“Medicine is a field where new discoveries are made and new developments occur almost on a daily basis. The doctors have to be regularly updated on new drugs or other new treatment methods available. Continued professional development means that every doctor should endeavour to be updated so that the patients will benefit from recent advances in medicine. Regular reading of at least the major medical journals, attending seminars at home or abroad are essential for this purpose.”____________________________
by Dr. Sarath Gamini de Silva
(April 05, Colombo, Sri Lanka Guardian) A public debate is going on at present on the interaction between the medical profession and the pharmaceutical industry. Claims have been made that these two groups have an unholy alliance to the detriment of the patients’ interests. Often wild allegations about the doctors prescribing expensive drugs to support the industry as well as the latter bribing the doctors with gifts and foreign trips etc. are commonplace in the local press. The recent cry for the doctors to use only generic names stems from this allegation. It is time that this situation is looked into objectively without any bias.
The pharmaceutical industry supplies the most important item in the armoury of a medical practitioner, the drugs. They are responsible for developing effective drugs, storing and delivering them properly to preserve their effectiveness and making them available to the public. Hence it is not surprising, and indeed it is desirable, that the doctors have a close association with the pharmaceutical firms. However, any conflict of interest has to be avoided as the doctors’ main concern should be the welfare of the patients while the industry is naturally concerned with making profits. Unlike in other business ventures, the patient (customer) is compelled to buy only what the doctor (salesman) prescribes. Hence the survival of the industry depends solely on the prescription habits of the doctor. Thus the stage is set for the doctor to be influenced in various ways by the pharmaceutical industry.
Medicine is a field where new discoveries are made and new developments occur almost on a daily basis. The doctors have to be regularly updated on new drugs or other new treatment methods available. Continued professional development means that every doctor should endeavour to be updated so that the patients will benefit from recent advances in medicine. Regular reading of at least the major medical journals, attending seminars at home or abroad are essential for this purpose. The local professional colleges and the Sri Lanka Medical Association organise conferences, lectures and workshops to ensure that the membership is kept informed. However, for various reasons, many of these activities take place in the main teaching centres in the country. Those serving in the periphery are left behind. They find it near impossible to attend these due to inability to get leave, and difficulties or the expenses involved in travelling. They are to a limited extent helped by educational material- mailed to them periodically by the colleges.
In other countries like the U.K. and in neighbouring India, many incentives are given to the doctors by the employers to develop professionally. In fact it is considered to be the responsibility of every employer to provide facilities for such activity. These take the form of duty leave and travelling expenses to attend conferences, financial support to buy books or to subscribe to the journals. Tax relief is granted for educational expenses.
Sri Lanka is a third world country, managing with difficulty to provide a free health service to its masses. The government finds it beyond its means to provide educational facilities to its doctors. The annual grant the hospitals are given by the department of health for the purchase of books is negligible considering the high cost of medical books and journals. To make matters worse, at times the doctors are prevented from going abroad on fellowships awarded by foreign agencies, for dubious reasons.
The World Health Organization and the Commonwealth offer fellowships and scholarships exclusively to medical teachers attached to the universities. The teaching hospital consultants in the health department, who do the bulk of clinical teaching of medical students, a are completely ignored by such agencies.
The pharmaceutical industry has stepped in to provide what the health authorities have failed to do. They are the biggest sponsors of all kinds of educational activity for the doctors. They sponsor almost all the medical conferences, workshops and lectures by both local and foreign experts. They even bear the cost of printing and postage of the educational material mailed to the doctors. It is no secret that they sponsor many doctors to attend various medical meetings abroad. It is also true that any educational, business or other overseas trip it undertaken by any individual in any field of activity is partly a holiday as well. Hence it is mischievous to suggest that the doctors are sent abroad on holidays by the pharmaceutical companies. They arrange meetings to educate the doctors about new drugs that are being introduced to the local market. Such conferences and meetings take place usually in large hotels as they have all the facilities to cater to a large number. At a time when even the political parties hold workshops in sea side resorts, it was ironic that some authorities blamed the doctors for enjoying such ‘voluntary’ projects sponsored by the pharmaceutical companies.
As explained above the doctor serving in the periphery is often cut off from all educational activity. For them the representative of the pharmaceutical companies could be the only provider of new information on drugs. The doctors are intelligent enough to understand that these representatives give them only their side of the story. However, in the absence of any information to the contrary, they are likely to be carried away with biased information. In the U.K. for example, every doctor in the National Health Service is provided with a free copy of the British National Formulary (BNF), giving the latest information on drugs, every six months. It is time that the health department considered giving a copy of the BNF at least once a year or even every two years, to each unit in the government hospitals. This will enable the doctors to seek new information when stimulated to do so by the company representatives.
The fact that all this generosity on the part of the industry is profit oriented cannot be denied. No business concern will spend a cent without expecting twice as much in return. But the plain truth is that, if not for their generosity, continued professional development of the doctors in Sri Lanka would have been at a standstill. If anyone is to be blamed for allowing any semblance of a conflict of interest, it should be the health authorities. They have left the doctors at the mercy of the pharmaceutical companies to fulfill this vital component of professional development. The doctors as well as their employers should be grateful to the pharmaceutical companies for the service they render in this regard.
It is naive to believe that the doctors will be totally carried away by the activities of the pharmaceutical trade. Though the impact on their prescribing habits by such propaganda cannot be denied, doctors are competent enough to make their own assessment in these matters. A few years ago, when saline of poor quality was supplied to the hospitals, the Government Medical officers Association spearheaded a campaign that led to the withdrawal of all affected stocks and blacklisting of the supplier. More recently a leading company importing drugs was alleged to have marketed unregistered drugs of unknown quality. Despite this company being a major sponsor of academic activities, the Medical Associations and Colleges suspended all their dealings with the company and many doctors stopped prescribing their drugs until the matter was sorted out by the authorities.
The doctors do not feel that they are under obligation to please their benefactors, yet human tendencies certainly play a part. A handful of doctors may be in the habit of prescribing expensive drugs. But, medicine being an imperfect science as it is, a logical explanation may be found for such action. In the case of a very ill patient with an infection not fully diagnosed due to lack of proper laboratory facilities, use of an expensive newer antibiotic may be life saving. To blame such action on the undue influence of the drug industry is unfair.
The samples of drugs doled out to doctors by the drug representatives (often called ‘bribes’ by the ignorant) usually end up in the wards of the govemment hospitals. They are given free to the patients as the hospital pharmacy very often does not have them. The drugs given to patients at the various medical camps organized by well meanmg people are also derived from the same source of free samples. There are numerous instances where, at the request of doctors, the pharmaceutical companies have air freighted urgently required drugs at no extra cost to the patients.
The doctors have to walk the tight rope between the patients’ interests and the drug industry. Given the sensitive nature of the relationship, they have to be always conscious of the possibility that their dealings with the pharmaceutical industry can be misinterpreted by the suspicious public. This is particularly true at the present time when there appears to be an organized campaign to blame the doctors for every possible shortcoming in the healthcare system.
The doctors must make use of their immense potential to influence the behaviour of the pharmaceutical industry for the benefit of the general public. The prices of expensive drugs will come down and cheap brands of unknown quality will disappear from the pharmacy shelves if the doctors refuse to prescribe them.
The Generic Name or the Brand Name?
There has been much pressure on the doctors to use generic names rather than brand names. Many letters have appeared in the press extolling the virtues of the former. This is a complex subject which has to be studied thoroughly before opinions are expressed. Otherwise the public will be misled into believing that here again the doctors are exploiting them for the benefit of the pharmaceutical companies.
The generic name gives the scientific name or the chemical name of the active ingredient. When this compound is manufactured by different companies, they give brand names to establish their individual identity. The manufacturer would project his brand name as a symbol of quality and would do everything in his ability to maintain it at a higher level than his competitor, This would naturally increase the cost of the product. Thus a generic drug will be cheaper than a branded product. Hence the reason for the health authorities, patients and other well-meaning people to clamour for prescriptions in gcncric names. However there are many other factors to be taken into account.
Firstly, is the quality-guaranteed? There is no efficient quality control system in our country. According to the World Health Organisation (WHO), quality, effectiveness and safety are the cornerstones of any health product. Tn a recent survey of generic products marketed in the third world, the WHO has reported a serious lack of quality. With the drug tenders being given to the lowest quotation, one is not sure whether good quality can be assured. Even when some of the branded products are of questionable quality, what guarantee is there that anyone will bother about the quality of a nameless product.
Is there any guarantee that the generic product prescribed by the doctor will be dispensed by the pharmacist? It is well known that the authorities have little control over the activities of pharmacies. Most of them are manned by unqualified people, often young school-leavers. They are poor in their knowledge of English and are known to make many mistakes in that regard. Even the ‘prescription only’ drugs are freely sold over the counter. There is no compulsion on the pharmacist to dispense only what is prescribed by the doctor. In fact the substitution of drugs is rampant at present. Generic products, being cheaper than the branded products, will not give a good profit margin to the retail pharmacist. Whatever the doctor prescribes the pharmacist is likely to sell what ever he wants, most likely to be a branded product which gives him most profit. Thus in this scenario, writing a prescription in generic names is like giving an open cheque to the pharmacist. Those who are trying to dictate to the doctors about generic prescription would do well to have their priorities right. Regularising the activities of the pharmacies should be their top most priority.
There are too many brands imported at present. Some antibiotics have as much as twenty brands. The doctors, pharmacists as well as the patients are confused by the multitude of brand names. It becomes more difficult to maintain quality standards when there is so much variety in the field. Merelv carrying a brand name does not ensure quality. It only gives a wider choice for the pharmacist to dispense when the doctor gives a prescription in generic names. More brand names means more drug representatives will be trying to woo the doctors. This leads to the common sight at hospitals where these representatives crowd the corridors or the car parks trying to meet the doctors. The public get the wrong impression that the doctors are been bribed. Although this is a free economy, there has to be some control or restriction of such imports. Even in U.K, there are only three or four brands for any drug. Regular quality control tests should be made on registered brands.
Matters dealing with the health of the people are too important to be left in the hands of ignorant officials and others making decisions purely on ill conceived ideas and emotions. There are competent professionals in the country capable of making such decisions purely on well- researched scientific facts. One can only hope that they are allowed to perform their duties without any influence, political or otherwise. Then the general public can rest reassured that their rights and interests will be safeguarded to the utmost by Ihe medical profession maintaining highest moral, ethical and professional standards.
- Sri Lanka Guardian
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