On January 16, 2002, at a National Health Policy Conference in Washington, D.C., Sharon Levine, MD, the Associate Executive Medical Director of the Kaiser Medical Group, said “Every physician … has a responsibility to be [a] fiduciary steward of [his or her] patients.” She believes that the profession must step up and take responsibility for its patients, especially when it comes to the cost of the drugs that physicians prescribe.1 Dr. Levine then discussed how Kaiser clinicians have become pharmaceutical process owners, committed to achieving appropriate drug-use outcomes. Kaiser’s formulary compliance rate is 97% to 98%.

You need to say it, you need to believe it, and you need to practice it. Otherwise, Levine believes, you are part of the problem. Kaiser prescribing clinicians work with drug education coordinators to support ‘optimal pharmaceutical management.’ Their COX-2 inhibitor use is one tenth of that of national retail levels. How many of us can claim similar success stories? Or do we settle for two out of the three above? This is one of the reasons why Dr. Levine is one of my new heroes.
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I also acquired great respect for Rex Force, PharmD, as I read his viewpoint in an article entitled “Confessions of a Fly-Fisherman and Sometime Drug Company Courtesan.” He vividly described the cognitive dissidence involved in trying to ‘do good’ within the constraints of ‘the system,’ and raised many conflict-of-interest issues in pharmaceutical industry-sponsored continuing education programs. Force pointed out that although there are many beneficial pharmaceutical products, pharmacists must be cautious when extolling the virtues of specific drugs on behalf of pharmaceutical companies when they receive personal ben-efts from such an arrangement. We would all be well served to realize that our own professional judgment and ethics are rarely fixed in place, but instead warrant continuous introspection. Force’s article reminded me of that fact.

I propose that drug marketing and continuing drug education are two distinct concepts, and so they should be handled by two different systems that are completely independent of one another.

Alas, the pharmaceutical marketing machine is a juggernaut; it knows human psychology better than Freud did. Shaughnessy and colleagues described some useful techniques for preparing oneself for the subtle art of professional drug-use persuasion in their article entitled “Separating the Wheat from the Chaf.” Persuasion psychology is not taught in most clinical curriculums, so most clinicians must rely on maturity and common sense to develop and guide their moral prescribing compasses. Although the moral fiber in most of us unequivocally promises immunity from being influenced in a negative way, we can all detect an occasional setback to the premise of evidence-based, cost-efficient practice (a.k.a., fiduciary stewardship) to preserve resources for the greatest good.

You will never even feel it when the compromise occurs, and most often only retrospective reflection will identify personal prescribing lapses. The pressure comes from many sides, with direct-to-consumer advertising of prescription products as an example of another technique used to exert influence on clinicians. Shaughnessy et al. encourage us to be skeptical of how pharmaceutical companies are selling us on a drug; instead of letting them use us to get to the consumers, we should use them to get the cold, hard facts about their drugs. And we should know how to get our drug information from other sources (e.g., drug bulletins, P&T committees) to make better judgements.

Make no mistake, a for-profit company’s primary mission is to sell products and services. Huge sales lead to increased market valuation of a company, larger bonuses for its employees, and more resources to spend on marketing. Sometimes there is even enough left over to increase research and development funding for new therapeutic areas!

To Drs. Levine and Force, I say: keep up the good work at the front lines. The troops need supportive, creative, and honest reports every now and then. Effective pharmacy resource management is a difficult activity, and conflict-of-interest issues can cloud our thinking. It’s a long war, but I just hope that I don’t have to make the economist’s classic choice between ‘guns or butter.’ I’d prefer my current therapeutics not to endanger the quality of life for future generations in the areas of housing, education, and so on.