Oh, Give Me a Home Where the Sales Reps Roam

Sales reps (detail reps, drug reps) have been sort of off our radar for a little while. Some think with new rules of conduct from PhRMA, limiting the gifts/bribes they can give out to docs, even doing away with the infamous pens and coffee mugs, they are no longer much of a threat to the scientific integrity of medical practice. Not so fast, a couple of sources would say.

First, the Baltimore Sun--
http://www.baltimoresun.com/health/bs-md-midei-deposition-20101214,0,3445835.story
--in ongoing coverage of the case of Dr. Mark Midei and his allegedly excessive use of cardiac stents, due to extensive wooing from Abbott, the manufacturer of one of his favorite devices. We need to take what's said in this case with some grains of salt due to the fingerpointing now going on, with the hospital and Dr. Midei each claiming that the other is mainly at fault and trying to dodge blame by accusing the other. However, in testimony before the administrative judge who's ruling on his licensure action, Dr. Midei, while insisting he took no payola from Abbott, claimed that Abbott reps wandered freely in and out of the cath lab at St. Joseph Hospital, in violation of the hospital's rules. The Sun cites a recent study that demonstrated that when sales reps were allowed free access to a cath lab, the use of their own company's devices went way up while they were around.

I have admitted that device reps are a bit different from drug reps in that no rep has to be on site to tell the patient how to swallow a pill, but sometimes a trained engineer-type rep is needed to help the staff adjust or fine-tune a complicated device. The device companies seem to use this exception to create a huge loophole, justifying the presence of their sales reps everywhere and all the time. I doubt that once a cardiologist has been trained on how to insert a stent, there is any serious need for a company rep actually to be in the cath lab while the stent is being placed--let alone show up on a regular basis and have a tight relationship with the staff, as is alleged in the Baltimore case.

More evidence on the ubiquity of drug reps is provided by our good friends at the Pew Prescription Project (http://prescriptionproject.org/initiatives?id=0005), as summarized by Kate Petersen on their Postscript e-mail blog. Kate looks at the latest AMSA report card for med schools (http://amsascorecard.org/) and notes that in many areas, great improvement is being shown--many med schools that used to get Ds and Cs are now getting As and Bs for tighter policies controlling relationships with the drug industry. But one area that seems to be a general exception to the trend of improvement is the refusal of academic medical centers to adopt strict rules banning drug reps from the campus. Many have policies limiting access of reps to specific areas, e.g. eliminating any patient care areas, but very few have taken the step of completely driving the moneychangers out of the temple. Kate offers some cogent thoughts on why this is strange, especially given the cuts in the numbers of drug reps as companies have retrenched in more difficult economic times. My own guess would be that the academic leaders get too much pushback from rank and file physicians when they suggest a no-reps-on-campus policy.

The bottom line: Don't think that the days when drug reps exerted considerable influence over medical practice are over just yet.

Van H, Yamen E, Blanchard J, et al. Does the presence of a corporate representative affect choice of coronary stent? [poster abstract] American Journal of Cardiology 106:204D, Sept. 21-25, 2009.