I would call those payments primers. Priming those who will become intoxicated by easy money (for big pharma!). I have seen it across the board. I’ve seen many fall for it and I have seen many (including my former Medical Director / whom I have the utmost respect for) throw reps outta their offices. When I was the director of my unit NO reps were allowed, and NO lunches allowed.
One thing to think about: in the 90's, the military really limited that kind of thing, at least in psychiatry, the sales rep contact with residents was reduced substantially (not to zero, but substantially) and I remember all kinds of talk in the program about how wrong it was that our residents were getting all their pharmacology education from salespeople!
Well, fast forward about 6 years later, I was an attending running the inpatient unit - my incoming residents didn't know how to use any drugs newer than haloperidol! Seems "we" forgot that the reason the residents were getting "all" their education from salespeople was that they weren't getting it anywhere else!
I agree with a lot of what you wrote. But I think that there are many incentives driving procedure volumes. The hospitals like the revenue. The attending physicians like the revenue, the prestige, and the time away from clinic. The patients feel like something is being done. And the training is like the experience.
There are lots of drivers to procedure volumes. Maybe the device companies have a little influence on this, but they are from the dominant one.
There are two sides to every transaction---in this case, the briber and the bribee. Exhortations about the "greed" of industry are useless. It is up to the doctor to employ critical thinking and honesty in judging the appropriate use of drugs and medical devices or procedures. That is one reason why I choose to support this website despite the fact that I may disagree with the authors on some individual questions. I guess my residency and fellowship training were a little too early as I never received any offers. My wife and I lived on a shoestring budget for several years like almost all others in postgraduate training. Somehow we all made it through. But I would probably have taken the money secure in the knowledge that it would never alter my decisions. Most young adults should have learned about salesmanship sometime during their formative years.
Everyone thinks that THEY can't be influenced by Industry largesse. And everyone thinks they're an above average driver. Industry keeps doing it because it WORKS.
As Danny Kahneman said, people are easily fooled, and the easiest person to fool is yourself.
I remember being told in residency of a brilliant article (which I cannot find) that asked doctors what value of gift would cause *other doctors* to modify their prescribing behavior. My recollection was that the answer was about $20 in (roughly) 2000.
We used to have drug rep lunches in the olden days and I actually liked one of the drug reps (who left the biz to become a high school science teacher). He hawked wellbutrin. I also remember hearing about victoza for the first time from a drug rep. My office mate said that he had sometimes had reps say "Can you make a committement to rx XYZ once before I come back?" I never had that level of hard sell.
I remember when the atypical femur fractures in bisphosphonate info first came out, asking our drug rep about it. I wish I had had a cell hpone w a camera to record her response. Her eyes got wide and she tilted her perfectly coifed head to the side, "MY DRUG being *bad* for the bones ever? No, I've never heard anything about that!"
Writing this out has made it clear to me how very old I am. A lot has changed, at least in primary care.
I absolutely believe industry has heavy influence on our "standard of care". I think conversations that focus on the payments totally miss the real game going on. I have been told by industry marketing people, that they realized years ago that physicians are far more motivated by praise and spotlight. They had previously actually paid off doctors more, but they bragged to me the amount of money invested into a physician actually didn't need to be very much. Instead, they would approach a doctor and praise them for how smart they were, ask them to be a speaker, sometimes fly them somewhere. After speaking for a company, their prescribing patterns dramatically change, and their influence on colleagues is far more impactful than any paid rep for the company. The sad thing, is that physicians are sold for almost no money at all ( your article illustrates how little these people actually got). These people are sold off for the pennies of praise.
And from the article below: The more money and promotional items a physician-in-training had received, the more likely he or she was to believe that discussions with representatives did not affect prescribing (p< 0.05).
Request: Could you publish a list of common cardiology practices/interventions that are not supported by evidence in a simple list, with references. Then I can carry it in my pocket should I ever have an MI!
..."The curious thing about many therapeutic fashions is their lack of evidentiary support."...and this is primarily the reason I cannot trust the medical industry. It is impossible to know where your loyalties lie.
I began working in a large prominant DC Cath Lab in the late 90's. The money from "industry" was clear and obvious (especially to a former floor and ER nurse, where even a pen was a big deal). Over my many years in cath labs, and management of cath labs and Interventional Radiology.....I saw a little decrease and more "rules" for transfer of that cash, but it was still glaringly obvious, the influence that industry had on practice.
There was a legitimate effort at pushback by the American Medical Student Association against the industry payments… until the payments got even bigger and the pushback curiously went away… more on that strange story here:
There has been an interesting trend at our institution to welcome industry lunches back at our workplace. For a while, we were written up if we took a pen, now lavish lunches poured on staff/fellows as competition to retain overworked CV staff and maintain a “happy place” heats up. The productivity gerbil wheel works for everyone in healthcare delivery but the folks on the front line of patient care.
Burnout high? Feed them cake. We all know how that worked out in the long run.
Perhaps if the fellows were paid more by their educational institutions (and treated better), they wouldn't feel such a strong desire to accept the money from industry. I don't know how things are now, but I remember well how they were when I did my 'not cardiology' residency. We were treated terribly and paid less than minimal wage once one calculated the hours we worked. This should not be taken as a call to make residency a cushier, more benign experience. I just don't think it is fair to the fellows and the residencies to take away money from industry without talking about why they are so likely to accept that money in the first place. Perhaps an established doctor who earns hundreds of thousands of dollars a year (and gets to actually spend some time with family now and again) doesn't feel like 1800$ is enough money to tempt them. But if you dangled 1800$ in front of me when I was a resident, it would have looked like a true pot of gold. That money would have allowed me to pay some of the enormous debt I carried down. Including the credit card debt I used to purchase groceries for some months. Maybe luckily for my soul, no one ever did offer me money like that when I was a resident. I like to think I would have refused it. But I still remember balancing my checking account down to the pennies every month to make sure I didn't bounce a check.
Never asked anyone to feel sorry for doctors. It would be nice, however, if people tried to understand what doctors go through and sacrifice (both in training and ultimately as attendings) to get the salaries they ultimately get.
I have the admiration and utmost respect for what doctors go through and must learn to take care of an entire living person. I would still stand up and give the doctor my seat.
I would call those payments primers. Priming those who will become intoxicated by easy money (for big pharma!). I have seen it across the board. I’ve seen many fall for it and I have seen many (including my former Medical Director / whom I have the utmost respect for) throw reps outta their offices. When I was the director of my unit NO reps were allowed, and NO lunches allowed.
Nicely said!!
One thing to think about: in the 90's, the military really limited that kind of thing, at least in psychiatry, the sales rep contact with residents was reduced substantially (not to zero, but substantially) and I remember all kinds of talk in the program about how wrong it was that our residents were getting all their pharmacology education from salespeople!
Well, fast forward about 6 years later, I was an attending running the inpatient unit - my incoming residents didn't know how to use any drugs newer than haloperidol! Seems "we" forgot that the reason the residents were getting "all" their education from salespeople was that they weren't getting it anywhere else!
I agree with a lot of what you wrote. But I think that there are many incentives driving procedure volumes. The hospitals like the revenue. The attending physicians like the revenue, the prestige, and the time away from clinic. The patients feel like something is being done. And the training is like the experience.
There are lots of drivers to procedure volumes. Maybe the device companies have a little influence on this, but they are from the dominant one.
There are two sides to every transaction---in this case, the briber and the bribee. Exhortations about the "greed" of industry are useless. It is up to the doctor to employ critical thinking and honesty in judging the appropriate use of drugs and medical devices or procedures. That is one reason why I choose to support this website despite the fact that I may disagree with the authors on some individual questions. I guess my residency and fellowship training were a little too early as I never received any offers. My wife and I lived on a shoestring budget for several years like almost all others in postgraduate training. Somehow we all made it through. But I would probably have taken the money secure in the knowledge that it would never alter my decisions. Most young adults should have learned about salesmanship sometime during their formative years.
Everyone thinks that THEY can't be influenced by Industry largesse. And everyone thinks they're an above average driver. Industry keeps doing it because it WORKS.
As Danny Kahneman said, people are easily fooled, and the easiest person to fool is yourself.
I remember being told in residency of a brilliant article (which I cannot find) that asked doctors what value of gift would cause *other doctors* to modify their prescribing behavior. My recollection was that the answer was about $20 in (roughly) 2000.
We used to have drug rep lunches in the olden days and I actually liked one of the drug reps (who left the biz to become a high school science teacher). He hawked wellbutrin. I also remember hearing about victoza for the first time from a drug rep. My office mate said that he had sometimes had reps say "Can you make a committement to rx XYZ once before I come back?" I never had that level of hard sell.
I remember when the atypical femur fractures in bisphosphonate info first came out, asking our drug rep about it. I wish I had had a cell hpone w a camera to record her response. Her eyes got wide and she tilted her perfectly coifed head to the side, "MY DRUG being *bad* for the bones ever? No, I've never heard anything about that!"
Writing this out has made it clear to me how very old I am. A lot has changed, at least in primary care.
I absolutely believe industry has heavy influence on our "standard of care". I think conversations that focus on the payments totally miss the real game going on. I have been told by industry marketing people, that they realized years ago that physicians are far more motivated by praise and spotlight. They had previously actually paid off doctors more, but they bragged to me the amount of money invested into a physician actually didn't need to be very much. Instead, they would approach a doctor and praise them for how smart they were, ask them to be a speaker, sometimes fly them somewhere. After speaking for a company, their prescribing patterns dramatically change, and their influence on colleagues is far more impactful than any paid rep for the company. The sad thing, is that physicians are sold for almost no money at all ( your article illustrates how little these people actually got). These people are sold off for the pennies of praise.
People who go through all the pain of med school and residency and make all those sacrifices are going to be motivated by praise and being "the best."
Here is an oldie, but a goodie: https://www.sciencedirect.com/science/article/abs/pii/S0012369216358810
And from the article below: The more money and promotional items a physician-in-training had received, the more likely he or she was to believe that discussions with representatives did not affect prescribing (p< 0.05).
https://scholar.google.com/scholar_lookup?title=Interactions%20with%20the%20pharmaceutical%20industry.&author=B%20Hodges&publication_year=&journal=CMAJ.&volume=&pages=
And this is interesting. It is written from the marketting of drugs POV, but I can't figure out how to get accesss to the actual article.
Request: Could you publish a list of common cardiology practices/interventions that are not supported by evidence in a simple list, with references. Then I can carry it in my pocket should I ever have an MI!
I would like this as well. The mitral clip is being pushed by some and results are dismal.
..."The curious thing about many therapeutic fashions is their lack of evidentiary support."...and this is primarily the reason I cannot trust the medical industry. It is impossible to know where your loyalties lie.
Any feelings on pharmaceutical reps flushing the clinics food for staff to access physicians?
I began working in a large prominant DC Cath Lab in the late 90's. The money from "industry" was clear and obvious (especially to a former floor and ER nurse, where even a pen was a big deal). Over my many years in cath labs, and management of cath labs and Interventional Radiology.....I saw a little decrease and more "rules" for transfer of that cash, but it was still glaringly obvious, the influence that industry had on practice.
excuse my misspelling of prominent!!
There was a legitimate effort at pushback by the American Medical Student Association against the industry payments… until the payments got even bigger and the pushback curiously went away… more on that strange story here:
https://thefederalist.com/2023/03/02/big-pharma-is-unopposed-in-its-domination-of-medical-education/
Thanks Dr. Gaty!
There has been an interesting trend at our institution to welcome industry lunches back at our workplace. For a while, we were written up if we took a pen, now lavish lunches poured on staff/fellows as competition to retain overworked CV staff and maintain a “happy place” heats up. The productivity gerbil wheel works for everyone in healthcare delivery but the folks on the front line of patient care.
Burnout high? Feed them cake. We all know how that worked out in the long run.
Perhaps if the fellows were paid more by their educational institutions (and treated better), they wouldn't feel such a strong desire to accept the money from industry. I don't know how things are now, but I remember well how they were when I did my 'not cardiology' residency. We were treated terribly and paid less than minimal wage once one calculated the hours we worked. This should not be taken as a call to make residency a cushier, more benign experience. I just don't think it is fair to the fellows and the residencies to take away money from industry without talking about why they are so likely to accept that money in the first place. Perhaps an established doctor who earns hundreds of thousands of dollars a year (and gets to actually spend some time with family now and again) doesn't feel like 1800$ is enough money to tempt them. But if you dangled 1800$ in front of me when I was a resident, it would have looked like a true pot of gold. That money would have allowed me to pay some of the enormous debt I carried down. Including the credit card debt I used to purchase groceries for some months. Maybe luckily for my soul, no one ever did offer me money like that when I was a resident. I like to think I would have refused it. But I still remember balancing my checking account down to the pennies every month to make sure I didn't bounce a check.
Now imagine living like that for the rest of your life and stop wondering why no one feels sorry for doctors.
Never asked anyone to feel sorry for doctors. It would be nice, however, if people tried to understand what doctors go through and sacrifice (both in training and ultimately as attendings) to get the salaries they ultimately get.
I have the admiration and utmost respect for what doctors go through and must learn to take care of an entire living person. I would still stand up and give the doctor my seat.
Same