Patients visiting Creekside Family Practice in Rapid City won’t find any pens, mugs or prescription pads advertising the newest medication on the market.

They also won’t find any free drug samples, and they certainly won’t run into any pharmaceutical salespeople bearing free lunches. 

Two years ago, when Dr. Nancy Babbitt joined Dr. Craig Hansen in the practice, the two physicians decided to cut all ties with pharmaceutical sales representatives.

Hansen already had a longstanding policy of not meeting with drug-company representatives, something he began during his residency.

“I’ve been an antagonist of the drug pharmaceutical reps from the beginning,” he said.

During his residency, Hansen remembers drawing criticism from an instructor when he refused to meet and greet pharmaceutical representatives as part of his training.

 “I thought it was a conflict of interest,” he said.

He still does.

For as long as most doctors can remember, pharmaceutical and medical vendor “reps” have been a fixture in clinic and hospital environments. Drug reps visit doctors and their staff, promoting and selling their company’s medications or products.

They often bring goodies to grease the sale. 

In the early years, it wasn’t uncommon for drug reps to ply doctors with free vacations and elaborate gifts. Those practices have largely been eliminated, but less elaborate practices remain, including providing free lunches to clinics and their staffs.

The relationship between doctors and pharmaceutical companies has drawn fire from the medical industry and industry watchdogs alike in the past 10 years. 

Two huge settlements have undoubtedly played a role in that growing attention. 

In 2001, TAP Pharmaceuticals paid the government $875 million to settle claims that it paid kickbacks to doctors to promote Lupron, the company’s prostate cancer drug, and cheat Medicare by filing false claims.

In 2004, pharmaceutical giant Pfizer was fined $430 million to resolve criminal and civil charges that it paid doctors to prescribe its epilepsy drug Neurontin to patients with ailments that the drug was not federally approved to treat.

Such settlements drew attention to a system that many believed made it too easy for pharmaceutical companies to influence doctors. As a result, the government and the pharmaceutical companies themselves began to take action.

In January, the Pharmaceutical Research and Manufacturers of America, the organization that represents pharmaceutical companies, adopted an updated voluntary code regulating their relationship with health care providers. The code makes recommendations regarding gifts, medical information and the relationship between pharmaceutical representatives and doctors. It also does away with the practice of giving doctors such things as pens, cups and pads advertising a certain medication.

The current House health care reform bill addresses the issue as well, including a regulation that would require pharmaceutical companies and vendors to closely report all gifts and samples.

Several states have adopted stricter regulations to limit the contact that drug reps have with physicians. Minnesota is one of them, said Dr. Douglas Wood, a physician at Mayo Clinic in Rochester. The state passed regulations this year restricting gifts and even the amount of food a drug rep can provide to a doctor’s office, Wood said.

Mayo Clinic itself has an extensive policy requiring doctors to report any details that may prove a conflict of interest. Even a family member of a doctor who owns stock in a pharmaceutical company raises a red flag, Wood said.

“If a conflict is identified, we have to find ways to mitigate that,” he said.  

South Dakota does not have such a state law, but most clinics and physicians follow American Medical Association guidelines, according to Megan Myers of the South Dakota Medical Association. The guidelines restrict physicians to gifts that benefit the patient and are not of substantial value. “Textbooks, modest meals and other gifts are appropriate if they serve a genuine educational function. Cash payments should not be accepted. The use of drug samples for personal or family use is permissible as long as these practices do not interfere with patient access to drug samples. … Individual gifts of minimal value are permissible as long as the gifts are related to the physician’s work, (e.g, pens and notepads). …”

Regional Health allows pharmaceutical representatives and medical vendors to visit their clinics and hospitals, but it has two policies addressing the practice, said Shawn DeGroot, vice president of corporate responsibility.

DeGroot said Regional Health is scheduled in an upcoming meeting to explore that policy further. “Conflict of interest is an issue,” she said.

Dana Darger, Regional Hospital’s pharmacy director, has seen the relationship between pharmaceutical companies and clinics/hospitals change in his 30 years as a pharmacist. He remembers a time when pharmaceutical companies themselves provided speakers at medical conventions to talk about diseases and promote their medications. That practice has largely been replaced with a grant system that allows convention organizers to hire their own, hopefully unbiased, speakers.

But Darger is not against allowing reps to visit with doctors at Regional Hospital, partly because he can play a role in that meeting.

 “I actually encourage them to come see us because I want to know what they are telling the doctors,” he said. “We have pretty frank discussions sometimes.”

Exactly what drug companies are telling doctors is part of the debate.

The two large settlements with TAP and Pfizer identified companies giving inaccurate information to providers — but that is not the intent or the norm, former pharmaceutical rep Ron McLaughlin of Rapid City said.

McLaughlin worked as a pharmaceutical representative for 17 years before changing careers three years ago to become a pastor. McLaughlin said the relationship between drug company representatives and doctors is not designed to be a sales relationship.

“I always felt like my job was to tell our doctors where our drug best fit their patients,” he said. “You’re really providing information.”

Providing meals to doctors was merely a vehicle for providing that information, he said.

When McLaughlin began working as a rep, he competed with 28 other reps in the area. When he left three years ago, there were 72. McLaughlin said as doctors became bogged down with more administrative chores and more drug reps competed for time, the best way to get a few minutes with a doctor was by providing a small lunch.

“I think some of the offices abused that. You would walk in and have to feed 30 people to talk to three people who needed the information,” he said.

But Dr. Babbitt, of Creekside Family Practice, believes the perception that pharmaceutical reps are merely providing information is a dangerous one.

“It’s marketing and sales,” she said. “I think doctors think they’re above it — and we know, based on evidence, that they are not.”

In 2000, pharmaceutical companies spent more than $15.7 billion promoting prescription drugs in the United States, with more than $4.8 billion spent on the one-on-one promotion of drugs to doctors by pharmaceutical sales representatives, according to an article published in the Public Library of Science.

In a 2004 survey of doctors, about 94 percent of those who responded reported that they had a relationship with the pharmaceutical industry, which included accepting food in the workplace and taking drug samples.

“More than one third of the respondents (35%) received reimbursement for costs associated with professional meetings or continuing medical education, and more than one quarter (28%) received payments for consulting, giving lectures, or enrolling patients in trials,” according to the results, published in the New England Journal of Medicine.

While the general belief has been that drug samples provided by drug companies help lower costs for patients, the opposite has been found, Babbitt said. A study in the journal Medical Care reported that patients who received samples spent more in the long term for their medication because they were started on a higher-priced medication rather than a generic.

Dr. Thomas Huber, president of the South Dakota Medical Association, said drug reps have been a part of his career from the start. While he recognizes the potential influence of pharmaceutical reps, he also accepts the realities of a free-market system.

“It’s just part of how things work, and you have to figure out what your philosophy is about it,” he said.

Huber allows drug reps to visit his office to talk about their company’s drugs but says he no longer accepts samples — and he never accepts their drug information at face value.

No doctor should, he said.

“My job is to do my own analysis,” he said. “I’m basically a nice guy. I’m not going to get confrontational with a sales rep. … I’ll either ignore what they have to say or do my own research on it and reach my own conclusion.”

Darger also sees the role of health care providers as disseminators of information.

“If you’re not good enough professionally to be able to sort out what’s important and what’s company line, you probably don’t have any business being in this business to begin with,” he said. “I think you have to realize that they’re getting paid to sell that product …”

Although he continues to meet with reps, Huber is supportive of doctors like Babbitt and Hansen.

“I applaud their efforts. They’re probably taking an approach that is ethically clean — and one we should probably all subscribe to,” Huber said. 

Dr. Jeffrey Bendt, a Rapid City obstetrician/gynecologist, has heard the arguments against having a relationship with drug reps and argues that doctor/drug rep relationships are a benefit to doctors.

“They give me valuable information,” he said. “I just have to be smart enough to decipher that information. … It certainly makes me aware of new drugs that are on the market or new indications for those drugs.”

Bendt said he is able to get basic information from the representatives — information he can take and explore further. He often gets the information over a simple lunch provided paid for by a drug company.

“That’s a good time to catch you because everyone has to eat,” he said. “That’s a time when I’m not in a hurry.”

Babbitt and Hansen have heard all of the arguments and stand by their position. Both are adamant that a pharmaceutical company with a profit motive should not have direct access to providers.

“Their purpose is to sell their drug,” Hansen said. “They try to sell themselves as patient advocates. They are not. It’s not good information. It’s biased.”

To get unbiased information on new medications and studies, Creekside Family Practice subscribes to three medical journals, Hansen said. That allows the providers there to focus on patients without any outside influence, and Hansen sees that as critical to his role as a doctor.

“Our position is one of patient advocacy,” he said. “The problem is doctors who are not being patient advocates.”

Calls to the National Association of Pharmaceutical Representatives for this story were not returned.

Contact Lynn Taylor Rick at lynn.taylorrick@rapidcityjournal.com or 394-8414.