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A spoonful of dismissal helps the medicine go down

For many McGill students, the Student Health Services Clinic is an obligatory stop on the way to deferring that final that they were too bedridden to study for. For others, it is a place to renew and seek out prescriptions, or to seek healthcare in a familiar environment within an unfamiliar city.

When I visited McGill Student Health Services a year ago to inquire about oral contraceptives, unsure whether they would be right for me, I encountered no resistance or cautions from physician and director of the Health Centre, Dr. Pierre-Paul Tellier. Perfunctory questions were asked and a prescription was written; a sample was pulled from a drawer and the little rows of pink and white pills stared up at me. After the procedure was explained to me (take one every day, at approximately the same time, and so on) I finally worked up the pluck to voice my concerns. Was Yaz – the brand of pill I had been prescribed – not in the news for increasing the risk of blood clots? How would this affect me? Was my doctor sure that this was the right choice?

The answers from Dr. Tellier were brief: He mentioned that yes, Yaz was in the news, but the media can hype things up; the risk of clots might be increased, but by such a small percentage that it was essentially negligible. Yaz is a low-dose pill, and he assured me that it was best for me. There was no discussion of a change of prescription; there was no allusion to other oral contraceptives being available.

I left the office, my worries hardly alleviated, the samples in my pocket.

In the end, I left the prescription unfilled, and instead went looking for answers about how these prescriptions end up in the hands of students, and how paying our student fees leaves us with only one option.

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Student Health Services certainly hopes to be more than just a producer of medical notes and prescriptions; their mandate lists four objectives that fit into the framework of providing “comprehensive health care to students in an academic setting.” These objectives include “[providing] preventative and curative health care by caregivers that are sensitive to [the student] health group,” “[providing] health education and promotion,” “[providing] training in the field of student health for health care professionals,” and “[gaining] knowledge of [the student] population by fostering research.”

Student health clinics like McGill’s have an incredible reach. In 2011, of McGill’s total enrollment of 37,835, there were 15,999 visitations to the centre. As long as students have paid the student services fee, they have access to Student Health Services. The fact that university health clinics serve such a large and, for the most part, age-specific population not only makes it difficult for students to secure appointments, but also makes the centres themselves an ideal target for companies that have a financial interest in the health needs of the young adult demographic.

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Pharmaceutical giants, such as Pfizer, Eli Lilly, and GlaxoSmithKline exist to research, develop, produce, and then market medicines and vaccines. When it comes time to sell their products, these corporations rely almost exclusively on pharmaceutical sales representatives, colloquially known as drug reps, to get the job done. Drug reps have gotten a lot of press in the past few years, resulting in a new public awareness of how the reps operate.

The primary difference between drug reps and most other salespeople is this: they woo the doctors, not the patients. In other words, drug companies and drug reps don’t have to sell their product to the individual who will be consuming, so much as they have to sell it to the individual advocating its use. In order to win new customers and reward the loyal, drug reps are known to lavish health care providers with gifts and rewards. In his 2006 article for the Atlantic, Carl Elliot wrote that he had heard “reps talk about scoring sports tickets for their favourite doctors, buying televisions for waiting rooms, and arranging junkets to tropical resorts.”

Because patients respect and trust their advocators – their physicians – these physicians are the only ones that need to be convinced about the quality of a certain medication. In a university setting, this means convincing only a few physicians, instead of thousands of students. The imbalance of power in this relationship can be dangerous. Physicians control knowledge – they can prescribe one medication without relaying other options, or restrict a patient’s understanding of their own condition in order to make one medication appear better than others. Add in an economic incentive to push one drug over another, and the risk of physicians abusing the trust of their patients increases exponentially.

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The uproar over fraudulent and unethical practices in the pharmaceutical sales industry has led to increased regulations, in an attempt to protect healthcare professionals (and by extension, their patients) from unethical external influence. The Pharmaceutical Research and Manufacturers of America (PhRMA) updated their existing Code on Interactions With Healthcare Professionals in January 2009, “to reinforce [their] intention that [their] interactions with healthcare professionals are professional exchanges designed to benefit patients and to enhance the practice of medicine,” according to the website. Changes to this code include prohibiting drug reps from providing restaurant meals to physicians, though “occasional meals in healthcare professionals’ offices in conjunction with informational presentations” are still permitted.

There have also been shifts in some physicians’ attitudes towards drug reps. In August, the Pharma Letter, an online news source focused on the pharmaceutical and biotechnology industries, wrote that oncologists (medical professionals who work with cancer patients) were “reducing the number of times they [would] see [pharmaceutical sales reps].” Of twenty common medical specialties measured in the spring 2012 AccessMonitor sales and marketing report, 61 per cent of US oncologists had placed restrictions on drug rep visits, making oncology the most restrictive specialty by far. Other areas of medicine, including primary care, were less restrictive.

In Canada, the total number of drug reps, and the amount of money spent on drug marketing, is lower than in the U.S., though still substantial. A 2004 McGill Journal of Medicine article by Joseph Barfett et al estimated that drug companies spend $1.7 billion a year in Canada to promote their products, compared to $21 billion in the United States. In addition, a 2010 Health Council of Canada Report titled “Decisions, Decisions” estimated that there are 6,000 drug firm reps pitching to physicians across Canada.

But for all their ubiquity and effort, do pharmaceutical reps truly influence the medicine that is practiced by physicians? “Decisions, Decisions” seemed to think so, pointing to pharmaceutical sales reps and unfamiliarity with new technologies as the main reasons for improper administration of prescription drugs. The report noted an 80 per cent increase in prescriptions filled in the past decade.

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University student health centres claim to be tough on drug reps. Dr. Tellier, stated in an email to The Daily that a pharmaceutical sales representative was allowed to speak with physicians twice, in both instances to educate the centre’s staff about a “product of importance to the student population.”  Reception of the sales representative is, as in private practice, the choice of the physician. “There are some physicians who will never see pharmaceutical reps and we respect that decision,” said Tellier.

Tellier also explained that relevance to the student population is a factor when deciding whether or not to grant drug reps an audience with physicians, explaining that “a sales rep who tries to detail an antihypertensive or cardiac medication, both of which do not apply to the great majority of our population, [is] banned.” When what the drug reps are offering aligns with the needs of the health centre, however, the centre is more willing to accept the representative’s offer. Tellier stated that the most commonly prescribed medications in his work at the McGill Health Services include “contraceptive pills…medication to treat yeast infections in women, and oral antibiotics.” Perhaps it is no surprise, then, that “the representatives [they] most often see are those who offer birth control pills, and vaccines.”

Tellier conceded that “all companies approach [Student Health Services,]” and Dr. Robert Franck, director of McGill Mental Health Services, stated that “no one company predominates,” adding that “reps are usually interested in promoting newer (and usually much more expensive) versions of medications.”

Yet not all Canadian university health centre’s function like McGill’s. At one university health centre in Ontario, where more than 21,000 students were seen last year, most physicians do not see drug reps by choice. The representative of this health centre requested that I keep the university anonymous, so as to prevent information from being obtained by interested pharmaceutical companies. Clearly, interest in university health clinics runs high.

After a few phone calls with various pharmaceutical companies, Pfizer Canada was the only one to eventually respond by email. Julie-Catherine Racine, a senior manager in Corporate Communications at Pfizer Canada, stated, “As a healthcare company we want to ensure physicians can make the best decisions for their patients, therefore we provide medical information and support to all clinics, including university health clinics.” Racine’s answer was the only comment I received from any of the companies contacted.

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University health centres may profess to be free of drug reps’ influence, appearing to avoid them whenever possible, but the most indispensible tool in the drug reps’ arsenal – the drug sample – lives on in university physicians’ desk drawers and cupboards. Franck stated, “Pharmaceutical sales reps will leave samples from time to time,” and added, however, that they “usually do not use them except in cases of financial need.” Tellier also told The Daily that samples at McGill Student Health Services came from clearing excess stock and direct purchases, in addition to pharmaceutical representatives. As for the aforementioned anonymous university health centre, a representative stated that “[they] do not have a great deal of sample medications in [the] clinic.” However, the few that are available are, naturally, “provided by the pharmaceutical industry.”

Why are samples so important? In the case of oral contraceptives, at the very least, Tellier concedes that he prescribes the medication that is provided as a sample. “I use a sample to teach the patient how to take her pill – this changes according to the packaging – and then I will usually prescribe that medication.” Indeed, a 2008 study by Sufrin and Ross, titled “Pharmaceutical industry marketing: understanding its impact on women’s health” found that physicians with access to free samples were more likely to prescribe brand name medication.

But keeping corporate interests at bay is not sufficient to ensure effective and unbiased prescribing practices. All of the student health centre representatives I spoke to seemed to agree on one thing: that compliance on the part of the patient was necessary in the process of successfully introducing and prescribing a new medication. To that end, each of them stressed that they did not have preferred medications, for the most part, and would be willing to provide a suitable alternative should the patient express doubts about the primary medication chosen. This, of course, is good medical practice. However, this was not my personal experience. When my concerns should have been responded to properly, I still left compliant, samples in hand.

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While it appears that doctors in university health clinics attempt to keep their prescribing practices independent from the pharmaceutical companies that solicit them, those practices are evidently still far from ideal. Perhaps it is difficult to offer one brand of medication when another brand’s sample is sitting right there, available for immediate demonstration and use.

Of course, all medications have side effects, and the choice of the media to fixate on a single brand’s detriments certainly does not make other brands safer – either in general or for the patient in question. But even given the possible risks associated with all prescriptions, patients should have the ability to choose the risks they find most acceptable.

The student population’s health and well-being should not be tied to commercial and financial corporate interests, and as physicians, the doctors in these health centres are the gatekeepers – the only gatekeepers – that can prevent this from happening. But simply shutting out drug reps is not the only step in giving the right prescriptions and in providing proper healthcare. Students certainly have a part to play – they should take control over their health and question the medications they are prescribed – but physicians are ultimately the ones with the power to listen, to consider, and to justify their patient’s trust.