Cover Story -August 2000
By Laurie Stoneham
A 52-year-old man calls his internist and asks for "that Bob
Dole stuff." A prescription for Viagra is mailed to the patient --
no questions asked, no exam required.
Hearing rave reviews from her sister about the pills that have
chased away the blues and evened out those roller-coaster mood
swings, a 44-year-old woman asks her obstetrician-gynecologist to
write a prescription for Zoloft. The physician complies, without
even attempting to diagnose depression.
These are actual examples of everyday patient-physician
encounters that make the prescribing of medication a
multibillion-dollar business and an expected practice that's part
of the American health care culture.
These vignettes also demonstrate the constant pressures exerted
by patients, managed care drug formularies, and the giant
pharmaceutical industry that affect how and what a physician
prescribes. Their influence is increasing, and writing a
prescription is not always just about what's best for the
Pushing the consumer
Patients asking their physicians for prescription drugs by name
is now commonplace. Joe Graedon, pharmacologist and author of the
books and syndicated newspaper columns, a public radio program
host, and Internet site operator, calls such requests the result of
a "full-court press of promoting drugs through direct-to-consumer
advertising" by drugmakers. Pharmaceutical companies will spend
close to $2 billion this year courting patients to ask their
doctors about the drugs they manufacture.
It's seductive marketing that has had an impact on the American
psyche. Mr Graedon sees it as "a growing tendency to medicalize the
human condition." He points out that the manufacturers of popular
serotonin reuptake inhibitors (SSRIs) are eager to promote their
products as treatments for everything from depression, anxiety, and
obsessive-compulsive disorder to premenstrual syndrome, bulimia,
and even shyness.
For many, Viagra was viewed originally as a treatment for older
men suffering from impotence. Now, it is also being sold to younger
men who may think their love lives aren't what they could or should
be if they are not having super erections.
"Even the language of disease has changed," Mr Graedon points
out. "We're no longer dealing with impotence, it's now 'erectile
dysfunction,' and incontinence is couched as 'an overactive
The economic culture
There's a lot of gold in them there pills. Billions. Last year,
2.8 billion prescriptions were written in this country, according
to health care industry watchdog, IMS Health. The pharmaceutical
consulting firm of Scott-Levin estimates that retail sales of
prescription medications totaled $111.1 billion last year. Leading
the pack was Premarin, a coagulated estrogen for postmenopausal
Phil Lee, MD, who has written several articles and books on
prescribing practices and is the former assistant secretary for
health with the US Department of Health and Human Services, says
writing a prescription at the end of a patient visit is essentially
a cultural phenomenon
"It validates the patient's complaint, legitimizes his illness, and
makes him feel better to walk away with a prescription," said Dr
Lee, senior scholar at the Institute for Health Policy Studies at
the University of California, San Francisco, School of
He recalls a French colleague who characterized American
medicine as "the one ill, one pill, one bill system of health
David Butler, MD, a family practitioner in Austin, abhors
direct-to-consumer advertising "because it colors the whole
encounter. Patients are already set on their treatment, predisposed
to a diagnosis." He says it's necessary to get the patient back on
track. "I need them to talk to me to begin the cognitive process of
evaluating their condition and arriving at a diagnosis and
treatment plan. Otherwise, I could make an error."
The Austin Regional Clinic practitioner dissuades patients from
asking for a particular medication. "I've had a lot of patients
leave the practice because I didn't write a prescription for an
antibiotic they thought they or their child needed. My patients now
know that I just won't do it."
Surendra Varma, MD, a pediatrician with Texas Tech University
Health Sciences Center in Lubbock, says while he doesn't mind
patients asking questions about drugs they've seen advertised, he
knows that ads don't tell the whole story and may even include
misleading information. As a consequence, he has to take valuable
time away from patient care to discuss the results of studies
referred to in drug ads.
Visits from pharmaceutical representatives "detailing" the
benefits of their drugs are part of practicing medicine in this
country. It happens regularly, and perks are offered and received
as part of the interactions. In exchange for the "face time" with
their customers, salespeople shower physicians with everything from
free samples to meals, tickets to sporting events, educational
seminars, and expensive gifts.
Several physicians noted that they give some of the thousands of
dollars of free samples they receive to uninsured patients.
Still, physicians are under a lot of pressure to prescribe the
newer drugs, according to Gregg Lucksinger, MD, a family physician
in Austin. Pharmaceutical representatives "are leaving free samples
of new drugs all the time so it's sometimes easy to forget that
older, less expensive, but very efficacious, drugs are available. I
think we have to continue to remember to use the older drugs,
Dr Butler relies on drug representatives to give him valuable
information about the products they represent. "I have a couple of
dozen pharmacy reps whom I genuinely like and trust and, quite
frankly, whom I'm loyal to," he said.
He recalls one of the representatives of a recently launched
sleep aid admitting that the drug wasn't that much more effective
than an over-the-counter medication. "Now, I trust that guy and
others, particularly those who've been doing it for a long time, to
give me accurate information."
As a dermatologist who specializes in treating skin cancer,
Aaron Joseph, MD, doesn't write a lot of prescriptions anymore in
his Pasadena practice. Still he talks with pharmaceutical reps
fairly regularly and believes that for the most part they offer
reliable information. "The reps who have been in the business for
10 or 20 years are reputable on the whole and don't BS you. They
give you information in a simple, straightforward way."
The time spent at dinners and sporting events, Dr Butler thinks,
is particularly valuable because that's where relationship and
trust are built. "You have to get beyond the salesmanship."
But pharmaceutical reps shouldn't be the sole source of
information, Dr Varma believes. "We as responsible physicians
should weigh all of the information and do independent research of
the literature and use the Internet to learn what we can about
these medicines," he said.
San Antonio family physician Abe Rodriguez, MD, agrees. Along
with the information received from drug reps, he thinks it's
essential for physicians to read journals and attend medical
meetings to learn the latest and most accurate, unbiased
Physicians receiving honoraria or travel reimbursements from a
pharmaceutical manufacturer in exchange for discussing the
company's products with other physicians is not uncommon. However,
some doctors frown on the practice. Dr Varma thinks it's unethical.
"We should not be bought by the pharmaceutical industry," he
For Dr Lucksinger, however, having a specialist come for an
in-office lunch to discuss various kinds of therapies is very
helpful. "I can learn more in that hour than I would talking for a
week with a sales rep."
Full disclosure of a speaker's relationship with drug companies
is something Texas Tech and other medical schools instituted years
ago. If a speaker is chosen by and supported by the pharmaceutical
company, it is noted that the presentation is being underwritten by
a grant. "We call these guys 'hired guns,' and we know it's biased
information," said Donald Wesson, MD, chair of internal medicine at
Texas Tech Health Sciences Center in Lubbock.
Dr Wesson explains the preferred sponsorship arrangement as one
in which the company provides an unrestricted grant to reimburse
the travel expenses of speakers the university selects. In this
case, the company's support is acknowledged and it is clearly
stated that the speaker has no relationship with the sponsoring
Managed care pressures
Having spent a number of years practicing in the Navy, Dr Butler
cut his teeth on drug formularies and saving money by prescribing
lower-priced drugs. Still, he asserts that "having to work with
formularies is No. 1 on my list of headaches -- and that includes
everything in my life, including two preteen children."
He is not alone. According to the most recent biennial survey of
physicians by the Texas Medical Association, 58% of the reporting
physicians say they have seen specific cases in their practices
where managed care policies adversely impacted the quality of
patient care. Of that 58%, 75% cited restricted formularies as a
cause of poor quality care. In a significant change from the last
survey in 1998, restricted drug formularies have replaced denial of
a referral to a specialist as the most frequent cause of poor
Dr Butler says he tries to prescribe the least expensive option
90% of the time. Then, when he wants something that's not within
the managed care plan's formulary, "my staff has this huge hassle
with phone calls and additional paperwork to do a little tap dance
with some HMO to prescribe the drug I think my patient needs. The
sheer chaos of it is what's so frustrating."
Formularies and other managed care rigmarole don't affect Dr
Lucksinger. "I do what I think I need to do for my patients. And if
a health plan becomes too difficult administratively, I'll drop
it." Dr Lucksinger thinks more physicians need to adopt a similar
attitude and practice.
Dr Rodriguez says he tries to rely on evidence-based medicine
regarding the efficacy and economy of a medication, but he also is
concerned about the patient's perception. "A patient has to feel
confident in the drug I prescribe. If I change to a less expensive
medication, for example, I have to spend time to explain that it
offers the same benefits. And, generally speaking, prescribing
generic drugs requires additional time to explain to the patient
that the drugs are equally as good as brand name drugs."
Dr Wesson thinks the medical profession in general and Texas
Tech in particular have not been aggressive enough in teaching
young physicians about how to interact with the pharmaceutical
industry. Just this past year, Texas Tech began including specific
didactic instruction on how to interact with pharmaceutical
representatives, how to process the information received from them,
and how to determine when such relationships may be inappropriate
to the point that they could compromise patient care. It is one of
the few medical schools in the country to have such instruction, Dr
"Our message is straightforward," he emphasized. "We tell our
students and staff to always be suspicious because the information
received from [drug] detail reps is biased. The person's goal is
not to educate and not to put the patient's welfare first; it's to
sell a product. The product may be a good one and one that should
be used, but the motivation is expressly a commercial one," he
"I don't want to paint drug companies as evildoers," he added.
"They are very helpful in providing academic support at a number of
levels. These companies make a very positive contribution to the
health care industry. But they are dedicated first and foremost to
Medical students begin learning about generic drug therapy as
part of the first- and second-year core curriculum, according to Dr
Wesson. Brand names begin to be discussed in the third year, and
prescribing practices are refined during residency.
In terms of prescribing patterns, Dr Wesson says the physicians
at Texas Tech are taught to first evaluate the drug's efficacy for
the diagnosed condition. If there is a choice of medications, the
next consideration is side effects. Finally, if side effects are
equal, price should become the final deciding factor. Academic
health centers have to be supremely sensitive to cost along with
providing the highest quality patient care.
Improving the practice
The business of prescribing medication for patient care is
extremely complex. The relationship between the pharmaceutical
industry and the health care industry is increasingly intricate --
some would say even unhealthy, bordering on incestuous -- as
pharmaceutical companies fund continuing medical education,
underwrite educational grants, and pay for clinical trials of
And there are no easy answers. As biomedical and pharmacological
technologies advance to offer newer, better prescription therapies,
physicians will have to be able to objectively understand,
decipher, and use increasing amounts of data.
Dr Lee believes a real-time information system available on a
handheld computer that physicians could access when writing a
prescription is the solution for avoiding or ameliorating the
pressures exerted by patients, pharmaceutical representatives, and
managed care organizations.
He envisions such a system helping physicians prescribe
medications that offer patients the greatest therapeutic benefit.
At the same time, the information would provide important patient
protections by alerting physicians about potentially dangerous
interactions both with other prescription medicines and with herbal
remedies patients may be taking.
Mr Graedon sees the pharmacy of the future filled with computers
for patients to use and robotics being employed to count pills and
dispense medications. "Pharmacists will be elevated to serve as
information specialists for both physicians and patients, answering
questions on everything from drug interactions to side-effect
profiles," he said.
"I think we're moving to a system wherein the patient and
physician will have greater control over making decisions and
managing costs," offered Jerry Patterson, executive director of the
Texas Association of Health Plans. "For example, there may be
something along the line of a defined amount of pharmacy benefits,
and the patient and physician determine how those dollars are spent
within those limits."
Meanwhile, how much control over writing prescriptions do
physicians really have? It's impossible to answer that question
definitively. What is clear, though, is that physicians are
receiving, as well as dispensing, a lot of advice in the
Laurie Stoneham is an Austin freelance writer.
Top 15 prescribed
pharmaceuticals in 1999
TMA Advantage: TMA Library
Commentary: Refills -- A