways.

I’ll admit to having a conflicted relationship with the reps. If we take Time Tunnel back to my pre-dx days (not that long ago in dog years, but it seems like five lifetimes ago to me with the 24-7-365 nature of Type-1 diabetes) I can remember waiting in my primary care doc’s office. And waiting. And waiting. And waiting. And…

My appointment was at 9am. It is now 11:44. Boy am I pissed. Then click, click, click, click, click on her high-heals comes Barbie. Blonde, busty, blue-eyed, beautiful MBA Barbie with her little rolling suitcase of samples and woooooooooosh, in the door she goes to meet with my doctor while I’m cooling my heals in the waiting room.

I really hate her guts.

At first.

Then, surprise! I got diabetes. WFT?

And I was given a glucometer. A free glucometer. A sexy, small, cool meter. And a bunch of strips. And some free pills (oops, well, I was miss-dx’d as a T-2 for a very short while). All “gifts” from Barbie’s visit.

Then I spent almost a year not paying for insulin as assorted doctors, specialists, and educators loaded me up with “samples.”

Well, now, this is benefiting me.

Then I end up on the receiving end of Barbie’s visit. I admit, I’m a sucker for all the cool little gadgets they bring. And I love having samples for my patient’s. There is no retail pharmacy in our town. We’ve got a small one at the clinic—cash pay for uninsured, but we don’t take insurance there (as a side note, many “insured” patients are now required to make such obscene co-pays that it is cheaper to pay out-of-pocket at our non-profit pharmacy).

So my patient’s with insurance sometimes only get to a pharmacy once a month when they load up three generations in the truck for the Sam’s Club run. Samples keep them going from med-start to monthly Sam’s run. For my really poor patients, samples keep them alive while the patient assistance paperwork crawls through the system.

And having a pretty girl flirt with me doesn’t damage my ego too much either.

But do the sticky notes, samples, pens and flirting affect my decision making?

Absolutely not. Well…..that’s not true, come to think of it.

Back before the BIG SCARE, when I recommended that we start a patient on a TZD I always selected Avandia over Actos. They both reportedly work much the same. Actos should have been a better clinical choice as it has a mild lipid-lowering side effect. But we always started Avandia instead. Why? Because we had samples in-house. The Actos rep couldn’t be bothered to call on us. We had two similar drugs to choose from and samples for one of the two. So that became our default.

For what it is worth after the BIG SCARE we dropped Avandia and switched patients wholesale to Actos which isn’t worth a shit (compared to Avandia) for lowering BGLs. Sigh………..

But will wineing and dining and bribing medicine decision makers really effect their decision for what’s best for the patient? I hope not. But clearly the big pharma companies think so.

So it was both the possibility and the appearance of influence that started the Pharma-Free movement.

Now you have to meet K. She’s young, bright, pretty. She looks like a pharma rep, but not in this lifetime. She’s a baby doctor. No, not a doctor who delivers babies, a doctor in training and if she wasn’t so dedicated to medicine you’d probably want to strangle her for just being so perky and perfect. She’s doing “locums” with us—basically exposure to the real world. She’s my shadow one day per week to learn about diabetes, diabetes meds, diabetes gear, diabetes treatments, diabetes care. I enjoyed her company immensely. And not because she is pretty and perky. I love her for her mind.

OK, we’re going to start this patient on Glucophage.

K: what’s it’s chemical name?

Metformin.

K: what does it do?

It holds back nocturnal hepatic release of glucose.

K: what’s its method of action? What’s the pharmacology? What’s….

She peals back every layer of my knowledge non-stop like she’s pealing an onion. Until finally, like a parent saying “because I said so” I have reached the limit of my knowledge, and her thirst unquenched, I have to resort to Just Google it.

Anyway, being young and idealistic, she questioned my relationship with the pharma reps. And told me her teaching hospital was Pharma-free. They even have stickers they put over the pharma pens to cover the logos.

Wow.

I love my pens. Especially the one with the laser pointer, flash light, tablet stylus and two colors of ink.

So I laid out my self-justifying why-we-need-Ken-and-Barbie arguments.

Which she shot down like Robin Hood at the archery tournament. I first allowed as how I did think the “ask you Doctor about…” TV ads should be banned. No, no, no. You don’t ask your doctor if an Rx is right for you. You tell your doctor where it hurts and its his (her) job to figure out what’s wrong.

But I wasn’t ready to close the door in Barbie’s face. Not yet.

K fenced with me off and on throughout the day and the next day on my drive to work her arguments finally worked their way through my thick skull and into my tangled, miserable, overworked brain.

Damn. You know she’s right, Wil. We really shouldn’t be taking samples and goodies from the makers of meds. We should be sitting in medical school libraries carefully comparing the scientific data and balancing the actions, side effects, and interactions of competing medications using evidence-based data.

At least in the perfect world. The world we don’t live in.

I arrive at my office, blow my nose on a Byetta kleenex, sanitize my hands with Zetia alcohol gel, glance at the time on my NovoLog clock, sit down and move my Merck paperweight out of the way, pick up my Lipitor pen and jot my self a note an a Lantus sticky note pad. Nope. No influence in my world.

So like so many other things in medicine I find myself splashing around in grey water.
At least in rural health we find ourselves in a symbiotic relationship with the pharma reps. I’m not sure who is the parasite and who is the host. But they need us and, for now, we need them. They need sales. We need samples. Ultimately the patient wins.

I hear some groans from the audience. So meet Jose, age 57. He is a plasterer—a tradesman who hangs wire on the outside of a New Mexico house, then coats it with a cement-like substance. His employment is seasonal. He’s Type-2 on basal insulin and orals. He’s also on a statin for lipids and today his blood pressure is 167/98. Hypertension generally takes more than one med to control properly. Oh, did I mention his average monthly income is $728? He has no insurance.

Jose will almost certainly qualify for Patient Assistance from the drug makers. But it will take 6 to 8 weeks by which time there is a good chance he will have had a stroke. With samples he can be medicated today, right now, while we sort it all out and get him the help he needs.

When K came in that morning with her stethoscope and Starbucks I challenged her: how do you choose the best medicine for your patient?

And she gave me the text book answer, to which I told her: Wrong. You give the patient NOT the medicine that is best for their condition, you give the patient the medication they can afford. The one you can get. The one that WILL DO today.

And so, the door is unlocked and click, click, click, click, click on her high-heals comes Barbie. Welcome home. Did you bring me a pen?