The journal Farmaindustria1 published a survey of 359 physicians in the Autonomous Community of Madrid (70.5% in primary care) on drug industry representatives' site visits to medical practices. The results show that 81% of the physicians felt these visits to be worthwhile, and that the element they valued most highly was the information provided. Most of those surveyed (97.5%) felt that these encounters should be used to present new therapeutic products. Curiously, when they were questioned about the industry representative´s appearance and manner, the features participants appreciated most highly were physical appearance, ability to establish rapport, and communication skills--which were valued more highly than scientific and technical knowledge, rigor, quality and content of the supporting materials, or scientific expertise.
These rather self-congratulatory results notwithstanding, visits from pharmaceutical industry representatives, and in general all relationships between physicians and the pharmaceutical industry, are currently under debate in Spain and in other countries.2,3 Many believe that patients would benefit if the relationship between prescribers and industry were characterized by a greater degree of detachment.2
Current Spanish legislation, as set forth in Real Decreto 1416/94 on advertising for medications for use in humans, define visits by medical representatives in the following terms: «The visit to a physician by a medical representative is the medium by which a relationship is established between pharmaceutical firms and persons authorized to write prescriptions or dispense drugs, with the aim of informing about and promoting drugs; [the visit is] made by the medical representative, and is based on the communication of appropriate technical information to permit an objective evaluation of the drug's therapeutic usefulness. In due performance of his or her functions the medical representative should promote the appropriate use of drugs.»
Clearly, visits by medical representatives fulfill the goal of promoting drugs, but what is less clear is whether they fulfill the second part of this description. Are these visits built on the communication of technical knowledge? Is the information objective? Is the information useful to prescribers or practitioners who dispense drugs? Do these visits promote the appropriate use of drugs?
The results of the study titled «Good morning Mr. Medical Representative, What's New?» Analysis of Drugs Presented by the Pharmaceutical Industry in a Basic Health Area suggest that these expectations are not being met. Only 6.6% of the products presented were novel, and of these, 71% were considered to provide little or no therapeutic improvement. Moreover, the authors offer another figure that should be cause for reflection: of all products presented, the percentage with high intrinsic pharmacological value was small, and the new products were significantly more expensive than those habitually prescribed at the center.
Another issue to consider, although it was not specifically investigated in this study, is the influence visits by medical representatives can have on prescribing, and hence on the use of medications by patients. One recent study4 found a significant relationship between physicians who had closer contacts with drug industry representatives and a greater willingness to prescribe new drugs, and to yield to patients' unjustified requests for prescriptions. According to the study just published in Atención Primaria, it appears that the information provided during the visits is not useful to physicians in enhancing the appropriate use of drugs.
Another point the study raises and that merits attention is the manner in which visits by medical representatives are organized at the health center. The customary face-to-face encounter (known to be the most effective way to modify prescribing habits) has been replaced with group sessions, to make the encounter more «professional» and less mercantile. Group sessions undoubtedly serve to restrain and filter out certain types of «special treatment» toward the client. These behaviors are a reflection of certain ethical connotations together with the serious problem of pharmaceutical costs. In an earlier editorial published in Atención Primaria, Altisent5 noted that the main problem does not lie with immoral behavior, which occurs in only rare cases, but rather with the confusing environment we are immersed in, and which can undermine relationships of loyalty and trust between physicians and their patients. Headlines in the daily newspapers that read «Pharmaceutical industry to limit gifts to doctors» (El Periódico de Catalunya, July 22, 2003), published after the new code of good professional practice for the pharmaceutical industry was announced, do not inspire trust in the physician-patient relationship.
Because of ethical considerations, visits by medical representatives should be modified to dignify the role of all parties involved, and to improve upon other aspects such as the undue time they take up, and patients' negative perception of these visits. Farmaindustria shares these concerns and has called for these visits to be reorganized in a way that will integrate them into the health care activities of health professionals. Moreover, this group is committed to guaranteeing, on a permanent basis, the quality of these visits as educational opportunities.6
In response to this situation, health authorities have published new regional regulations that include detailed procedures regarding how, where and when medical representatives should meet with doctors, the responsibilities and rights of medical representatives and doctors, and how compliance with regulations should be monitored. However, regulations, codes of conduct, and other guidelines will be futile unless there are changes in certain circumstances that lead inevitably to situations which are often undesired by both parties involved.
The omnipresence of the pharmaceutical industry at scientific congresses, in continuing professional education, in research, in science journals and in scientific societies indicates that something is amiss.3 Health professionals believe that their integrity is immune to the overtures of the pharmaceutical industry, and often justify their relations with industry by citing their educational needs. Administrators, while concerned about the cost of medicines, tolerate these relations to compensate for perpetual budgetary shortages. There is always a pretext to be found to justify the relationship, and this situation makes it difficult to remain free from bias.
Visits by medical representatives need not have negative connotations, but to avoid these connotations, they should fulfill their basic function as opportunities to provide information. The relations between medical representatives and physicians should be clear and transparent, and each party should accept due responsibility for bringing about change.
