How Can Physicians Stay Current on Prescription Drugs?

Robert M. Centor, MD; Pennie Marchetti, MD; R.W. Donnell, MD; Roy M. Poses, MD

Disclosures

August 30, 2006

Pennie Marchetti, MD: Divorce Ourselves From Drug Companies

Keeping up with the latest innovations in drug therapy can certainly be a challenge. Many times, patients hear about new developments from the media before we lowly physicians learn of them. It's not uncommon for my patients to ask for a drug that's just been approved by the FDA the day before --- long before it makes it to the marketplace, let alone my own knowledge base. So, what's a busy physician to do?

First of all, let's start with what not to do. Do not rely entirely on pharmaceutical sales representatives, any more than you would rely on a car salesman for information about a car. Pharmaceutical sales reps, and the companies who hire them, have done a good job of convincing themselves (as well as the public and some doctors) that one of their key missions is to educate physicians. Don't believe them. Their key mission is to close a sale. As the Harvard Business Review reports, the new CEO of Schering-Plough credits his company's turnaround to "motivating and organizing salespeople to create trusting relationships with doctors."[1] The information they provide is often inaccurate,[2,3] and our ability as a group to sort the misleading information from the valid is abysmally poor.[2] It should be no surprise, then, that the more pharmaceutical reps a physician sees, the poorer his prescribing habits will be.[4]

That leaves us with the medical experts --- those doctors who are the leaders in their fields, who give lectures at conferences, who publish papers in respected journals, and who write guidelines. But not all experts are created equal. Too many of them have financial ties to pharmaceutical companies that rival those of the sales reps. Recent examples include the influence of drug company money on defining hypertension[5] and on classifying psychiatric illnesses.[6]

Even patient advocacy groups are financially intertwined with the pharmaceutical industry, and not just in the form of grants or donations. Executives from Eli Lilly, for example, recently gave the American Diabetes Association a helping hand with its business strategy.[7] Such coziness certainly gives one pause when mulling over new treatment guidelines.

What about journals? The New England Journal of Medicine, JAMA, and other professional society journals can be important sources of original studies about drugs. In fact, they are the only source we have to fact-check the experts and the drug reps. However, these too must be approached with a healthy skepticism and an eye for industry bias, not only from authors of drug industry-funded studies but from the editors, too.

Consider the case of Redux, the antiobesity drug that benefited from a very favorable editorial in The New England Journal of Medicine. There were reports in 1996 that Europeans who used the drug were suffering from higher than usual rates of pulmonary hypertension,[8] but the editorial argued that the weight loss facilitated by the drug outweighed its associated pulmonary risks.[9] With such a ringing endorsement from such a respected source, the drug's sales skyrocketed. Just a year later, however, there were more reports of fatal pulmonary hypertension[10] and of heart disease[11] associated with the drug. It was removed from the market. And The New England Journal of Medicine's respected editorialists? As it turns out, they were in the employ of the diet pill industry.[12] To the journal's credit, it did publish all of the original articles documenting the drug's dangers, but lax editorial standards contributed to the widespread adoption of a drug of very little benefit at substantial risk.

That doesn't leave us with much in the way of reliable sources, does it? Who has the time to look up every study on newly introduced drugs, let alone analyze them carefully? Luckily, there are some reliable sources remaining, sources that do the analyzing for us. One of those is The Medical Letter, which reviews the claims of new drugs and the research behind those claims (published and unpublished) in an unbiased fashion. Not coincidentally, it doesn't accept advertising. Another good source is the Cochrane Reviews, a database of evidence-based assessments of various interventions, including drugs. Both require a subscription, but the American Academy of Family Physicians runs a feature in its monthly journal summarizing various Cochrane Reviews,[13] available online for free, even to nonmembers.

It's rather sad that there's more wrong than right with the current state of physician pharmacologic education. Obviously, as a profession, we could do better. And the place to start is by divorcing ourselves from drug company money.

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