Comments on my piece on regulating drug promotion

I thank Dr Ken Harvey very much for his comments, which you can read here (I haven't been able to figure out how to get Blogger to post comments with the original). I would also urge readers to follow some of the links Ken has provided and check out the evidence for themslves.

If you read my piece carefully, I don't actually argue that doctors are not influenced by the promotional activities of pharmaceutical companies. Of course, they are also influenced by their cultural backgrounds and religious beliefs, what medical school they went to, their patients, what they read in the newspapers as well as in the medical journals, what their colleagues tell them in the tea-room (evidence-based or not!), and whether they had time for breakfast and have had that all-important first cup of coffee yet (sponsored or not!). But I don't hear people clamouring for the ACCC to investigate the effects of each of these - and their interactive effects - on prescribing behaviour.

In the course of interviewing hundreds of GPs and specialists about influences on their clinical decision-making, I have been utterly flabbergasted at some prescribing practices that clearly owe nothing to company promotion (let alone any sort of logic). Of course doctors deny that they are influenced by promotion - from Federal Court judges and competition commissioners to mug punters at the local TAB, we all like to think of ourselves as rational decision-makers, but it's just not the case. But I've seen numerous product managers squirm when they hear the news that doctors can't recall the quirky brand name, thought it was only approved for a different indication, still prescribe the old one out of habit, etc. etc.

Anyway, I don't argue that there is no influence. But I will continue to argue most strenuously with those who make a giant non sequitur, leaping from the question of influence to the conclusion that this harms patients or community health or welfare. For example, the ACA says sales reps should be externally regulated because “representatives attempt to influence doctors’ prescribing patterns in non-rational ways which have negative outcomes for consumers”. This single, unreferenced, sentence paints the sales rep as deceptive, the doctor as potentially irrational and the consumer as unwitting victim. The Medicines Australia code mandates reference support for claims about drugs, but there is clearly no such code for the ideologue!

And speaking of influence, consider some of the incredibly emotive language used by Graeme Samuel in his opinion piece in today's Melbourne Age. At first, he reserves judgement and concentrates on transparency: "Regardless of whether such largesse actually influences a doctor or not... the perception of influence is enough". But, just when we think he's keeping an open mind, CLANG! the cell door closes: "Doctors prescribing medication based on anything other than the patient's needs offends the morals" and these are "grubby issues" and "an unpleasant stain" (presumably the remains of one of the "lavish dinners" at "top-class restaurants"). In other words, we’re not saying it happens, but it’s disgusting and we’re going to act anyway!

Finally, while we're on the subject of the difference between rational and emotional persuasive appeals, both Ken Harvey and the ACA played "the tobacco card" in their submissions to the ACCC. The ACA actually said "a parallel can be drawn between the methods employed by the pharmaceutical industry now and those that were employed by the tobacco industry" - you can read this outrageous quote for yourself here.

ACCC prescribes castor oil for greedy doctors

Doctors – supposedly the “victims” of the pharmaceutical industry's promotional excesses and "sophisticated" persuasive techniques – will be the biggest losers under new requirements of the Australian Competition and Consumer Commission (ACCC) for greater levels of disclosure and transparency in relation to pharmaceutical company sponsorship, announced yesterday. (The ACCC authorises the industry self-regulatory code developed and administered by Medicines Australia.)

In fact, pharmaceutical marketers may actually benefit from closer public and regulatory scrutiny of their spending on entertainment for doctors, but doctors will be further disadvantaged if sponsorship of prescriber education is reduced as a consequence. But the bottom line is that the changes are likely to have no discernible effect on the health and welfare of consumers and the community as a whole.

There have certainly been some excesses in terms of pharmaceutical entertainment and largesse in the past... and I've been to some fairly lavish affairs put on by drug companies (and usually wound up asking myself why they were bothering). But, from a marketing perspective, many promotional practices viewed in the pharmaceutical industry as ‘the usual’ or ‘cost of entry’ are actually undertaken without any evidence of their marketing effectiveness.

Just because companies do something doesn’t mean it works... or, indeed, that it is harmful to the health of individuals or the community. Many of those urging the ACCC to impose tighter controls on the activities of pharmaceutical companies don’t cite any evidence that promotion actually has harmful effects on the attitudes or behaviour of prescribers.

In many cases, it's possible that cutting back on largesse might actually enhance pharmaceutical company profitability by reducing wastage. Drug companies should be ensuring that they invest their marketing dollars where they will be most effective. In the spirit of value-based marketing, the industry should probably look at this new requirement for transparency as an opportunity – it may well force greater internal scrutiny and justification of some of the "traditional" lines on their marketing and promotional budgets.

But the whole issue of further regulation leaves a bitter taste for doctors. Firstly, any increase in scrutiny inevitably raises implications about the perceived intelligence and integrity of prescribers. This type of regulation sends an unequivocal signal to the community that the ACCC feels doctors cannot be trusted to evaluate clinical and scientific evidence for themselves or, at worst, to behave ethically when selecting treatments.

The underlying message is that the regulator we trust to protect us as consumers – egged on by lobbyists such as the Australian Consumers Association (ACA) – believes that a doctor might put his or her own interests ahead of those of the patient for the price of a restaurant meal and half a bottle of wine. If you think I'm being melodramatic, check this out... In a submission to the ACCC, Prof Ken Harvey of La Trobe University argues for tougher regulation of pharmaceutical promotion not on the basis of evidence but on the astonishing assertion that pharmaceuticals are like tobacco and alcohol, and that any “highly profitable industries which spends (sic) a large proportion of their earnings on sophisticated promotion all encourage overconsumption and unhealthy habits”.

Secondly, prescribers are still expected to act as agents and "gatekeepers" for the Government in administering the Pharmaceutical Benefits Scheme (PBS), a role for which they are completely unremunerated, while what minor compensations there might be for undertaking this role are whittled away.

The PBS is a massive program under which Australian consumers get extraordinary access to the world’s best and latest drugs. Yet doctors are expected to spend their own time and resources keeping themselves up to date with the intricacies and fine print of PBS listings, which change every three months. Even the most strident advocates of centralised regulation of pharmaceutical promotion acknowledge the reality that doctors remain reliant on the pharmaceutical industry for information about new drugs and changes to PBS listings and requirements.

QBrand's own experience conducting research with hundreds of GPs and specialists confirms that doctors take this gatekeeping role extremely seriously if grudgingly. Yet in no other sector of Australian society would professionals be expected to fulfil such an agency role without some form of consideration or compensation... like the occasional dinner and a drink!

Naming rights: If you can't lick 'em...

We're pretty accustomed now to various stadiums, events and sporting teams carrying sponsors' names. There's Colonial Stadium, now the Telstra Dome; the Marlboro/Ford/Kia Australian Open tennis; the Foster's/Emirates Melbourne Cup (and even the year when - horror of horrors - Toohey's New, a beer from north of the border, had the naming rights). The Collingwood Football Club is now based at the Lexus Centre - no longer Victoria Park. And in the recent World Cup (Germany 2006), we even had the Qantas Socceroos.

But what about naming rights to public spaces? I was surprised recently to find that one feature of Brisbane's very attractive Southbank recreation precinct is an appealing (if artificial) kids' swimming area (pictured here) with a white sandy foreshore and even its own lifeguards... for which naming rights have been sold. Yes, the signs, banners, etc. proclaim that it is Streets Beach (Streets as in the Unilever ice cream brand - the Australian equivalent of Good Humor, for readers in some other markets).

If it's OK - in the name of philanthropy - for commercial interests to sponsor galleries, or to endow chairs at universities, then why was my initial reaction to Streets Beach one of some discomfort?

Perhaps it's just an emotional response to Unilever's relatively blatant, undisguised intent to link an indulgent product so obviously targeted towards children to a public activity and resource provided for children. On the other hand, on a purely rational basis, I can't really see why this should be any more objectionable than linking a cultural institution like the Melbourne Cup to a beer brand.

And I guess if I were marketing manager for Streets, it might have seemed like an attractive opportunity. As ever, though, I'd be very interested to look at the return on investment. In my experience, even the largest corporations seldom measure the real effects and cost-benefit of this type of sponsorship with any degree of spohistication.

Which bank creeps out its customers?

Number 3 in a series reporting bizarre customer service encounters at my local branch:

Back in March this year, the Commonwealth Bank announced a "new strategic direction focussed on customer service". What I'm seeing at my branch, however, appear to be some very un-focussed and, frankly, downright weird manifestations of that strategy.

I went to bank a cheque the other day. When the teller brought up my account details on screen (where I couldn't see them), he peered at them then smiled at me and asked: "How's your home loan?". Perhaps this was simply meant to be a friendly enquiry or, more likely, a clumsy introduction to some kind of "up-sell" (e.g. "Can I make an appointment for you to talk to one of our lending advisers?"), but I found it disquieting. It's like going to the doctor with a cold and having him/her look you up and down and ask "How's your liver?". My natural reaction: Why are you asking? Do you know something I don't? Have I turned yellow since I last looked in the mirror? etc.

Am I just being paranoid? I don't think so. I actually appreciate "Do you want fries with that?" customer service scripts when they are contextually appropriate! Unfortunately, when the context and delivery are inappropriate, the effect is invasive and creepy. Another example of the Commonwealth stalking its own customers!