The Efficient Ophthalmologist

Physician Rx: What Drives Our Prescribing Behavior?

By Steven M. Silverstein, MD, FACS

What motivates us to select the specific medications that we prescribe for our patients? Despite the federal government’s ridiculous assertion that our motivation is somehow predicated on the mesmerizing influence of a 39-cent pen, note pad or, most offensive, lunch, the truth is that this is a multi-factorial, complex issue that controls the expenditure of hundreds of billions of dollars.

Generics Often Substituted

Indeed, of every $10 spent on health care, a dollar goes to pharma; generics drive 70 cents of that. So, shouldn’t all involved direct more focus, regulation and scrutiny toward quality control, properly conducted studies and oversight of the generic marketplace? How is it ethical that pharmacists are not only allowed to convert our “dispense-as-written” prescriptions to generic substitutes, but are also paid financial incentives to do so?

I have given considerable thought to what I call prescription-writing behavior modification in part because I want to be truthful about my own habits. Perhaps this is also a catharsis to quell my frustration of being licensed to perform surgery, order patients under general anesthesia and prescribe potentially addictive or lethal drugs, but I am not trusted with a paperclip dispenser that bears the a drug company’s name lest I over-prescribe a given brand of artificial tears. Well, I suppose that I am still not over it.

I have identified five consistent reasons why doctors prescribe the medications we write. If you think about it, you will likely assign your own habits into one or more of these categories — categories, mind you, that fluctuate based upon the class of medicine, payer and the patient’s best interest:

►Efficiency of the medication.

►The side-effect profile.

►Dosing regimen.

►Price point or pharmacy plan.

►Relationships.

The last category is defined as our relationships with our reps or district managers, our involvement in clinical research, lecturing and consulting, and our overall confidence in or allegiance to a given company — if all other aspects of a given class of products are equal.

Do Your Own Evaluation

How can we validate that our prescription-writing behavior is sound?

I suggest using three criteria.

First, read the literature. Carefully compare the different medicines that share a given space. Pay particular attention to the methods section of each manuscript, because even subtle differences in protocol can influence — and at times skew— the study authors’ conclusions. In other words, be careful about making apples-to-apples comparisons of two medications until you are convinced similar methodologies were used to investigate them.

An example of this is the prostaglandin comparative study published several years ago. This was a standard head-to-head comparison of different glaucoma medications that share a similar space.

For a particular class of medicines, the company that produced one of the medications claimed its product was superior because the study showed the trough pressure was lower than the other products at a specific time point. Another company touted its product as the victor because it showed the best pressure-lowering effect at a different time point in the same study.

Second, examine the economic impact of a given product — especially glaucoma meds and the like that patients use long-term. Be sensitive to the patient’s insurance or socioeconomic factors, though not in exchange for efficacy or potential side effects.

Third, unless contraindicated or when a particular prescription will place an undue economic burden on the patient, write for name-brand products in a given class that are frequently more potent and have less allergic potential than their generic equivalent.

More Choices Needed, Not Fewer

It’s becoming clear that we will have fewer novel — and potentially better — medications available to treat our patients if the pharmaceutical companies do not adequately fund their research and development. This is not just me drinking the Kool-aid that the pharmaceutical companies are putting out. Lack of good choices to prescribe for our patients is a genuine concern for practicing physicians who have to deal with limited formularies. We have recently witnessed several solid small and mid-size companies fail or go out for bid due to, in part, their inability to adequately capitalize their product pipeline.

Lastly, when faced with a given medical or surgical scenario that requires a prescription, ask yourself which medication you would demand for your own eye or for a loved one in a similar situation. That is a sure way to focus your thinking.

The Last Word

And by the way, since the enactment of the PhRMA guidelines, there has been no shift or trend in prescription-writing behavior definitively attributable to this completely political mandate. I guess the real losers are the ballpoint pen and sticky-note companies. There, I feel better already. OM

Steven M. Silverstein, MD, FACS, is a cornea-trained comprehensive ophthalmologist in practice at Silverstein Eye Centers in Kansas City, Mo. He invites comments. His e-mail is ssilverstein@silversteineyecenters.com.