American College of Physicians: Internal Medicine — Doctors for Adults ®

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Letters

From the October ACP Observer, copyright 2003 by the American College of Physicians.

Errors

We read with great interest the steps outlined to prevent errors in medical practice. ("Seven simple steps to prevent outpatient drug errors," June ACP Observer.)

Several studies suggest that about one-third of adverse drug events are associated with medication errors and are thus preventable.

As many as 56% of these are caused by errors in writing orders. A good computer program for order entry at our New York City University affiliated teaching hospital has almost excluded all these potential drug errors. We have eliminated the errors caused by handwriting, while the computer program already has different dose and frequency options that we just need to click on.

Our computers are linked to Micromedex via computer, so we can check dosages and dose calculations as needed. The computer does not allow us to write a prescription for a patient unless the allergies are documented—and in case of allergy, we cannot proceed. Potential decimal errors are avoided automatically.

In the hospital, pharmacists and nurses do not accept verbal orders. The pharmacist can identify the prescribing physician on the computer-generated prescription and, when in doubt, can confirm the dose and/or medication with the prescribing physician.

The Institute of Medicine report on medical errors in 1999 suggested that 44,000 to 98,000 people die in hospitals each year as a result of medical errors. If we are preventing most of these errors by our system here, then it is worthwhile to implement such systems nationwide.

Zahra S. Sheikh, MD, MPH
Shobhana A. Chaudhari, ACP Member
New York

Drug detailing

Your article cites the statistic that the pharmaceutical industry has recently "more than doubled its sales force from roughly 41,000 ... to 87,000." ("Too close for comfort? How some physicians are re-examining their dealings with drug detailers," July/August ACP Observer.) Another statistic that might be of interest is the increase in prime time advertising, marketing in periodicals and other methods of spurring patients to request higher priced medicines on the premise that more expensive drugs might be "better."

Your article made no mention of the effect this ramped-up marketing blitz has inflicted on the cost of medicine—even though it is well recognized that the cost of prescription medications is a significant part of this country's health care expenses. Many middle-class wage earners as well as income-limited seniors are finding it increasingly difficult to pay for rising medicine costs.

I am old enough to remember a time when a doctor could make a prescribing decision based on the clinical indications and merits of a particular drug, and nightly television programs were not peppered with commercials encouraging us to "ask our doctor" for a plethora of medicines. Many of us still rely on evidence-base methods and are able to take care of our patients without the influence of detailers.

It is harder, however, to avoid the influence on the patient himself due to the advertising mechanisms cited above. The result is a time-consuming process of explaining why the "new and improved" purple pill is not better than the white pill. I would agree with all of the clinical and conflict of interest reasons cited in your article. I also think our system would benefit economically if the drug reps and the advertising blitzes were eliminated entirely.

Frank E. Mott, FACP
Temple, Texas

I find it hard to believe that the profession, the government or anyone else thinks it is wrong for drug companies to try to influence the sales of their products by "feathering" the nest of physicians.

Isn't that the American way? Every time I turn on a golf tournament, all the golfers wear advertisements. Baseball players, football players, movie stars, retired presidents—they all get paid to push some product. All those dollars spent run up the cost to consumers. How is that different from drug companies buying expensive meals?

I hope ACP Observer will stay away from this topic and try to instead find some help in getting us paid at a fair rate.

C. R. Barksdale, ACP Member
Montgomery, Ala.

Your article nicely summarized some of the ethical and economic implications that surround the interactions between physicians and the pharmaceutical industry. What you did not address was how health care institutions, such as hospitals, are proceeding through this ethical minefield.

Our hospital recognized that some aspects of our relationship with pharmaceutical representatives are collaborative. Unrestricted funding for lunches and educational conferences provides, with proper oversight, learning opportunities.

Sample programs allow our indigent clinics to provide patients with essential medications. And several representatives have even made special efforts to acquire grants and samples for missionary trips taken by our nurses and physicians.

At the same time, some aggressive drug representatives paid unsolicited visits to our housestaff in their havens of learning and relaxation—the medical library, resident call quarters and cafeteria. Other representatives subtly undermined our hospital drug formulary through conversations with the hospitals' health care providers.

Drug reps sometimes distributed direct-to-consumer literature and fliers in patient care areas—perhaps persuading patients, sitting in our own waiting room, that our hospitals were not allowing them access to the best medication. And drug reps were found bending the ears of surgeons and other proceduralists during surgeries and procedures.

Most drug reps are decent people just doing their jobs. Unfortunately, the rogue behavior of a few of their colleagues compelled us to fashion a policy that attempts to minimize the negative aspects without sacrificing the positive aspects of our interface with the pharmaceutical industry.

Pharmaceutical reps must sign-in and sign-out in the pharmacy each time they visit the campus for business purposes. Pharmaceutical promotion is prohibited in patient care areas, the physicians' lounge, the cafeteria, the medical library and the housestaff call quarters.

All material posted within the campus confines must be pre-approved by the pharmacy. Formulary drugs may not be counter-detailed for nonformulary uses and nonformulary items may not be promoted at all on hospital grounds.

Pharmaceutical reps may not attend procedures. The policy outlines specific means for monitoring compliance with and enforcement of the policy, as well as specific consequences—including a permanent ban from our campuses. Representatives and their supervisors are required to sign a contract agreeing to abide by the stipulations contained in this policy in order to maintain privileges at our hospitals.

We chose to exempt the resident clinics from the policy. Learning how to interact with the pharmaceutical industry is essential, and what better venue for housestaff to acquire this skill than under the auspices of the teaching faculty?

Each institution must define its relationship with the pharmaceutical industry, in order to safeguard its physicians-in-training and needy patients without ignoring its fiscal bottom line. Adoption of a formal policy with the endorsement of all affected individuals—physicians, nurses, pharmacists, administrators and educators—goes a long way towards meeting that goal.

Michael W. Rich, FACP
Akron, Ohio

The responsibility for professional behavior lies squarely with the profession and we cannot blame industry or advertisers.

The College has issued guidelines that are mentioned in the article. Arguably, the most comprehensive and specific guidelines were published by the AMA in 1990 and have been revised since. Opinion 8.061 in the AMA's "Code of Medical Ethics" represents the latest iteration and is the standard to which many licensure boards and courts refer.

I wonder whether the omission of a reference to the AMA opinion is itself evidence of subtle bias in an article published by an organization with its own set of guidelines.

It is the responsibility of both individual physicians and medical organizations to be aware of these efforts at professional self-regulation and, absent a publicly disclosed reason not to do, endorse and follow them.

Herbert Rakatansky, FACP
Providence, R.I.

I am amazed at my colleagues' continued denial of the influence of drug detailers. How intelligent, well-educated, scientifically-minded professionals can claim they are unaffected by the $13.2 billion the pharmaceutical industry spends on physician marketing each year is beyond my comprehension. Do physicians think these companies are fools who love to waste their money?

The most recent egregious example of the impact of this marketing is AstraZeneca's success in getting a 20% market share of the proton pump inhibitor (PPI) market for esomeprazole (Nexium). When Prilosec, a $4 billion product, went generic, you would have expected AstraZeneca to see a significant drop in earnings. Instead, the company's earnings are up $1.9 billion.

Why? Because it has managed to convince physicians (under some pressure from patients asking for "the purple pill") to write Nexium for one in five PPI prescriptions. While there may be a few patients who need a specific PPI like Nexium, clearly it's not 20% or even close to it.

I encourage any of my colleagues who can explain AstraZeneca's success without admitting the powerful pull of pharmaceutical marketing on physicians' behavior to respond to this letter. Otherwise, let's get our heads out of the sand and recognize that we're like all other American consumers: powerfully influenced by advertising, detailing or whatever you want to call it.

Edwin M. Montell, ACP Member
Hilo, Hawaii

Key contact award

Thank you for the very flattering article about my winning the Key Contact Award this year. ("One internist takes her advocacy efforts on the road," July/August ACP Observer.) It was an exciting night and an honor of which I am very proud.

Having said that, I need to acknowledge my colleagues in South Carolina who contributed to my receiving the award. First, I would like to thank the Governor for our chapter, William N. Boulware, FACP, for his guidance and support.

Next, I want to thank my colleagues who took the time and energy away from their families and practices to travel by car to Washington: Kimberly S. Davis, FACP, chair of the chapter's membership committee; Raymond M. ("Mac") Chapman, ACP Member, chapter treasurer; and Mary E. Poston, ACP Member, who assists the chair of the chapter's Associates committee.

Finally, I want to acknowledge the chapter's entire Governor's Council. Over the years, each of the council members has become an example of advocacy to us all, helping to change policies in favor of our patients through their contacts with policy stakeholders.

While I appreciated the article, I wanted to make sure it was noted that the award was not received in a vacuum. I received this award because I was able to stand with my committed colleagues from South Carolina.

Dawn E. Clancy, FACP
Johns Island, S.C.

Health care reform

Since our present health care system is facing bankruptcy, drastic changes are necessary. Medicare, Medicaid and other programs should be replaced by a federal program for the underserved, which would include all citizens with an annual income of less than $40,000. Legal immigrants would also become eligible. Professional organizations could negotiate equitable fee schedules. Insurance reform could become available for the remaining population. Competition would determine professional fees.

In order to prepare students to become doctors, reform should be considered for medical schools: biochemistry-pharmacology and microbiology should be pre-med courses; anatomy and pathology should be combined, along with physiology and physical and laboratory diagnosis, as the pre-clinical year; and the last two clinical years should be changed to a rotating internship. This preparation should lead to better career choices.

Admissions should be aimed at those students who recognize that medicine is a lofty, difficult and demanding profession. Applicants must be committed to at least 25 years of work and study.

Lastly, American medicine must educate its own doctors. It is unfair to steal the best doctors from impoverished countries.

O. Roger Hollan, FACP
San Antonio

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