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In an 2002 article, Dr. Peterson wrote: "Despite the lack of
evidence of a significant difference in efficacy between older and
newer agents, clinicians perceive the newer agents to be more
efficacious — these findings are significant as they highlight the
discrepancy between empirical evidence and clinical practices and
suggest that other factors influence clinicians' medication choices
in the treatment of depression."
The effect is easy to see in our department. The antidepressants
fluoxetine, known popularly as Prozac, and paroxetine, known as
Paxil, are now generic and cost patients and insurers pennies a day.
Newer, rival drugs including sertraline (Zoloft), escitalopram
(Lexapro) and Venlafaxine (Effexor) are 5 to 20 times as
expensive.
In the last seven years, I have watched our residents prescribe
the newest medications almost exclusively.
While doctors' prescriptions are based on more than efficacy and
cost — they must also consider potential drug interactions,
lethality of the drug if overdosed, the patient's prior history and
patient preference — the abandonment of older medications by our
residents cannot be justified given available data.
Programs that limit contact between industry and trainees do
result in changes in behavior and attitudes.
In 2001, Dr. Brendan McCormick of the University of Toronto and
his colleagues published a study in The Journal of the American
Medical Association. The research compared internal medicine
residents at McMaster University, who were prohibited from meeting
with drug representatives during training, with trainees at the
University of Toronto, across town, who had no such limitations.
After training, when they were free to meet with whomever they
chose, the McMaster trainees had less contact with company
representatives and were less likely to find such contact
helpful.
In 1999, in response to growing concern in academic medicine,
most pharmaceutical companies voluntarily adopted American Medical
Association policies restricting lavish gift-giving to doctors. Some
training programs went further, developing strict policies that
limit access to medical students and residents. Policies adopted by
the University of Michigan, the University of Iowa and and New
York-Presbyterian Hospital, among others, have restricted
pharmaceutical sponsorship of educational activities, have limited
or completely eliminated their representatives' contact with
trainees and have restricted gifts and where they can be
displayed.
Unfortunately many programs have failed to address the issue.
In his Pulitzer Prize-winning book for 1984, "The Social
Transformation of American Medicine," Dr. Paul Starr, the Princeton
sociologist, argued that doctors won legitimacy during the early
20th century by aggressively taking on charlatans who offered cures
and remedies. At the time, the American Medical Association argued
that only doctors were objective enough to evaluate the benefits of
competing medications. While there were other factors, the
association leveraged physician objectivity to garner greater
independence in practice, higher salaries and the legitimacy doctors
have enjoyed since.
If medical schools are unwilling to separate trainees from
pharmaceutical company representatives, we risk the appearance of
being "bought and sold."
This is sure to lead to governmental regulation and greater
erosion of independence. And it should.
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