NP + drug rep, ethical dilemma

[VivaRN]

I've been reflecting on this lately and am wondering how others reconcile.

Pharm dinners are using NP's to present on various drugs. It is almost like a mark of prestige to speak for a drug company. I have found on a few occasions during these presentations (after doing my own lit review) downplaying of serious adverse events or other undesirable aspects of the drug. These NP's are respected in the community and state that they are free of bias - but what they say doesn't measure up. I find this phenomenon mildly alarming.

Do clinicians really think they won't be influenced by accepting money from a drug company? Or that drug reps want to be friends because you're such a cool person?

There have been studies on physicians about this phenomenon: drug rep presentations do affect prescribing, accepting money/gifts creates a feeling of obligation to promote, drug company literature is biased and inaccurate statements are made during presentations with the majority of participants not aware of the inaccuracies.

The flipside is learning about new drugs coming out and the educational value. I guess what bothers me most is that NP's I respect are giving these presentations without understanding of how they've been influenced. How do you balance your interaction with drug reps?

The nursing literature talks about raising awareness in NP education about the tactics of influence, since as prescribers we are being targeted. Did you talk about this in your NP program? (we talked about it in mine).

Would you (or do you) speak for a drug company? What is your take on the relationship between NP's and the pharmaceutical industry? And, most importantly, what is best for patients?

Thanks ~

VivaRN

[buckblinn]

You have to understand that drug companies are promoting or selling a product. Just like any other company pharmaceutical industry :wink2::nurse:has the right to promote and sell a product. The FDA requires the drug company to promote only the package insert information to health care professionals. That means that if a practitioner presents the information about a product they must provide all information from the package inforamation insert of the product.

I am sure that there are some providers who become blinded by the lure of money and programs that are provided by a drug rep. However the practitioner must keep in mind that the best product to prescribe for the patient is the one that has the greates efficacy for the patient.

[traumaRUs, MSN, APRN]

When I go to a presentation sponsored by a pharmaceutical rep/company, I know there will be a strong bias. I don't look for unbiased info at these presentations. What I am looking for is more detailed info on that particular product. If I want nonpartisan info, I do my own lit search as well as use nonbiased info from conferences NOT sponsored by drug reps/company.

[Corey Narry, MSN, RN, NP]

The trend in this area is to do away with industry-supported presentations, free dinners, free items, and such in healthcare institutions because marketing of these products do affect their utilization and the prescription practices of providers. This has become a policy in a couple of hospitals in this area. Our own hospital does not even allow the use of drug pens, OR hats showing drug names or product names, and other similar items while in the premises. I, however, am not aware how this trend is affecting the out-patient settings in the area. What I do notice is that our state's NP association still conducts monthly educational meetings with an invited speaker who has sponsorship from drug companies. Like others said, you have to approach these meetings with the knowledge that there is bias towards the product the sponsor is selling. One should also remember that those who agree to be speakers in educational presentations involving products and pharmaceuticals are required to disclose their affiliations and whether they have received funding from these companies in their practice.

[VivaRN]

Thank you for offering your perspectives, they're very helpful.

I understand that medicine is a business but... there's something about the whole arrangement that hits my conscience and sense of integrity. It's not transparent. There's a hidden agenda that involves getting providers to prescribe a drug that may NOT be best for the patient. For example, one drug rep the other day was trying to get us to use a 3rd line agent as 1st line. And I would argue that they are successful or they would not continue this methodology.

I think it is interesting how some nursing literature views using NP's for drug presentations as becoming more equal with MD's, like our value is being recognized by drug companies when previously we were ignored. Though I wonder if this is a way we WANT to be equal - seeing as how commercial interests have been seen as corruptive to the medical professon.

Knowing that you can be influenced by what you hear & see without being consciously aware (the reason for the ban at your hospital, pinoyNP), I think that is what people have a hard time admitting to - especially when you are getting free dinner at a nice restaurant and carefully titrated ego stroking. It's like no one wants to go against something that feels so good, even though it can be harmful - like when they first tried to regulate cigarette smoking.

The nursing organizations I'm a part of also do pharm dinners every meeting. Were I to decide not to attend such presentations it would kill my professional life. They have done a great job of integrating themselves into our social network. I wonder if the best solution is to work from the inside, ask these organizations to seek unbiased sources of education - if not every month than perhaps every other month.

It is difficult to talk about these things with the NP's around me because with drug companies it's like everybody's doing it, including my role models.

Wow, you can tell I've been thinking about this a lot...

[*RN123ABC*]

Viva, your point is interesting and timely to me. I have a friend who is a FNP, and she refuses on principle to accept any gifts from drug companies. She will not eat the free meals, use the free pens, etc. It is killing her professional associations, since in this area, the free drug dinners are about the only way the medical community socializes together. One drug co even took a bunch of docs to Hawaii last month under the guise of a conference. She was invited but didn't go and while she doesn't regret not going, she is wondering how long she can keep foregoing opportunites to get her name "out there" in the medical community. Now, the only thing anyone knows about her is that she is the hippie freak NP in Dr So&Sos office who won't socialize with them. She said it is even hurting her at the office. They get free lunches from drug cos at least 3- times a week. EVERYONE in the office partakes, except her. She said in the beginning they just made fun of her brown bag lunches while they had their catered fare from the best local restraunts. After a while it became clear they resented her for what they inferred (incorrectly) to be her passing judgement on them for participating, and now she eats alone in her office.

[VivaRN]

Viva, your point is interesting and timely to me. I have a friend who is a FNP, and she refuses on principle to accept any gifts from drug companies. She will not eat the free meals, use the free pens, etc. It is killing her professional associations, since in this area, the free drug dinners are about the only way the medical community socializes together. One drug co even took a bunch of docs to Hawaii last month under the guise of a conference. She was invited but didn't go and while she doesn't regret not going, she is wondering how long she can keep foregoing opportunites to get her name "out there" in the medical community. Now, the only thing anyone knows about her is that she is the hippie freak NP in Dr So&Sos office who won't socialize with them. She said it is even hurting her at the office. They get free lunches from drug cos at least 3- times a week. EVERYONE in the office partakes, except her. She said in the beginning they just made fun of her brown bag lunches while they had their catered fare from the best local restraunts. After a while it became clear they resented her for what they inferred (incorrectly) to be her passing judgement on them for participating, and now she eats alone in her office.

I feel for your friend and admire her ability to take a stand. This is what I fear should I decide to make a similar decision. It's unfortunate that not engaging pharm companies means punishment in other areas. It shouldn't be that way.

What would be the best way to change this system?

[core0]

When I go to a presentation sponsored by a pharmaceutical rep/company, I know there will be a strong bias. I don't look for unbiased info at these presentations. What I am looking for is more detailed info on that particular product. If I want nonpartisan info, I do my own lit search as well as use nonbiased info from conferences NOT sponsored by drug reps/company.

I think that this is the right approach. The provider should be the expert. You should know enough about the drug and condition to separate the wheat from the chaff. Ideally you know much more about treatment options than any rep.

From the point of view of someone that does industry sponsored lectures, by FDA rules you are required to use the industry supplied slide deck. You are not allowed to alter the slides or discuss off label use. However, in reaction to questions you can discuss real life applications including off label use. This is where you can tell the difference between someone who is an industry shill and someone who is there to present good information about treating patients. When I lectured on Interferon, I was on the speakers bureau for all three drug manufacturers. I was frank about problems with the different drugs not matter who paid for the dinner. As a result I was asked to appear more frequently than physicians who would only advocate for one drug.

On the other hand I am amazed by the lack of critical thinking that some providers use in regard to drug reps. When Vioxx went off the market, one of the Mobic reps went around telling the orthopods that Mobic did not cause ulcers. Simple perusal of the PI would have shown this was false. However in GI circles this was a Cha-ching moment. Ulcer city.

David Carpenter, PA-C