Family junkets to Singapore are passe. Switzerland is the preferred destination now. Notepads, calendars and gift vouchers of malls on festivals too are things of the past as doctors have moved on, by leaps and bounds. Gift cheques of Rs 1.5 lakh for the daughter’s wedding and sponsoring a floor of their under-construction house are now figuring in the pharmaceutical company’s annual expenditure excel sheet. Add to that business class air travel and five-star hotel expenses for the umpteen conferences held for them.
The long list of freebies that smiling medical representatives leave in the swank clinics of doctors along with packets of newly launched capsules is showing a healthy growth, confirm health industry sources, the meltdown notwithstanding.
Pharma company employees admit that doling out gifts to doctors is one of their key expenditure areas and one they do not cost cut on, ever. Doctors, on their part say, that pharma companies force themselves on them and they have no choice but to entertain them. But clearly, the two share a symbiotic relationship with the former’s only source of (not just freebies) but even education being the medical representatives (MR) visiting him or her.
On the wish list of every MR are cardiologists, as they can recommend the most expensive drugs, followed by general physicians who can prescribe a range of drugs and then neurologists and nephrologists both scaling impressively in the ‘most wanted’ list.
The kickbacks depend on the cost of the drug the doctor has managed to peddle to the patient. For regular drugs it would be the routine notepad-pen-conference drill, but if its a cardiac product such as a stent then the kickback could be anything the doctor wishes, well almost. “Stents are very expensive and the competition (between firms) is stiff. So if a doctor prescribes your stent (the cost of which ranges anywhere between Rs 1 lakh to Rs 3 lakh), you are willing to take the entire family on a summer vacation,’’ says a senior manager with a pharmaceutical firm which is into stent manufacturing. But does it make business sense? “It does. There are a large number of cardiac patients and several undergo angioplasties. A doctor (happy with his junket) could prescribe our stent with many of his patients scheduled to undergo the procedure,’’ the manager says.
Then there are the tried and tested ways of selling products. “If a company wants to promote a new drug they often get consultants from other cities and sometimes even other countries to introduce the drug to doctors. These sessions which last for one to two hours, of course, always end with cocktails and dinner as otherwise doctors wouldn’t come,’’ says general physician Dr Anshuman Khaitan.
A city gynaecologist adds that competing firms try to outdo the other by dumping large number of samples at their clinics. “I am sitting in the midst of three varieties of the abortion pill,’’ the gynaec says.
Old timers in the profession are both amused and worried at this growing trend. “Ever since I joined the profession 35 years ago, these freebies have been getting more and more attractive. And more doctors are accepting such offers than ever before. These pharmaceuticals companies give away plush cars, television sets, refrigerators, dinners at 5-star hotels and foreign trips. Nowadays, it is the ayurvedic drug manufacturing companies that are beating their allopathic and homeopathic counterparts,’’ says Dr S Pal, who retired recently from the position of a chief medical officer.
Pharma majors argue that they have no choice but to pamper doctors.”We have no option but to oblige, especially if the person is a prospering doctor. And even if we refuse, some pharmaceutical company or the other will do the honours. So what is the point,’’ says the regional manager of a pharma major. “Ideally, I think spending on academic-related things like books and conferences still makes sense, but sponsoring their personal foreign trips and buying books for their children should not be entertained,’’ he says, recalling an incident when a doctor handed him his school-going child’s book list asking him to get it. Needless to say, the pharma company made its first purchase of Class VIII books under its ‘books and periodicals’ section.
Dr B P Prasad, president of the Indian Medical Association’s AP chapter says, the freebie culture is a fallout of a large number of sub-standard local companies that are extremely commercial and give gifts to doctors. “The better the turnover (of the firm) the more expensive the gift,’’ he says, adding that while small gifts like calendars and pens are fine, accepting air conditioners, refrigerators and foreign trips is unethical and doctors shouldn’t indulge in it. “This is against the protocol,” he says.
Nevertheless, sources in the industry say that earlier if doctors were sent alone for academic conferences, now more often than not they are accompanied by their families. But what takes the cake are the targets pharma companies set for their ‘patron’ doctors to achieve. “There are several schemes and the doctors are given targets based on their potential. If they achieve the target, they win prizes,’’ says a medical representative. He adds that doctors are most often willing to achieve the target, which is usually to prescribe a certain drug to a certain number of people in a given period of time.
Patients go Doctor Shopping: When Sudeshna Roy’s father was detected with colon cancer, the doctor treating him said he needed a surgery. The daughter spent lakhs of rupees on the surgery only hoping that her 80-year-old father would be fine by the end of it. However, when the operation was through and the patient was still recuperating, the same doctor suggested yet another surgery. “Another operation meant so much more money again and also my father was old, so I was not sure if he could take it,’’ says Roy adding that it was then that she decided to opt for a second opinion.
Surprisingly, when she approached another doctor her gut feeling was proved right. The doctor advised her against the surgeries and that a man her father’s age may not be able to withstand the pain. “Since then, even for the slightest problem I tend to seek a second opinion,’’ says Roy.
This feeling of uncertainty after walking out of a doctor’s clinic haunts several patients. While surgeries are an important decision and people do tend to take a second opinion, they say they are skeptical even of the drugs the doctor has prescribed. There is an increased rate of awareness among people who perhaps still don’t question the doctor but prefer to seek a second opinion. This trend is common among people planning to undergo a surgery. They compare the charges of variors hospitals before zeroing in on the hospital offering the most cost-effective package. Some also do not hesitate in doing away with prescribed tests that they feel are unnecessary.
Take for instance, Aakansha Gupta’s case. Her decision to undergo an “unavoidable’’ surgery (as her doctor put it) barely three months after she delivered her child was a difficult one. Her gynecologist had advised her, through her pregnancy, how she must get the fibroids in her uterus removed post delivery. “I did not think of consulting any other doctor initially. But when my gynecologist insisted I get it done at her clinic, I decided to see another doctor, who put me on medication. This was six years ago. I am fine now and also glad I took a second opinion,’’ she says.
Moreover, the doctors’ indifference towards patients is egging the latter to visit another doctor and then arrive at a decision. Management consultant Prakash Narang, 34, says he jogged regularly on the road until his knee started hurting. “I went to a corporate hospital where the doctor did not even examine my knee or check for any inflammation but simply wrote seven tests without as much as touching my knee. I was livid,’’ he says. Narang then visited an orthopaedic at the not-so-fancy Nizam’s Institute of Medical Sciences and to his surprise was given a rather sane prescription— physiotherapy for a month and jogging only on soft soil.
This concept of a second opinion, it seems, is not only catching up among patients but also among doctors. Doctors these days say that sometimes just to make a patient feel confident that he is being treated the right way, advising them to go in for a second opinion is not a bad idea. “Just today I advised a patient against surgery but he did not look satisfied. So I asked him to seek another opinion on this matter. Often doctors are the ones who ask their patients to go in for a second opinion in order to prove to them that they have been diagnosed correctly,’’ says Dr Avinash Dal, cardiac surgeon, Apollo Health City.
Docs Life Style: A platinum coupon if you prescribe drug ‘X’ to 10 patients. A gold coupon if you prescribe brand ‘Y’ to 25 patients. The more coupons you get, the greater your chances of winning. The prizes — cars, frost-free refrigerators, television sets, digital cameras and silver coins.
If you knew your doctor was a contestant for these prizes, how confident would you feel that what has been prescribed to you is what you need, not what improves his chances in the contest?
Such contests for doctors are not unknown in India. In one such case, 100 doctors who topped the prescribers charts from cities like Ahmedabad, Chennai, Alwar, Belgaum, Ambala and Agra participated in a lucky draw and were awarded publicly by the Gujarat-based Torrent Pharmaceutical.
In another, the same company let some other doctors and their families sample traditional Turkish cuisine and culture in Istanbul as part of a so-called international symposium on metabolic medicine. Another lot from 12 metros splashed around in the best water parks in their cities courtesy the same company.
This company has also not spared expenses in helping ‘educate’ doctors to decide which drugs to prescribe — it took a batch of Sri Lankan doctors on a safari to Kenya for their education. These aren’t allegations — the information is available on the company’s own website. In fact, check out how Torrent itself described the Istanbul junket: “Torrent has once again raised the bar in offering a perfect combination of knowledge sharing and hospitality in the pharma industry’’.
Representative of another pharma firm told TOI that his firm has earmarked an annual budget of Rs 2 crore for sundry freebies for doctors in Delhi. This does not include gifts and trips abroad, coming from company’s central funds.
ON OFFER
Coupons for lucky draw with prizes including car, frost-free refrigerators, TV sets & digital cameras
Trips to exotic locations like Turkey, safari in Kenya to ‘educate’ doctors
Delhi branch of one pharma firm alone has budget of Rs 2cr for freebies for doctors
Many countries have banned such practices Drug firms’ doles for docs against norms
Should drug companies handing out gifts to doctors be legal? Several countries have brought in legislation to crack down on unethical marketing practices, and the penalties are stiff. Drug companies have had to cough up millions as fines in Europe, the US, Canada and Australia. Over 25 medical centres including prestigious ones like Harvard Medical School, Yale University, University of California and the Stanford School of Medicine have put in place strong conflict-of-interest policies that include zero tolerance for company gifts and free meals and curbs on travel for conferences.
In India, however, we just have vague assurances of self-regulation by the drug industry and reliance on doctors’ ethics. Both the associations of drug manufacturers in India, the Indian Drug Manufacturers Association (IDMA) and Organisation of Pharmaceutical Producers of India (OPPI) on paper have a code of ethics for marketing practices with detailed procedure for registering and examining complaints.
However, OPPI DG Tapan Ray refused to divulge the number of complaints received or what action was taken. “I cannot reveal (that) because it is a self-regulatory process,’’ says Ray. The Federation of Medical Representatives Associations of India (FMRAI) had sent a complaint against drugs major Torrent with evidence to the IDMA. “Forget about acting on our complaint, IDMA has not even acknowledged receipt of the complaint,’’ says Amitava Guha, joint general secretary of FMRAI.
Indian Medical Association general secretary Dr S N Mishra says reports of doctors being bribed are just allegations till proved. “We condemn bribing of doctors, but IMA has no teeth to take action. The government ought to bring in strict regulations,’’ he says. Repeated attempts to get comments from the Drug Controller General of India Dr Surinder Singh proved futile with faxes and calls remaining unanswered.
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