A new campaign, to be formally launched at the Royal Australian College of General Practitioners conference in Adelaide on Saturday, will urge doctors to stop seeing pharmaceutical company reps.

The “No Advertising Please” campaign aims to reduce inappropriate and harmful prescription of medications.

It asks doctors to take a pledge – already signed by more than 70 health professionals – stating that they will not see drug reps for a year.

The Consumers Health Forum of Australia has welcomed the campaign, saying it “brings a new and refreshing level of transparency into medical practice”.

The Forum’s CEO, Adam Stankevicius, said in a statement: “It can only boost the level of trust patients place in their doctors to see a NAP poster in their waiting rooms.”

In an ironic twist, Medicines Australia has given something of a gift to the campaign – by issuing an attack press release that is likely to help generate media coverage.

“…the idea that you can ignore information from a pharmaceutical company that has conducted extensive research and development to help treat disease is laughable at best and negligent at worst,” said Medicines Australia Chairman Dr Martin Cross.

In the article below, one of the campaign’s instigators, Croakey’s Naked Doctor columnist Dr Justin Coleman, explains the evidence behind why he wants medical colleagues to back the campaign.

“If I were a patient, I would have more confidence in the quality of my doctor’s prescribing if they did not see drug reps,” he says.


No Advertising Please

Dr Justin Coleman writes:

Despite door-to-door sales having become as dated as Encyclopaedia Britannica volumes, travelling pharmaceutical representatives have almost singularly resisted the decline.

Remarkably, not only does their trade continue to flourish (US$6 billion annually in the US alone), but the myth that their purpose is educational rather than promotional still has a firm foothold among many of the doctors who answer their knock. The ultimate triumph of marketing: so effective, it vanishes.

A survey found more than half of ‘high-prescribing’ doctors cite pharmaceutical representatives as their main source of information about new drugs.

Such reliance on company sales reps is remarkable, given the amount of independent drug information readily available from NPS MedicineWise, Therapeutic Guidelines, Australian Medicines Handbook and countless hospital therapy guides, which provide balanced, evidence-based information with the sole objective of improving patient care.

In contrast, the reps’ primary concern is to increase sales of their product – this is the condition under which they accept employment. This aim only partially overlaps with improving care for patients.

Imagine, for example, five reps promoting similar drugs for an identical medical condition. Nothing wrong with any of the drugs – they all work just fine. Each visiting rep aims to increase prescriptions for their brand and decrease the prescriptions for the other four. Patient benefit simply doesn’t feature in the equation.

The doctor might then choose between similar drugs based on side effects and individual patient factors, but this information is readily (and more reliably) available from independent sources.

Finally, if all five drugs are suitable, the doctor’s choice might reasonably be based on cost. As a rule of thumb, the cheapest drug for the condition is probably the one where no rep turns up at all!

No reason any of this should stop the five salespeople knocking on the door, but it should give pause to the doctor before opening it.

In many circumstances, guidelines recommend against any drug treatment at all – an educational pearl likely to be missed even by those energetic high prescribers who might claim that seeing all five reps achieves a state of balance.

Whatever equilibrium they find among the free lunches and branded toys is unlikely to involve any cheap drugs off-patent (with many years of evidence and real-world safety data), let alone any free options.

They will never be taught about ‘deprescribing’, and have as much chance of finding a not-for-profit ‘Exercise Rep’ at their door as finding Santa’s elf. A pity for their patients, because regular exercise leaves many cardiovascular drugs for dead. Read the independent guidelines.

The Blue Cross report ‘Getting doctors to say yes to drugs’ indicates that although the pharmaceutical industry’s stated purpose is to encourage “the right drug for the right person at the right time,” too frequently the opposite is encouraged.

Examples would include marketing that leads physicians to prescribe drugs where no drug therapy is indicated; to prescribe high-cost drugs when lower-cost drugs would be equally effective; or to prescribe a wrong category of drug. In each instance, excess costs are added to the health-care system. (Millenson)

In an evidence-based world, online access to high-quality, unbiased information should have killed off the ‘necessary for education’ argument as effectively as it has undermined hard-copy encyclopaedia sales.

As Dr Fiona Goodlee, Editor-in-Chief of the British Medical Journal, told a recent BBC Panorama program, Who’s Paying Your Doctor?:

The drug industry has an irreducible conflict of interest. They’re there to make money for their shareholders—quite right and legitimate—and in doing so, they often create good products that we rely on and need. But they don’t have a legitimate role in the education of doctors.

Yet most doctors still consider rep visits as a normal part of their working week. Outside hospitals, many of the rare opportunities to discuss clinical issues with colleagues are conducted with a pharmaceutical rep in the room gently nudging the discussion back to a brand name.

These muffin-facilitated conversations are reinforced by the branded reminders left behind. Those who insist that doctors are too intelligent to be swayed by cheap gifts forget that pharmaceutical marketers are also intelligent – and have far more carefully researched the science of gift giving.

Gifts create both expectation and obligation. The importance of developing loyalty through gifting cannot be overstated…The essence of pharmaceutical gifting is ‘bribes that aren’t considered bribes’. (Fugh-Berman)

So why do doctors still see reps? GPs interviewed by Prosser et al. suggested the reasons include: education and rapid answers to questions; social interaction and time-out during a busy day; gifts and lunches; medical cultural norms and; peer pressure if colleagues see reps.

Certainly, most reps are personable, tertiary-educated conversationalists, so may provide a pleasant break during a demanding session. They are generally courteous and friendly. But it is not their job to actually be the doctor’s friend in the usual reciprocal sense of the term. Indeed, Fugh-Berman describes their art as ‘finely titrated doses of friendship’.

Doctors tend to think they can ‘sort the wheat from the chaff’, discarding the more biased information and believing only what is more likely to be true.

When Steinman et al. asked doctors how much they thought pharmaceutical reps influenced their prescribing, 61% thought they had no effect, and only 1% thought they had a big effect. Yet when they asked the same doctors how much influence they thoughts reps had on other doctors, the results were remarkably different: only 16% thought they had no effect, and 51% believed they had a large effect!

A paradoxical finding? Well, no – just human nature. Doctors are smart enough to realise pharmaceutical companies owe it to shareholders to ensure the billions spent on reps are recouped through increased prescriptions.

But doctors also know their prescribing decisions should be based on evidence rather than marketing. This mental discordance is resolved by 99% of doctors believing that they are not among the 51% of doctors whom they estimate are influenced. Those must be the other docs!

In the end, does it really matter if pharmaceutical marketing has a large influence on prescription decisions? The drugs still work, right?

The best evidence comes from a 2010 Spurling et al. systematic review of 40 years of published research. It found an association between doctors seeing pharmaceutical reps and increased numbers of prescriptions, more expensive prescriptions and less appropriate choices of drug, which were less likely to follow approved guidelines.

On average, therefore, this points to a distinct disadvantage for patients whose doctor regularly sees reps – in terms of cost and appropriateness of medication.

If I were a patient, I would have more confidence in the quality of my doctor’s prescribing if they did not see drug reps.

I frequently argue this case in the medical media, sometimes to stark opposition from doctors. One such reply earlier this year was:

What have we GPs got to be ashamed about? There will be the odd hysterical article from time to time in the tabloids but the average patient really could not give two hoots.

I beg to differ. Health consumer surveys consistently indicate concerns about promotions influencing doctors’ choice of prescriptions, and in fact are even more likely than their doctors to believe that pharmaceutical gifts are both influential and inappropriate.

Patients do give two hoots, and the Consumer Health Forum of Australia gives even one or two more.

It’s high time we politely encouraged doctors to receive their drug education from independent sources, rather than marketers.

Go to the No Advertising Please campaign website at noadvertisingplease.org to offer your support to doctors who have signed the pledge to not see visiting pharmaceutical reps.


Some examples of misleading promotion of medicines marketed in Australia
(from the Consumers Health Forum statement)

Vioxx: aggressive and misleading promotion played down the risk of heart attacks of pain drug Vioxx[i](rofecoxib) and the manufacturer ultimately paid a fine of almost US$1 billion in the US, including for offences related to illegal marketing of the drug[ii]

Pradaxa: A BMJ investigation recently reported that important safety information was not publicly available about the aggressively marketed anti-coagulant for stroke prevention, Pradaxa (dabigatran)[iii] ; the manufacturer also recently settled litigation in the United States, for US$650 million, relating to allegations the drug caused serious and sometimes fatal bleeding[iv]

Avandia: Its manufacturer faced a record US$3 billion fine in 2012, in part because it failed to report safety data about its heavily promoted type 2 diabetes drug Avandia (rosiglitazone) which was linked to heart problems[v]

Tamiflu: Following several years of campaigning, researchers finally succeeded in obtaining internal company data on the popular flu drug Tamiflu (oseltamivir): evidence showed modest benefits, and risk of side effects, and led researchers to question whether the drug should be stockpiled to fight pandemics[vi]

[i] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1779871/

[ii] http://www.nytimes.com/2011/11/23/business/merck-agrees-to-pay-950-million-in-vioxx-case.html?_r=0

[iii] http://www.bmj.com/investigation/dabigatran

[iv] http://www.nytimes.com/2014/05/29/business/international/german-drug-company-to-pay-650-million-to-settle-blood-thinner-lawsuits.html

[v] http://www.nytimes.com/2012/07/03/business/glaxosmithkline-agrees-to-pay-3-billion-in-fraud-settlement.html?pagewanted=all

[vi] http://www.bmj.com/content/348/bmj.g2545


• Declaration: Melissa Sweet was informally involved in an email network that contributed to the campaign’s development.


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