Markian Hawryluk, a reporter for The (Bend, OR) Bulletin—circulation 32,455— has written one of the best pieces I’ve seen in a long time about the ties between the nation’s doctors and the pharmaceutical makers that push the medicines we take. The myriad ways drug companies influence doctors has been well known in health policy circles for years. ProPublica has contributed to a growing body of knowledge about how drug companies operate with its disclosures of physician fees, conflicts of interests, and names of docs who even prescribe harmful drugs. Hawryluk’s piece, however, reaches ordinary folks in ways that I haven’t seen before, and shows what a small, rural newspaper—the kind that still makes money and enjoys high readership—can do for its community. Hawryluk’s story, a model for both journalists and physicians, deserves a CJR laurel.
The piece is approachable from the lede to the kicker—no wonk stuff or zillions of documents to click through. It is smooth and interesting, thanks to fine reporting and narrative writing, along with good editing. Readers get good, simple explanations of how drug selling works, its insidious effect on physicians whom the literature shows tend to prescribe what the last rep pitches, and how this practice hooks consumers on medicines that are most profitable for the bottom line but may not be the best for them.
I particularly liked how Hawryluk described a not-so-well-known business of the American Medical Association (AMA) that aids drug companies in their sales efforts. Not well known by the public, that is. Drug companies buy prescribing information from health information companies that have purchased de-identified records from pharmacies about the drugs we all take. Drug companies then match each of our records with the doctors’ prescriber numbers sold to them by the AMA. Thus, what each doc prescribes makes its way into the sales pitches delivered in doctors’ offices. If docs are not prescribing what pharmaceutical reps want them to sell, the reps try to change their prescribing patterns. The little gifts they leave—the note pads with Cialis or Lipitor on them or the pens sporting drug company logos—remind harried docs come prescription-writing time. Hawryluk characterized the process this way: “Doctors are categorized by drug reps into percentile groups based on their prescribing volume and given colorful monikers such as high-prescriber, spreader, mercenary or sample-grabber.” These labels allow the sales people to fashion just the right pitch for individual doctors.
The paper’s story began with an engaging lede about how docs at the rural Madras Medical Group (about an hour north of Bend) had become wary of drug reps and had considered banning them. Still, they doubted that was the right move. Then came a sumptuous meal, complete with butter shaped into fancy curlicues, hosted by a drug rep who was doing a little “educating” about his company’s latest brand name drug. The dinner “was really something,” one doctor recalled. “That sort of pushed us over the edge.” The meal, combined with the fact that drug reps were by then visiting the small clinic at a pace of “several per day,” as Dr. David Evans told the paper, made the medical group, as Evans said, “start to think a little more. What is this about? It just doesn’t feel right.”
The story takes the reader along the road the doctors at the clinic traveled to end the drug rep visits at the beginning of 2006. It wasn’t easy and often there were conflicts. They worried that the samples the salesmen and women left would dry up, and they wouldn’t have any free medicines to give patients who couldn’t afford to buy them. As it turned out, giving them free samples was not the best idea. Once patients got used to a free-sample medication and then had to buy it on their own, price became a barrier. Hawryluk checked the literature and quoted one study from the University of Chicago that found patients who received samples paid between $212 and $244 a month on average for medicines compared with $168 for those who did not receive samples. Why? Docs usually prescribed the expensive brand drugs pushed by the drug reps and once patients became accustomed to a drug, they were reluctant to switch them to cheaper generics. Judy Carroll, a nurse at the Madras clinic, told the paper, “Truthfully, the pharmacy reps don’t leave anything that’s useful to our patients. It’s the expensive stuff that no one in this area can afford.”
Finally, the doctors tired of asking the drug reps whether their drug was covered by Oregon’s Medicaid program. “We got tired of hearing people say, ‘No, but it’s covered by Blue Cross.’” In 2004, the withdrawal from the market of Vioxx, a popular anti-inflammatory drug heavily promoted by the industry with help from the press, pushed the clinic to its final decision. The drug, as CJR wrote in 2005, caused 61,000 fatal heart attacks and thousands of non-fatal heart attacks before it was withdrawn. We concluded the Vioxx saga was not the media’s finest hour.
The Bulletin’s story shows how the press can redeem itself. It can and should reveal the dark side of the drug industry.
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