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Annals of Family Medicine 3:177-179 (2005)
© 2005 Annals of Family Medicine, Inc.
doi: 10.1370/afm.295
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Stimulus, Response, Interpretation

Kurt C. Stange, MD, PhD, Editor

In this On TRACK, I consider the stimulus provided by articles in the last issue of the Annals and the response of thoughtful readers commenting in the Annals online discussion (TRACK), and I provide my own interpretation. I encourage readers to write your own interpretation as an online comment to On TRACK or the original article.

PHARMACEUTICAL REP ADDICTION

The ethical analysis by Howard Brody1 provided a powerful stimulus for thoughtful and deeply felt replies. Dr. Brody argues that physicians ought to refuse to see pharmaceutical representatives (reps) on the grounds of both professional integrity and sensible time management.

Responses range from agreement2–4 to taking offense that "Dr. Brody must not practice in the real world."5 Others suggest ways for physicians to manage, rather than avoid, the confl ict,4,6–8 while one writer calls for a new code of conduct for education and practice, organizations, and individuals.9

Picking up on an analogy in Dr. Brody’s analysis, John Scott labels the phenomenon as "Pharmaceutical Rep Addiction,"10 and prescribes a cure—abstinence.

One solo physician describes his own "recovery," saving 1 to 2 hours each day and an offi ce room, both of which allow him to spend more time seeing patients. He also describes a dramatic reduction in telephone calls from pharmacies as he began to prescribe fewer nonformulary drugs.11 A physician in group practice echoes the sentiment that eliminating free samples of the most expensive drugs "has not hurt our patients or our practice in the least. It gives us extra time to focus on patient care."12

Two physicians note the additional confl ict of direct-to-consumer marketing.12,13

Discussants argue for the benefi t of providing samples to needy patients, "If you do not see a rep you do not get samples,"5 and learning from the reps, "I appreciate the opportunity to learn about the latest innovations that occur regarding medical care."7

Adam Goldstein decries the educational value of pharmaceutical reps, saying that the relationship "comes down to 1 of 2 things: either a plea for samples or a plea for food."14 In an interview for US News & World Report,15 Dr. Goldstein refl ects that pharmaceutical-sponsored meals "are part of our culture."

My own analysis of the discussion is that Dr. Brody’s appraisal hits hard because it not only documents the moral argument but makes the practical case as well. The practical case is hard for family physicians to ignore, because we think of ourselves as pragmatists focused on what is best for our patients.16 Brody shows us that giving time and taking (skewed) information and (expensive) samples is neither practical nor in our patients’ interest.

As family physicians, we prescribe abstinence for our addicted patients, but offer cutting back as an option for those who are not ready to abstain. The fi rst step should be to recognize the ignoble nature of our dependency and the insidious way in which we became addicted—typically through professional socialization during training and having the best intentions for our patients as practicing clinicians. We should try the experiment of cutting back or abstaining and explore other options for meeting our patients’ needs for affordable drugs, as well as our own needs to keep up with new knowledge. Brody’s analysis gives us good reason to believe that the experience of Drs. Mitchell and Fior11,12 will be our experience—that patients and our professionalism will benefi t from the experiment. If we can break this addiction as individuals, we will gain the moral authority to ask our professional organizations to do the same.

DEPRESSION MANAGEMENT IN PRIMARY CARE

The cluster of 6 studies of depression17–22 and the related editorial23 provided a stimulus for responses addressing the following:

I interpret this discussion as a cry for reduction in the fragmentation of care. Those on the front lines see fragmentation as a major cause of increased costs. This fragmentation lowers the effectiveness of diagnosis and treatment of depression and reduces the effectiveness of health care in general. Both researchers and clinicians see the potential of integration of care as a powerful way of enabling people to get on with their lives to the best extent possible, given chronic somatic and mental illness.

OTHER STIMULUS AND RESPONSE

Studies from the last issue of the Annals stimulated readers and shaped their thinking and responses. These studies "undermine the notion that there is a perceived ethical confl ict between commitment to the well-being of the individual patient, and a concern for distributive justice and the health care needs of the entire society."37,38 They also "raise the intriguing question of how much lower the criteria will become for the diagnosis of ‘diabetes’ and how far ahead we should be thinking."39,40

Studies from the November/December 2004 issue of the Annals stimulated further responses that many are awaiting the results of the national demonstration project for the New Model of family medicine41 proposed by the Future of Family Medicine Project and fi nancially modeled in the recent supplement.42,43 Writers also expressed frustration from both patients and physicians with overburdened access systems that result in no-shows.44–49

The revisiting of the biopsychosocial model continues to resonate. "[M]oving from objective detachment to refl ective participant could serve as a galvanizing sound-bite for what is required to move into high performance primary care. We all, patients and physicians alike, so desperately need a time and place where we can consult, ‘mind-fully,’ and we physicians need a workload and practice systems that will permit us to be prepared, available, attentive—indeed ‘attending physicians.’"50

Please join these and other writers in adding your insights at http://www.AnnFamMed.org. Click on "discussion of articles" or follow the links for the comments or the article on which you wish to comment.

REFERENCES

  1. Brody H. The company we keep: why physicians should refuse to see pharmaceutical representatives. Ann Fam Med. 2005;3:82–85.[Abstract/Free Full Text]
  2. Bettigole CA. The costs of a free lunch [eletter]. http://www.annfammed.org/cgi/eletters/3/1/82#1558, 3 February 2005.
  3. Hoffman JR. Meeting with the drug reps – why we shouldn’t do it [eletter]. http://www.annfammed.org/cgi/eletters/3/1/82#1549, 2 February 2005.
  4. Kelly MJ. Time management [eletter]. http://www.annfammed.org/cgi/eletters/3/1/82#1539, 31 January 2005.
  5. Rafool F. Re: pharmaceutical rep addiction [eletter]. http://www.annfammed.org/cgi/eletters/3/1/82#1526, 29 January 2005.
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  9. Frey JJ. Sweeping off our own back porch [eletter]. http://www.annfammed.org/cgi/eletters/3/1/82#1568, 7 February 2005.
  10. Scott JG. Pharmaceutical rep addiction [eletter]. http://www.annfammed.org/cgi/eletters/3/1/82#1479, 28 January 2005.
  11. Mitchell DL. Response about drug reps [eletter]. http://www.annfammed.org/cgi/eletters/3/1/82#1589, 14 February 2005.
  12. Fior TW. What about direct to consumer (DTC) advertising [eletter]? http://www.annfammed.org/cgi/eletters/3/1/82#1537, 30 January 2005.
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  14. Goldstein AO. The ethics of food [eletter]. http://www.annfammed.org/cgi/eletters/3/1/82#1500, 29 January 2005.
  15. Brink S. Wooing doctors: Say no to drug reps. Health Watch. February 14, 2005:62.
  16. Stephens GG. The intellectual basis of family practice. In: The Intellectual Basis of Family Practice. Tucson, Ariz: Winter Publishing Co, Inc; 1982.
  17. Rost K, Pyne JM, Dickinson LM, Elliott CE, deGruy F. The cost effectiveness of enhancing primary care depression management on an ongoing basis. Ann Fam Med. 2005;3:7–14.[Abstract/Free Full Text]
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  21. Van Voorhees BW, Fogel J, Houston TK, Cooper LA, Nae-Yuh W. Beliefs and attitudes associated with the intention to not accept the diagnosis of depression among young adults. Ann Fam Med. 2005;3:38–46.[Abstract/Free Full Text]
  22. Chene R, Garcia L, Goldstrom M, Pino M, Roach D, Thunderchief W, Waitzkin H. Mental health research in primary care: mandates from a community advisory board. Ann Fam Med. 2005;3:70–72.[Abstract/Free Full Text]
  23. deGruy F. Depression care: progress and prospects. Ann Fam Med. 2005;3:3–6.[Free Full Text]
  24. Meyers DS. CBPR and PBRNs: methodologies for exploring primary care [eletter]. http://www.annfammed.org/cgi/eletters/3/1/70#1610, 23 February 2005.
  25. Macaulay AC. Recommended reading in community based participatory research [eletter]. http://www.annfammed.org/cgi/eletters/3/1/70#1597, 21 February 2005.
  26. Herbert CP. Essential learning for community-based researchers [eletter]. http://www.annfammed.org/cgi/eletters/3/1/70#1547, 2 February 2005.
  27. Smith JL. Can single-disease care managers be ‘faithful with much’[eletter]? http://www.annfammed.org/cgi/eletters/3/1/3#1562, 5 February 2005.
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  29. Bachman JA. What’s good for the patient is good for the business case [eletter]. http://www.annfammed.org/cgi/eletters/3/1/7#1566, 7 February 2005.
  30. Rost K, et al. The unavoidable constraints of delivering improved depression care [eletter]. http://www.annfammed.org/cgi/eletters/3/1/7#1503, 29 January 2005.
  31. Schulberg HC, et al. Multiple paths to diagnosing depression [eletter]. http://www.annfammed.org/cgi/eletters/3/1/31#1583, 11 February 2005.
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  33. Dickinson LM. One size does not necessarily fi t all [eletter]. http://www.annfammed.org/cgi/eletters/3/1/3#1466, 26 January 2005.
  34. Steiner JF. Adherence decisions and disease management [eletter]. http://www.annfammed.org/cgi/eletters/3/1/23#1440, 26 January 2005.
  35. Dowrick C. Is underrecognition of depression really a problem [eletter]? http://www.annfammed.org/cgi/eletters/3/1/31#1587, 14 February 2005.
  36. Fogel J. Detecting and treating depression in primary care settings [eletter]. http://www.annfammed.org/cgi/eletters/3/1/31#1453, 26 January 2005.
  37. Spurling MC, Vinson DC, Beach M, et al. Physician conceptions of responsibility to individual patients and distributive justice in health-care. Ann Fam Med. 2005;3:53–59.[Abstract/Free Full Text]
  38. Brody H. Individual patients vs societal responsibility [eletter]. http://www.annfammed.org/cgi/eletters/3/1/53#1460, 26 January 2005.
  39. Koopman RJ, Mainous AG, Diaz VA, Geesey ME. Changes in age at diagnosis of type 2 diabetes in the United States, 1988–2000. Ann Fam Med. 2005;3:60–63.[Abstract/Free Full Text]
  40. Smith K. Re: the age of diabetes [eletter]. http://www.annfammed.org/cgi/eletters/3/1/60#1581, 11 February 2005.
  41. Task Force 1 Writing Group.Task Force 1. Report of the task force on patient expectations, core values, reintegration, and the new model of family medicine. Ann Fam Med. 2004;2:S33–S50.[Abstract/Free Full Text]
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  43. Spann SJ, et al. Productivity and malpractice [eletter]. http://www.annfammed.org/cgi/eletters/2/suppl_3/s1#1577, 9 February 2005.
  44. Jamison JF. USA/Mexico border no shows in pediatrics [eletter]. http://www.annfammed.org/cgi/eletters/2/6/541#1543, 2 February 2005.
  45. Anonymous. Why they don’t show up [eletter]. http://www.annfammed.org/cgi/eletters/2/6/541#1443, 29 January 2005.
  46. Bately NJ. Open access scheduling not equal to longer waiting room time [eletter]. http://www.annfammed.org/cgi/eletters/2/6/541#1472, 28 January 2005.
  47. Johnson SL. Reverse no show [eletter]. http://www.annfammed.org/cgi/eletters/2/6/541#1445, 26 January 2005.
  48. Menard EH. Timeliness and respect [eletter]. http://www.annfammed.org/cgi/eletters/2/6/541#1421, 5 January 2005.
  49. Blicher AP. Disturbing preconceptions [eletter]. http://www.annfammed.org/cgi/eletters/2/6/546#1572, 8 February 2005.
  50. Green LA. A sense of imminent progress [eletter]. http://www.annfammed.org/cgi/eletters/2/6/576#1411, 2 January 2005.



TRACK Comments:

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Will We Ever Resolve this Issue?
Lawrence I. Silverberg
Annals of Family Medicine, 11 Apr 2005 [Full text]
This Article
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