Drugs prescribed by a Doctor can be bought and is mostly available only from the store he mentions in the prescription.
Big doctors have their own store.
You go anywhere else very rarely you can find the same drug.
Most of the times doctors will prescribe additional 2-3 generic seasonal medicine which you mostly do not need just to achieve targets so that they can claim their gifts (TVs, Foreign Trips, etc.)
This a serious issue in India which no one is batting an eye on.
What kind of drugs do they prescribe ? Alopathic ? Ayurvedic ? Do they favour one over the other ?
If only a particular doctor can prescribe his own brand of drugs, does it mean he designs and manufactures them or is there a pool of common recipes from which any pharmacist can make the drug and sell it under very different names ?
1 - Allopathic.
2 - No much clarity on that.
But think these guys (these = pharma company) sell area wise. Say if they tied up with pharma store A for x medicine. They will not sell the same in any other pharam store in that area. And will tie up with Doctors in that area to sell that medicine.
I will try to get more info on this. Each company has MR (Medical Representatives) they meet docotor every week on one day and present their schemes and offers.
You're right about this being an epidemic. However, due to rising awareness in recent times, there is a reverse trend.
I live in an expensive neighbourhood in a TIER 1 city in India and can confirm that many general physicians now prescribe medicines by their generic names.
That being said, it doesn't change the fact that the practice is still widespread. For e.g. I have never been to a dermatologist who will not insist on purchasing a particular often over priced brand, many even have their own pharmacy at their clinic.
I'm often shocked by the leniency of laws subject to doctors in India.
In France, the prescription is valid in any pharmacy and the pharmacy seller (who has a degree in pharmacology) can and often do propose the generic version of the prescribed drug.
There has been some marketing to present generics as cheap knockoffs of bad quality, leading to many people choosing to pay for the prescribed drug (which will be reimbursed anyway) but it all comes down to the patient's behavior.
Generics might be cheap knockoffs. It's uncertain if the purity, formulation, method of production, and quality control for a generic will yield the same benefits (or any benefits) for a particular drug. There are countless stories about how some people like some brands of generics better than others.
There was some reporting around these parts recently that generics don't really undergo any kind of efficacy studies, they are assumed to just work, and there's really not much oversight whatsoever.
It’s kind of weird. The FDA, and agencies in other countries modelled after it, usually have two jobs:
• for drugs, such agencies verify that new drugs are safe/effective in concept (rather than in any particular manufacturing implementation)
• for food, the agency looks at specific manufacturers and distributors of a food, and—given a particular food they’re claiming to be producing—the agency verifies that their product meets the agency’s own definition of what that named food “should” be (i.e. you can’t sell Cheez Whiz as “cheese” because it doesn’t contain enough [whatever], though you can sell it if you don’t try to call it “cheese”; you can’t sell beef as “beef” if it contains toxic levels of thyroid hormones, though you could sell it as something else, e.g. as a hypothyroidism supplement, since those levels would be expected for that product; etc.)
But, strangely, these agencies don’t have any mandate to to apply the “food”-type rules (checking manufacturers and distributors for their output being within tolerances to a definition) to the drugs—even when those drugs are known to be produced through a process that can leave harmful reagents in them if not cleaned properly.
I suspect it's all about who benefits. In the food industry, we've seen the effects, the industry is consolidating and forcing smaller players out.
In the case of generic prescription drugs, those are still very large players. There seems to be a cartel for all but the most common drugs, where manufacturers don't bother competing for market share.
Hmmm, I must confess I don't know the specifics of the laws and controls, but box of medicine have to state the composition: the molecules present and their quantities. Got prescribed 3 mg of TradeMarked(tm) <moleculeXXX>, a generic would be 3mg of NoName <moleculeXXX>. I think labeling a generic incorrectly would result in pretty heavy fines.
Consider magnesium supplements. You can get magnesium in a variety of forms: magnesium oxide, magnesium citrate, magnesium taurate, magnesium glycinate.
Each one of those formulas is going to contain magnesium, but the magnesium is bound to another molecule. One form of magnesium maybe be more effective than another for any given individual or condition. Some products are labeled as just "Magnesium" and it's unclear what form the magnesium is in.
Then there's a consideration of yield and purity. If you're making a compound through a given process, it's going to yield X amount of the desired compound, and Y amount of something else (other compounds or unconverted materials). Some of this is going to make it into the end product.
If two companies are using totally different processes to create the same end compound, everything is going to be different.
> I think labeling a generic incorrectly would result in pretty heavy fines.
Who's watching? I don't recall hearing much about generic manufacturers of prescription medications facing much scrutiny.
In Portugal it's the same way, and I'm glad to say that the countermarketing+regulation is working effectively: more and more people are choosing generics
> There has been some marketing to present generics as cheap knockoffs of bad quality
The last I've seen drug-related marketing, the message was the exact opposite, with the message being pushed by the Social Security system, since they're the one that would pick up part of the bill if people take the prescribed drug and not the generic.
In Germany doctors are not allowed to sell you prescription drugs, or tell you to which pharmacy to go to. The doctors have to select the cheapest of comparable medications and the pharmacy has to replace with the cheapest available medications.
All this just applies for public healthcare. Private healthcare is basically an unregulated Wild West.
It actually most likely isn't common. In the past it was, but there was a serious crackdown on doctors improving their golf handicaps in luxury resorts on the dime of big pharma and all variations on that theme. Surprised to see this make a recurrence.
Sometimes that crackdown is because the big pharma companies are happy with their current positions, so they propose cutting all of these expenses across-the-Board.
Then they maintain their incumbency and reduce a lot of their costs without a huge hit to revenue.
And if you’re a new pharma company with a truly awesome product, good luck getting anyone to prescribe it when you didn’t buy them a round of golf a decade ago because you didn’t exist.
I bet the doctors’ lobby will deny that payments will have any impact on their behavior. The same way they deny that working 24 hour shifts and being sleep deprived has no impact on their performance.
Its amazing how the people we trust with understanding science and evidence-based medicine are completely unable to unable to act in accordance with evidence when it comes to themselves. Good lesson for anyone who trusts our medical system.
Doctors are not scientists. Doctors understanding basic science are 1:1000, and the rest of us follow EBM practices blindly similarly to a religion.
However, it's not scientific ability that makes a good doc. Scientific ability is really not a criteria for adjusting your trust in a particular practitioner. I'd even say it's often that supposedly doctor-scientists (academics) are the worst.
From what I’ve seen in those doctor review sites and some pharmacy experience, what makes a good doctor in a lot of patient’s minds is whether they get whatever they want or not.
Telling patients that a requested test/referral/intervention isn’t supported by evidence really upsets people.
Indeed. And 'flexibly sticking to guidelines' goes a long way too. There's a balance to find between pleasing your patient and doing the 'medically correct' thing. That's where the difficulty lies.
They will certainly deny the impact. Which is absurd given that pharma companies all spend that money as vigorously as they can. Do doctors believe that pharma companies are extremely good at optimizing complex systems when it comes to drug production, but suddenly really bad at it when it comes to how they sell the drugs?
And as an aside, I think the long-shifts thing is a slightly different case. I've talked with doctors, and one pointed out that a big threat to patients is information loss during handoffs. The more you change shifts, the more information gets lost.
It's similar to how we developers will often keep working on a problem until it's solved. That's especially true in incident response, where the same people tend to keep working on an issue until it's solved, rather than saying, "Oh, it's 5 pm, I'm going home; somebody else can figure out why the site is down."
That's not to say doctors have the right balance now; they definitely have a macho-culture problem where people tough it out when it isn't necessary or beneficial. But it's definitely not as simple as I thought at first.
When I was in medical school, a question posed to us in lecture was, "Would a pharmaceutical company giving out free pizza at lunch influence you?"
I think fewer than 5 of us agreed that it would.
Of course it would! I was really struck by this. It's hard to have a conversation about proper vs improper influence when we can't even agree about what would influence us.
Of course! My point just being that even if it were simply free pizza, that’s still an influence, even if small. Talking about what to allow or disallow would be So much easier if we could all agree that the phenomenon exists at all (which of course I am convinced it does).
Right. I know that it does. Or at least, I recall seeing studies about that. But it's been too many years, and I didn't retain any records of that life.
GP in France is such a shitty job that people will go to great lengths to avoid that sector. French GPs earn ~25$ (base price) per patient, so they have to work their ass off to have a decent lifestyle. The people here talking about golf courses and living the life just have no idea what they're talking about. It's VERY different from the issues of the american system and it's no wonder this is happening.
My GP sees ~10 people per hour, ~7 hours a day. That sounds like it would be worth 1750 per day. Assume 250 day working year for the ease of my mental maths, you've got ~450k revenue?
Assuming tests/drugs etc are all extra, and that the surgery takes a sizable chunk - it still feels a decent distance from the breadline?
Yes and no. You are forgetting unpaid (compulsory) on-call work and the necessity to pay administrative staff if you want to work full-time (the amount of papers is such that you can't do without).
So far from the breadline on objective criteria, yes. Far enough that people wouldn't do anything to work in another specialty or do something where you have a better lifestyle, no. So GPs are usually not doing that by choice.
My GPs in France would see me for at least 30 minute each time, taking great care to check everything. It was quite a shock when I arrived in the UK and my GP would show me the door after 10 minutes.
The downside is that the French GP will never take you on time for your appointment, but you will feel that you are taken care of, unlike in the UK system.
I came once just for a quick health check before start a new sport, and I got an electro-cardiogram (to check for heart murmur, for free obviously), simply because I never had one in my life. They will often ask if your vaccinations are in order, how do you feel, things like that.
My GP takes 10 minutes per appointment and they sometimes take about 5 minutes after to enter information. Seeing 4-5 people per hour enter their office is a normal day.
Edit: To be clear, this will afford them a salary that is a multiple of mine while still leaving room for about 3 assistants per GP (maybe more, given that assistant work is something that your insurance or you also end up paying for), rent for the office and equipment. They're certainly not underpaid. I don't think they are overpaid either, as the time taken to study before you can become one is very long and the work is probably quite unpleasant.
You are telling me random GP in France gets paid 2x more per patient than hourly wage of specialist on ER shift in central Europe, and this is somehow a slave wage now??
No, I'm saying the compensation is not what people think it is. No golf, yachts, or anything of that kind. They just live an average life. However, ER shifts are ARE slave work.
If you want GPs to do good work, you have to offer them some incentives. Incentives have been insufficient since a long time in France, and in Europe generally. Which is why we are short on GPs.
GPS being underpaid is not that different in the USA. For instance, when Medicare got together to decide upon reimbursement rates for services, they gave ONE seat at the table to each group of doctors. So, the eye doctors got a seat, the foot doctors, the kidney, the liver...and ALL geriatrics got one seat. Think about that...a government program for healthcare for the elderly, and geriatrics is by far under-represented in setting reimbursement rates?!?!
No wonder preventive care is extremely undervalued. Special interests dominate healthcare in the USA, and in other countries too, it seems.
I very much doubt it's 20'000 EUR for GPs. It's likely much lower, because what you are citing includes data for surgeons, dermatologists, ophtalmologists, etc. who all are much higher priority targets for pharma marketing.
In a previous lifetime, I had access to pharmaceutical industry data, at the level of individual products, which reported the relationship between detailing (visits to doctors by drug reps) and prescription behavior (for target drugs and competitors).
Bottom line, pharmaceutical manufacturers employ drug reps because they increase sales. For up-and-coming brands, detailing is a major promotional component. And it's carefully managed.
"During this outbreak, Muyembe has also made a decision many thought unthinkable even a few years ago. He decided that all of the blood samples collected during this Ebola epidemic will stay in Congo. Anyone who wants to study this outbreak will have to come to his institute." not sure if this is a good idea
In the US, you can look up your doctor here https://projects.propublica.org/docdollars/ Apparently drug and medical supply companies are required by law to report anything they gift to doctors or hospitals.
58 comments
[ 3.3 ms ] story [ 127 ms ] threadDrugs prescribed by a Doctor can be bought and is mostly available only from the store he mentions in the prescription.
Big doctors have their own store.
You go anywhere else very rarely you can find the same drug.
Most of the times doctors will prescribe additional 2-3 generic seasonal medicine which you mostly do not need just to achieve targets so that they can claim their gifts (TVs, Foreign Trips, etc.)
This a serious issue in India which no one is batting an eye on.
If only a particular doctor can prescribe his own brand of drugs, does it mean he designs and manufactures them or is there a pool of common recipes from which any pharmacist can make the drug and sell it under very different names ?
I will try to get more info on this. Each company has MR (Medical Representatives) they meet docotor every week on one day and present their schemes and offers.
IMO, the practice ought to be made unlawful. Medicine is a life-critical sector. As such regulations need to be the tightest around it.
The exact degree may vary, but it happens everywhere.
Usually the laws and regulators allow prescribers tons of discretion, which is often subject to abuse that costs time/money/outcomes to somebody else.
I live in an expensive neighbourhood in a TIER 1 city in India and can confirm that many general physicians now prescribe medicines by their generic names.
That being said, it doesn't change the fact that the practice is still widespread. For e.g. I have never been to a dermatologist who will not insist on purchasing a particular often over priced brand, many even have their own pharmacy at their clinic.
I'm often shocked by the leniency of laws subject to doctors in India.
There has been some marketing to present generics as cheap knockoffs of bad quality, leading to many people choosing to pay for the prescribed drug (which will be reimbursed anyway) but it all comes down to the patient's behavior.
There was some reporting around these parts recently that generics don't really undergo any kind of efficacy studies, they are assumed to just work, and there's really not much oversight whatsoever.
• for drugs, such agencies verify that new drugs are safe/effective in concept (rather than in any particular manufacturing implementation)
• for food, the agency looks at specific manufacturers and distributors of a food, and—given a particular food they’re claiming to be producing—the agency verifies that their product meets the agency’s own definition of what that named food “should” be (i.e. you can’t sell Cheez Whiz as “cheese” because it doesn’t contain enough [whatever], though you can sell it if you don’t try to call it “cheese”; you can’t sell beef as “beef” if it contains toxic levels of thyroid hormones, though you could sell it as something else, e.g. as a hypothyroidism supplement, since those levels would be expected for that product; etc.)
But, strangely, these agencies don’t have any mandate to to apply the “food”-type rules (checking manufacturers and distributors for their output being within tolerances to a definition) to the drugs—even when those drugs are known to be produced through a process that can leave harmful reagents in them if not cleaned properly.
What’s up with that?
I suspect it's all about who benefits. In the food industry, we've seen the effects, the industry is consolidating and forcing smaller players out.
In the case of generic prescription drugs, those are still very large players. There seems to be a cartel for all but the most common drugs, where manufacturers don't bother competing for market share.
Each one of those formulas is going to contain magnesium, but the magnesium is bound to another molecule. One form of magnesium maybe be more effective than another for any given individual or condition. Some products are labeled as just "Magnesium" and it's unclear what form the magnesium is in.
Then there's a consideration of yield and purity. If you're making a compound through a given process, it's going to yield X amount of the desired compound, and Y amount of something else (other compounds or unconverted materials). Some of this is going to make it into the end product.
If two companies are using totally different processes to create the same end compound, everything is going to be different.
> I think labeling a generic incorrectly would result in pretty heavy fines.
Who's watching? I don't recall hearing much about generic manufacturers of prescription medications facing much scrutiny.
The last I've seen drug-related marketing, the message was the exact opposite, with the message being pushed by the Social Security system, since they're the one that would pick up part of the bill if people take the prescribed drug and not the generic.
All this just applies for public healthcare. Private healthcare is basically an unregulated Wild West.
edit: Source: https://blogs.mediapart.fr/emmanuel-kosadinos/blog/310818/no...
Then they maintain their incumbency and reduce a lot of their costs without a huge hit to revenue.
And if you’re a new pharma company with a truly awesome product, good luck getting anyone to prescribe it when you didn’t buy them a round of golf a decade ago because you didn’t exist.
However, it's not scientific ability that makes a good doc. Scientific ability is really not a criteria for adjusting your trust in a particular practitioner. I'd even say it's often that supposedly doctor-scientists (academics) are the worst.
Telling patients that a requested test/referral/intervention isn’t supported by evidence really upsets people.
And being nice goes a long way.
It's similar to how we developers will often keep working on a problem until it's solved. That's especially true in incident response, where the same people tend to keep working on an issue until it's solved, rather than saying, "Oh, it's 5 pm, I'm going home; somebody else can figure out why the site is down."
That's not to say doctors have the right balance now; they definitely have a macho-culture problem where people tough it out when it isn't necessary or beneficial. But it's definitely not as simple as I thought at first.
Plenty of great theories have been crushed by evidence.
I think fewer than 5 of us agreed that it would.
Of course it would! I was really struck by this. It's hard to have a conversation about proper vs improper influence when we can't even agree about what would influence us.
And it's a great investment. Because prescribing habits tend to persist after training, for many years. Sort of like Kuhn argued for science.
My GP sees ~10 people per hour, ~7 hours a day. That sounds like it would be worth 1750 per day. Assume 250 day working year for the ease of my mental maths, you've got ~450k revenue?
Assuming tests/drugs etc are all extra, and that the surgery takes a sizable chunk - it still feels a decent distance from the breadline?
So far from the breadline on objective criteria, yes. Far enough that people wouldn't do anything to work in another specialty or do something where you have a better lifestyle, no. So GPs are usually not doing that by choice.
The downside is that the French GP will never take you on time for your appointment, but you will feel that you are taken care of, unlike in the UK system.
I came once just for a quick health check before start a new sport, and I got an electro-cardiogram (to check for heart murmur, for free obviously), simply because I never had one in my life. They will often ask if your vaccinations are in order, how do you feel, things like that.
Edit: To be clear, this will afford them a salary that is a multiple of mine while still leaving room for about 3 assistants per GP (maybe more, given that assistant work is something that your insurance or you also end up paying for), rent for the office and equipment. They're certainly not underpaid. I don't think they are overpaid either, as the time taken to study before you can become one is very long and the work is probably quite unpleasant.
If you want GPs to do good work, you have to offer them some incentives. Incentives have been insufficient since a long time in France, and in Europe generally. Which is why we are short on GPs.
No wonder preventive care is extremely undervalued. Special interests dominate healthcare in the USA, and in other countries too, it seems.
https://fr.wikipedia.org/wiki/Industrie_pharmaceutique#Lobby...
In 2003 pharma industry was pending more than 20 000 EUR per year per doctor in France. Not far for a full time employee per doctor.
One quarter of revenue on marketing, more than for research.
Most of this is because of government granted monopolies aka patents.
Alternatives are proposed, see Dean Baker for example
https://www.nytimes.com/roomfordebate/2015/09/23/should-the-...
http://cepr.net/publications/briefings/testimony/drugs-are-c...
https://www.ncbi.nlm.nih.gov/pubmed/15346683 (yes nothing new :)
Book : https://deanbaker.net/books/rigged.htm
Blog : http://cepr.net/blogs/beat-the-press/
They wouldn't be spending money on marketing if those expenses didn't bring in more dollars. Which in turn means more money for research...
Bottom line, pharmaceutical manufacturers employ drug reps because they increase sales. For up-and-coming brands, detailing is a major promotional component. And it's carefully managed.