Saturday, December 1, 2007

Are Devices Different from Drugs?

John, Swen, a Pfizer VP, asked a very good question at a health policy forum in Minneapolis last month. Minnesota, as I have noted in earlier posts, has one of the most stringent programs in the country for recording and publicizing the money that physicians in the state get from drug companies. So why, said Swen, do the device companies get a pass? Why does the law only apply to drug manufacturers? The Pioneer Press reported on the debate:

Essentially two answers were given in the article, neither satisfactory. First, it was admitted that when the current laws were written, device makers were simply not on anyone's radar screen. Second, many medical device companies are based in Minnesota and have a lot of political clout.

The question, "Are devices just like drugs or not?" keeps popping up and so I am going to restate the case without offering a definitive answer--and invite comments from you readers.

I can think of two ways in which the device industry differs in some basic way from the pharmaceutical industry. Please bear a couple of things in mind as I explain these two things. I am, by training and experience, a family physician. We family docs are not big-time device users. So I am left at a disadvantage in talking about this topic compared to surgeons, cardiologists, and other specialists whose bread and butter involves medical devices. Also please bear in mind that the end result of all this talk is supposed to be the benefit of the patient. We are not trying to rein in pharmaceutical industry influence, and get greedy docs to clean up their act, simply so we can all get gold stars in the teacher's grade book. We are trying to reform this system because of our conviction that at present, it is not serving the patient.

So, my nominations for how devices are legitimately different from drugs and so may mandate a somewhat different regulatory approach:

  1. Several academic medical center policies that basically ban drug reps outright do not ban device reps, and I think that is justifiable. I don't need a drug rep on site to show me how the patient is supposed to swallow a capsule. Virtually all the information that I need to know about how to prescribe a drug could be provided to me in writing. For many devices this is not true. The company rep may be in fact a skilled engineer. Many devices need fine adjustments to work properly and the company staff may know much more about how to make these adjustments than anyone else in the hospital. And the adjustments may well require a hands-on demonstration if the physicians and nurses are to become adequately skilled at using the device.
  2. Just as device reps have knowledge that physicians really need to take good care of patients, some physicians have knowledge that device manufacturers truly need to design the next generation of devices. In today's world, I doubt that a single drug is ever discovered or developed as a result of a practitioner calling up the drug company and saying, "I sure wish I had a drug that I could give my diabetic patients who have foot pain." The company's in-house scientists know far better than any practitioner what classes of molecules are out there that could become new drugs, and what bodily functions those molecules affect. But I assume that many medical devices are developed because, say,. an orthopedic surgeon calls up the company and says, "This artificial hip that you make is pretty good but I find it a bit awkward to apply the cement. Now, it dawned on me that if you modified the surface where the prosthesis attaches to the femur, the cement would go on a lot easier and you could have a much more secure attachment." (Or however they attach the danged thing--I have no clue.) So there is much more room for legitimate consulting between the company and a group of medical specialists in the device than in the drug case.
That said, there is one obvious and glaring similarity between gifts and consulting/speakers fees paid from device companies and drug companies to docs: at least some of these payments, if not the majority of these payments, are thinly disguised bribes to use the drug/device rather than an equally good drug/device made by a competitor company.

I would invite the executives of the device companies, if they want transparency and reform as much as some of them have said in Minnesota, to help legislators and regulators decide which payments are which. I also propose that medical professionalism remains an important part of the equation here because it is often the case that if there is a difference, the physician who gets the fee knows it--though the ability of physicians to go into rationalization-and-denial mode when their gravy train is interrupted is probably just as great on the device as on the drug side. Meanwhile I invite readers to comment at will.


Anonymous said...

An interesting post. My first impulse in reading your title was to say "no, they should be regulated the same way." But your points are fair.

I am a family physician too (in Australia), and while I do not accept gifts or meals from drug reps, I can reflect on occasions where contact with industry about devices has been useful. I am not talking about prosthetic hips; rather I am thinking of things like insulin delivery devices and contraceptive devices.

When I consider prescribing a new medicine, I try to learn about medicines from independant sources rather than the drug company. This is usually fairly easy to do. However, I've never had an independant agency come to me with an insulin pen or an Implanon implant and explained to me how it is to be used. For that hands-on stuff, only the industry has helped.

However, I would still argue for transparency about payments or gifts etc. I think it would be wrong to be paid to attend a course about one of these devices. Perhaps sources of independant prescribing education need to consider talking about devices, and doing hands-on sessions too.

Edmond said...

A bribe is a bribe is a bribe. When it comes to health, money should be number two and life should be number one. To accept bribes or gifts or whatever euphemistic term comes to mind, is to give preference to the company that offers it, even if simply to allow them to make a presentation to you which you evaluate "fairly". It's a matter of equal opportunity so to speak: If you only hire Whites but fairly promote amongst them, then are you being fair? By the same token if you preferentially attend CME seminars that pay then are you not shutting out the alternates that don't pay? And while a businessperson can do this because their job is to make money, can you justify this as someone whose job is to improve the health of your patients- to safeguard their very lives? Your ultimate reward as a physician (besides living a life that is much better than 99.9% of those around you- yes you are in the top 0.1% of bread-earners) is making your patients healthier. If you have this mindset, does it matter which company gives you more $ to attend their seminars, or does it make better sense to attend those which have the best product even if they don't pay you a dime? Likewise, how would you view politicians that only meet with potential government contractors and have meetings to permit lucrative mining deals only with companies that pay them handsomely to attend their seminars to explain how their mine or company is in the best interest of the citizens? Any politician caught accepting this sort of bribe is expected to resign in shame immediately, and they usually do. Are MDs held to a lower standard than politicians? MDs are not idiots and I rather prefer to think they are smarter than our politicians, but evidently when it comes to money, even the brightest minds succumb to rationalizing away the most evil activities.