Guide to talking with a drug rep
There are many myths about drug reps. One set of myths posit that drug reps are bad people. The other set suggests that they are nice people and because of this, we should trust them. We disagree with both sets of myths. In fact, we think that the framing the question of pharmaceutical influence in terms of the personal ethics of drug company representatives is missing the point. While there are exceptions, most drug reps are amiable, well-informed usually attractive people, generally acting morally within the business paradigm where their job is to convince you to use their product. They have been selectively educated by their company and thus their information inherently will represent a skewed perspective.
Some people advocate for completely avoiding contact with drug company representatives all together. They note the nature of the drug reps’ actions are basically lobbying for their employer, the pharmaceutical company, and may cause our knowledge and predilection towards the use of their medication to be manipulated, unknowingly on our part. This occurs partially because we are exposed to only a piece of the whole story and but more importantly because the interactions evoke an automatic response that precedes and trumps the rational thought process. Studies on the effectiveness of salespeople, governmental lobbyists, and drug company representatives show that their success relies on our automatic, unconscious responses, such as a sense of reciprocity, that turns out to be a stronger motivator than our rational thought, no matter how scientific and cynical we are. Studies confirm that people’s behavior is driven by the tendency of all people, including but not limited to health care providers, to respond positively to people who are nice to them.
It is difficult to counter the automatic responses but your analysis of the information provided is improved if you remember that they will cast their product in the most positive light possible, although not necessarily overtly lying. They choose to tell you only those aspects of their product that will engender your loyalty to its use and to eliminate recriminating evidence and often to not mention the basic equality of multiple brands of the same class of medications.
For those of us who agree with many health care providers that interaction with drug reps is beneficial for our patient care, then it may help us to be prepared with what information we hope to elicit from the interaction and an awareness of the topics of logic that are used to influence our opinion.
Guide to talking with a drug rep
What do we want to learn?
Patients sometimes present with a request for medication based on an advertisement for a condition you have not previously diagnosed in that patient. Sometimes it may be for a condition you have never heard of. You will probably turn to the medical literature to read more about it but may later find our self in conversation about it. In considering the advertisements claims for the medication requested or promoted, whether you are talking to a patient or drug company representative, it might help to consider the following questions-
Does this patient have the condition?
- What are the criteria that this drug promotion is suggesting using to diagnosis of the condition?
- What is the evidence establishing these criteria?
- What is the prevalence of the disease?
- If the patient has the condition, does it need to be treated? – Consider what the effects are of not treating it or the symptoms the patients has related to having it??
If you establish that the patient does have the condition and that it needs treatment or if medication is simply something you want to know about, things you might want to consider are-
- Is a medication necessary for the condition it is promoted to treat?
- What is generally used to treat people with this condition?
- Why is there a need for a new medication for this condition?
- If there is, is this the best medication?
- Does this medication work?
- If it works, how strong is its effect, measured in a metric that
is clinically significant?
- What are these claims based on (quality of the study and number
needed to treat - NNT), what are the side effects, both serious
and minor, and the ratio of benefits and risks (making sure the
cure isn’t worse than the disease)?
- More specifically- (consider in critiquing studies supporting the drug,-
- Were they randomized, double blind studies? What did they use for the comparison (control)?
- How long and how complete was the follow-up?
- Did they look at the results in terms of the categories people were randomized to?
- What were the reason for drop-out and the rate of drop-out rate in each group?
- What were the side effects?
- What were the results expressed in the absolute reduction in risk, the relative reduction and the number needed to treat?
- For significant side effects, what was the number needed to harm? What is the balance of harm and benefit?
- What are these claims based on (quality of the study and number
needed to treat - NNT), what are the side effects, both serious
and minor, and the ratio of benefits and risks (making sure the
cure isn’t worse than the disease)?
- How does this medication compare in effectiveness and cost to other choices of medication commonly used for treating this condition?
- How does it compare in effectiveness and cost to using a hygienic approach that doesn’t involve using medications at all?
- Will patients in general use the medication as prescribed- i.e., tolerability and simplicity of use. A mnemonic for these facts is listed below.
- How long will the patient have to be using this medication?
You may want to ask the industry representative– why is this drug being promoted now? Not all drug company representatives will know that answer but it sometimes they will give you interesting information.
When faced with a new medication, ask yourself or the drug rep-
- What is generally used to treat people with this condition?
- Why is there a need for a new medication for this condition?
- If there is, does this medication work?
- If it works, how strong is its effect, measured in a metric that is clinically significant?
- What are these claims based on (quality of the study and number needed
to treat - NNT), what are the side effects, both serious and minor, and
the ratio of benefits and risks (making sure the cure isn’t worse than
the disease)?
- More specifically- (consider in critiquing studies supporting the
drug,-
- Were they randomized, double blind studies? What did they use for the comparison (control)?
- How long and how complete was the follow-up?
- Did they look at the results in terms of the categories people were randomized to?
- What were the reason for drop-out and the rate of drop-out rate in each group?
- What were the side effects?
- What were the results expressed in the absolute reduction in risk, the relative reduction and the number needed to treat?
- For significant side effects, what was the number needed to harm?
- More specifically- (consider in critiquing studies supporting the
drug,-
- How does this medication compare in effectiveness (benefit), side effects (risk) and cost to other choices of medication commonly used for treating this condition?
- Is there a generic version with equal effectiveness that costs less?
- How does this medication compare in effectiveness (benefit), side effects (risk) and cost to using a hygienic approach that doesn’t involve using medications at all?
- Will patients in general use the medication as prescribed- i.e., is it tolerable and simple enough to use.
- How long will the patient have to be using this medication?
A mnemonic for these facts is listed below. During your interaction, check off any examples of this type of information you gain -
“STEPS” for evaluating new medications
S Safety
T Tolerability
Look for “pooled drop-out rate”
E Effectiveness (comparative) – Studies showing new drug is better than current choice
P Price
S Simplicity of use
Preskorn SH, Advances in antidepressant therapy, San Antonio: Dannemiller Memorial Educational Foundation, 1994)