AMA Journal of Ethics^®

Case

Dr. Sentzer takes pride in keeping her office free of pharmaceutical advertisements. She refuses pens and paper plastered with drug company logos. She does not attend dinners sponsored by pharmaceutical companies, even when they are at her favorite French bistro. And she does not see company representatives—nor accept their free medication samples.

In preparation for her afternoon appointments, Dr. Sentzer reviews the chart for the first patient—Martha Lodge, a 72-year-old woman whom Dr. Sentzer sees regularly. Martha takes several medications but manages them meticulously. She does not welcome changes to this regimen, as it complicates her daily routine and her monthly budget. But she tends to follow Dr. Sentzer’s advice faithfully.

Dr. Sentzer enters the exam room and is greeted by a relieved and grateful smile from Martha. “Thank you for squeezing me in, doctor,” she dives in immediately. “I hate to bother you when I’m doing well, but I really need your help. Do you remember how we changed my blood pressure medicines at my last visit? Because I was—well, you remember—not making it to the bathroom in time? I’m afraid the change didn’t help at all.”

“I’m sorry to hear that, Martha,” replied Dr. Sentzer.

Martha continued: “The exercises are no help either, doctor. I can’t go out with my husband for dinner or with my friends to a movie because if I laugh too hard…. Even at home, sometimes I suddenly need to go, but I can’t always get to the bathroom in time. Can you help me?”

Dr. Sentzer does have a solution, but she knows it is not what Martha wants to hear. “There are medications I could prescribe—to calm down your bladder. They might give you more control. But it would add another medication to your pillbox. And the once-daily pill only comes as a brand name, so it wouldn’t be a cheap addition.”

“Dr. Sentzer,” said Martha, crestfallen, “there really isn’t room in our budget for another brand name drug. Between my husband’s pension and our Social Security, we barely cover our medicines already. Some of my friends say that their doctors give them free samples to cut down their costs. Could I at least start with some samples to see if it works for me?”

The frustration on Martha’s face wins Dr. Sentzer’s sympathy. She does recall turning away a salesman for one of these medicines just last week; he managed to leave his business card, but she refused to accept the free samples that he wanted to leave with her.

Commentary

One must surely pity poor Martha Lodge; she has an overactive bladder, and, like so many others in the US, she has underactive health insurance. And now she has Medicare Part D to deal with—enough to make anyone run for the bathroom. One can also sympathize with Dr. Sentzer; any physician would want to do everything possible to help a patient in such a mess.

But is providing a “free” sample really the solution to Mrs. Lodge’s problem?

It is an interesting phenomenon—and a brilliant marketing coup—that physicians have come to see pharmaceutical samples as bandaids for a broken health care system instead of what they actually are: a hugely successful promotional ploy. Of the billions of dollars spent yearly by the pharmaceutical industry on the marketing of prescription drugs in the United States, over half is spent on samples. And for good reason: as both personal experience and the medical literature attest, once a patient is given a sample, there is a good chance that he or she will be prescribed that medication in the future. Since samples are almost exclusively the newest, most expensive medication, this results in a physician’s ultimately writing a prescription for a specific medication that the patient neither needs nor can afford (think Vioxx, for several years one of the most heavily promoted and heavily sampled medications). If pharmaceutical companies were really concerned about providing medication for patients who lacked prescription drug coverage, rather than merely promoting their products, they might provide vouchers so that these medications could be filled at the pharmacy (in the quantity the patient needed), rather than promotionally packaged samples to be “filled” by the physician.

It is instructive to contrast what happens when a medication is dispensed by a pharmacist with what happens when it falls from a physician’s sample cabinet. In the case of the pharmacist, medications given to customers are labeled with the patient’s name, the date, and dosing information and include printed instructions with information about side effects and interactions. This information is rarely, if ever, provided by the physician when handing out samples. The patient who leaves the doctor’s office with samples is likely to require a shopping bag to carry out a month’s worth of medication. When (and if) she returns in a month for another bagful, that medication may or may not still be in the cabinet. If it is not, she may or may not be given a slightly different medication, until (and if) she returns a month later.

To be fair to industry, almost any medication can be acquired for eligible patients through company-run patient assistance programs. While most physicians have come to see these programs as time-consuming and difficult to use, the Internet has made the information gathering and the application process much easier to negotiate. Several web sites currently make information about these programs more readily accessible [1].

Likewise, more medications are going off patent (as evidenced by the long-acting formulations and enantiomers flooding the market), meaning that cheaper generics will soon be available. Though the Detrol that Martha has most likely seen advertised on TV is not yet available generically, oxybutynin, which is equally effective, is. And Martha might be interested to learn that 1 month’s worth of oxybutynin costs about $20, compared to $120 for a month’s worth of Detrol, though that $100 per month in saving may also come with a drier mouth [2]. There are even now patient assistance programs for obtaining generic medications [3].

It is worth noting that the deluge of direct-to-consumer advertising has probably not helped matters. Martha—whether watching Oprah or the evening news—has probably recently seen an ad for the very medication that is likely to come tumbling down from her doctor’s sample closet. Unsurprisingly, doctors’ cabinets are filled with the same medications that are heavily advertised to consumers. It is possible that Martha didn’t even know she had this condition until she saw the ad on TV. It is very possible that Dr. Sentzer’s next patient—or perhaps Martha, the following week—will be complaining of a restless leg, or an irritable bowel. Industry will say that these ads get people to their doctors and this gets the conditions diagnosed and treated. No doubt there is some truth to this. But the question is, for all these spastic bladders, restless legs, irritable bowels, not to mention flaccid penises, how many “patients” are we creating for each one that we are helping? How many people, who, prior to turning on their TV sets naively believed that they were “well,” have we in fact made ill? This remains an unanswered question.

Dr. Sentzer should be commended for “saying no” to industry inducements and enticements and getting her information from less biased, nonindustry sources. She is doing good for her patients. Doctors often frame the problem as “samples or nothing,” but this is a false choice. There are alternatives; alternatives that in the long run will very likely save patients’ money and perhaps even their lives. Instead of spending so much time defending our right to bear samples (and the lunches that come with them), if we really wanted to advocate for our patients we should be reminding our congressmen and women about all the Martha Lodges out there who have a difficult time paying for their medication. And while we’re at it, remind them that these folks vote!