To the Editor:

While I normally enjoy Dr. Brown’s Practice Diary, I was disappointed by his somewhat laissez-faire attitude toward gifts, goodies, perks and free dinners from pharmaceutical companies [“Drug Money,” April 2002, page 55]. This attitude is all too common among physicians, who feel that they can’t possibly be influenced and that they are easily able to sort the wheat from the chaff.

If only that were true. Studies repeatedly show that we don’t know how much drugs cost, don’t discuss drug costs with our patients often enough and too often reach for the most expensive drug when a less expensive alternative exists. Few physicians have the training to critically appraise studies or understand marketing ploys, such as the appeal to authority and the bandwagon appeal. The pharmaceutical industry spent $15.9 billion in 2000 on product promotion for one reason: It works. Spending on drugs increased by 17.9 percent last year, and the number of elderly seeking care in the Veterans Affairs health system has doubled in recent years, largely because they can no longer afford their medications. Patients choosing between an expensive proton pump inhibitor (PPI) and an anti-hypertensive may forgo the latter, since taking the former relieves symptoms and has a more immediate benefit.

Dr. Brown stated that he heard a lecture sponsored by Merck one month and then heard the same speaker at a Pfizer event several months later talking about a competing product. He says, tongue-in-cheek, that he considers this evidence that the drugs are probably equivalent. What we won’t hear about at these dinners, though, is equally effective generic alternatives. At these dinners, we’ll hear about the next generation of PPIs, but not ranitidine (which studies show is equally effective for half of long-term PPI users), and about an expensive new calcium channel blocker, but not hydrochlorothiazide or atenolol (which are both proven better at reducing mortality in hypertensive patients).

Dr. Brown also feels that drug cabinets are a useful resource for his patients. While I admit that they can occasionally be helpful, we are too often seduced by the samples into starting a patient on a new, expensive drug when an older alternative would be just as effective. Did seven free days of a new, expensive PPI really help a patient who could have been successfully treated with generic ranitidine for the next 20 years?

Our patients trust us to make decisions for their care based on the best available evidence, our clinical experience and our knowledge of their values and resources. Our integrity as a discipline is at stake if we don’t stop kidding ourselves about these free lunches.

Author’s response:

Unfortunately, there are hardly any inexpensive drugs anymore. When I first started out in this business, no drug cost more than a dollar apiece. Now, it’s hard to find one that costs less, with $2 to $3 a pill being the norm. Even generics can cost up to 70 percent of the brand-name price, especially if a medicine has just gone off patent. Atenolol is cheap, as are most diuretics, but not everyone can take them. Many patients need the newer drugs.

My local pharmacist tells me 91 percent of his customers get third-party help with their medications. In California, patients on Medicare are charged Medicaid drug prices. In addition, pharmaceutical companies have begun patient-in-need programs and offer discount coupons. Most patients have small co-pays to fill 30-day prescriptions, with the cost differential between generic and brand names being relatively minor. The situation isn’t hopeless.

Although it would be ideal to only prescribe generics, sometimes the best-available evidence calls for a brand-name drug. For the 9 percent of my patients with no financial relief, I’m glad to have my drug closet as a resource and appreciative of the reps who fill it. Since I occasionally enjoy socializing with them, my conundrum is this: Can I retain the integrity of my discipline by paying for my own lunch, or must I additionally banish drug reps and their samples from my premises?