Mind the Gap
Sometimes referred to as a patient educator, the nurse ambassador role was created by pharmaceutical companies that specialize in drugs that treat chronic illness. Patients who have diabetes, multiple sclerosis or rheumatic disease often have complex medical regimens that create a unique set of challenges. The best medications may do no good if the patient is taking them incorrectly or can’t get approval to take the medication in the first place.
A nurse ambassador may provide a number of services, such as teaching a patient how to self-inject medications, helping with insurance and pharmacy paperwork and promoting medication adherence.3 In other words, they fill in the gaps.
I know that, in an ideal world, I would help a patient complete paperwork, drive to their house to show them how to use the injector associated with their drug and then check up on them every two weeks to make sure they have developed a routine. I just don’t have that sort of time.
For a nurse who enjoys patient education and problem solving, this can be a gratifying job. Katheryn Bowles, an associate professor at the University of Pennsylvania’s School of Nursing, notes, “It’s a very important service that’s much needed. Patients with multiple chronic conditions see a variety of doctors and end up on 12–14 medications with complex rules and schedules. Errors and dangerous interactions happen.”4 A nurse ambassador may play an important role in ensuring that a complex management plan is seen through to completion.
So what’s the problem?
Ambassador Ethics
Nurse ambassadors are asked to walk a fine ethical line between the patient who is receiving the services and the company that is paying for the services to be rendered. Crossing that ethical line is sometimes called white coat marketing. Adriane Fugh-Berman, a professor at Georgetown University Medical Center, Washington, D.C., describes the practice as “marketing laundered through your doctor.”5
The nurse ambassador runs the risk of blurring the lines between practitioner and marketer, because helping patients start and remain on drugs supported by nurse ambassador programs will ultimately enhance a company’s profits.
Some see nurse ambassador programs as an illegal kickback to the prescribing physician. When I was in training, it wasn’t uncommon for a pharmaceutical representative to take a large group of interns out to dinner at a restaurant none of us could afford. In 2009, the pharmaceutical industry adopted a voluntary code of conduct, which curbed pharma freebies. The nurse ambassador program gets through on a technicality. By providing valuable services (e.g., assistance with insurance paperwork or monitoring patient adherence) for free, nurse ambassadors may have inadvertently become the drug dinner of the 21st century.
This is a particularly insidious conundrum because physicians are notoriously cheap. In one study, physicians attending a single lunch promoting a brand-name drug were twice as likely to prescribe that drug over a generic alternative. The average cost of that lunch? Less than $20.6 Although I can’t cite any studies, it’s not hard to imagine that a nurse ambassador, who could potentially take many patient problems off my plate, would buy at least as much goodwill as a burger and fries.
Shahram Ahari, a former pharmaceutical sales representative who is now an emergency medicine physician, notes, “[F]ood and payments aren’t the only ways pharma reps get products in front of medical providers. In my experience, sometimes the ‘gifts’ were less literal: They included simple friendship. … Little favors have a subtle way of making the recipient feel obligated to reciprocate in some way.”7
Not surprisingly, these concerns have led to lawsuits. In 2018, Gilead Sciences, Amgen, Eli Lilly, Bayer Pharmaceuticals and AbbVie were all accused of violating federal kickback laws by their use of nurse ambassadors.8 In 2020, AbbVie agreed to pay $24 million to settle a lawsuit that alleged its nurse ambassador program violated California’s Insurance Frauds Prevention Act by providing free professional goods and services to physicians to induce them to prescribe their tumor necrosis factor (TNF) inhibitor. As part of the settlement, AbbVie agreed to make clear to patients that the nurse ambassador program is paid for by the company and not by the prescribing physician.
That last bit makes a good point: When someone gives you advice, you should know who is paying the bills. Even the most scrupulous nurse ambassadors would probably be reluctant to bite the hand that feeds them, and even if this bias is slight or subconscious, the patient deserves to know the bias may exist.
