Renee Rulin, Medical Director at Commonwealth Care Alliance and a clinical professor of family medicine at Brown University, talked to PostScript about the way pharmaceutical companies affected her days in private practice, and the work CCA is doing now.  She says that just showing up is often the biggest weapon in a drug reps arsenal.

PS: As medical director of Commonwealth Care Alliance, how does pharmaceutical marketing influence the work you do?

RR: Well, as vendors for Medicare and Medicaid, we have a pretty standard formulary, and we negotiate with the drug companies through our Pharmacy Benefit Manager.  So the pharmaceutical companies interact with our PBM, who then selects drugs for the CCA formulary based on our requests.  But a lot of times the way drugs are “bundled” by pharmaceutical companies creates a formulary based more on cost than clinical relevance. 

Despite this, our formulary is broad and follows our philosophy of giving all the authority and decision making back to the doctor, who does the best job of patient care.  We want to get the doctors free to do what they do best.  We really try to get out of the way.

PS: So do doctors make their own decisions about drug reps, or does CCA have a policy?

RR: CCA does not have such a policy.  Our docs make their own decisions.

PS: As a physician and a professor now at Brown, have you seen any shift in how the pharmaceutical companies operate throughout your training and teaching?

RR: Over time, AMCs have really tried to keep Pharma out.  Faculty have begun to see the magnitude of influence they exert in teaching hospitals and in the wards, and are making efforts to replace drug rep visits and CME with real teaching, evidence-based teaching.

But when I was in private practice, every pen was from a drug company, every post-it note.  And that’s true in every private practice, you always end up in a negotiated relationship with the drug reps.

PS: In every practice?  What do you mean by a negotiated relationship?

RR: They would just show up constantly–constantly.  They just sail in, sweet talk the receptionist.  “Can I see the doctor?”  You try to restrict them as much as possible, but they bring lunch for your staff, chocolate chip cookies, and the samples, of course.  I mean, it’s like a gift to have some one show up and  tell you something you want to and need to  know, on your schedule. 

They are generally attractive, well-dressed, and articulate and mostly they are there, willing to talk to you whenever you have a minute.  And all of that is very attractive.  So you sort of delude yourself, saying you’ll pull out those nuggets of information you can use and ignore the marketing.  And it is, it’s a delusion.

Frankly, the docs tend to like that conversation; they like to hear from drug reps.  I think that if academics could counter-detail in the very same way–to really meet docs where they are–they’d do very well.

PS: So when it comes to Academic Medical Centers, you mentioned you see somewhat of a turning tide.

RR: Yes.  They are much more conscientious about keeping out the drug representatives—all the time. 

For instance, the Family Care Center at Memorial Hospital (Brown Family Medicine Residency training program) does not allow pharmaceutical reps into the clinic.

PS: Did you have any particular interactions with drug reps that stand out?

RR: I was no longer a resident, I was a clinical precept, but the reps brought in a lasagna for the whole teaching hospital and gave half of all family medicine residents salmonella.  Half the staff couldn’t work for two months.

Then there are docs that say, “I read the Medical Letter, and I let the drug reps in.”  And I think there are probably people who do that—who get their information independently, take their food and free samples, maybe argue with them.  But I think they are the exception, not the rule. 

PS: So beyond the Medical Letter, are there other good alternatives to detailing out there?

RR: Yes, I think that information is out there: online, in organized courses, in publications such as the Medical Letter.  The thing about drug reps is they just show up, and they have goodies.  And it’s tough to push back against that, it just is.