“I don’t believe in a government that protects us from ourselves.”
Ronald Reagan
I just got back from Chicago and part of the American Medical Association’s Annual Meeting.
I’ve been very involved with organized medicine over my medical school career.I think I fairly readily admit the faults of organized medicine (and forgive them) and I also realize that my involvement has been mostly, nearly fatuous. Many of my positions exist largely to draw medical students in to organized medicine and not as conduits for the medical student voice in shaping policy. That’s okay, I’ve learned a lot about both policy and the functioning and innards of organized medicine.
I truly believe that organizing physicians and other health care providers and speaking with a semi-cohesive voice is important. Politicians in Washington and the public don’t understand the nuances of fractured physician opinion. Nothing gets done on your behalf up in Washington without a concerted, concentrated effort. Criticisms of the AMA and organized medicine in general are not inappropriate, but if you want change it won’t be by backing out of the system altogether. If you disagree with policy you need to work to change it from within has always been my perspective. Because even as involvement in organized medicine by practicing physicians dwindles, it remains the voice for medicine in all of the places that matter.
I lay all the above out because such is the light I want to look at the topic of industry funding of medical education. When I left Chicago the docs still up there were facing a report (word doc) from the AMA’s Council on Ethical and Judicial Affairs. In dramatic flair, already championed by several academic institutions (see here for example), the report calls for physicians and medical institutions to forgo industry funding of all educational activities except for certain technical training (such as learning how to use a new device in the operating room).
The American Medical Association wasn’t ready for such. They’ve referred it for further study, while also, in an obvious rebuke, passing a resolution (word doc) in support of industry funding for continued medical education.
Baby Steps To Ethics
The result is a mixed bag. I would hope the AMA would take a leading step towards ethics. As always, I respect the right of physicians and academic institutions to take as much pharma and other industry money as they like. Legislation to dampen such would be appalling. But if the refusal of such money is by personal choice that is an obviously different matter altogether.
Being innovative and adventurous is difficult for any large and diverse policy body admittedly and so I remain hopeful. It is likely inevitable, eventually that it becomes the ethical standard for industry not to fund medical education. We’ll ease into it and the catastrophe of the death of free or cheap continued medical education or that catered pasta dish at grand rounds won’t look quite so disastrous from the other side. Or so I predict.
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Photo: Mike Licht / CC License
It may come as a surprise the relationships some physicians have with drug companies. Thousands of physicians, practicing physicians, maybe your physician, serve as Vaudevillians for a host of drugs. Psychiatrists are especially guilty of this, but they’re not alone. In a New York Times piece one psychiatrist goes into how he was dragged into the mess.
How many doctors speak for drug companies? We don’t know for sure, but one recent study indicates that at least 25 percent of all doctors in the United States receive drug money for lecturing to physicians or for helping to market drugs in other ways. This meant that I was about to join some 200,000 American physicians who are being paid by companies to promote their drugs. I felt quite flattered to have been recruited, and I assumed that the rep had picked me because of some special personal or professional quality.
The first talk I gave brought me back to earth rather quickly. I distinctly remember the awkwardness of walking into my first waiting room. The receptionist slid the glass partition open and asked if I had an appointment.
“Actually, I’m here to meet with the doctor.”
“Oh, O.K. And is that a scheduled appointment?”
“I’m here to give a talk.”
A light went on. “Oh, are you part of the drug lunch?”
Regardless of how I preferred to think of myself (an educator, a psychiatrist, a consultant), I was now classified as one facet of a lunch helping to pitch a drug, a convincing sidekick to help the sales rep. Eventually, with an internal wince, I began to introduce myself as “Dr. Carlat, here for the Wyeth lunch.”
During my first few talks, I worried a lot about my performance. Was I too boring? Did the doctors see me as sleazy? Did the Wyeth reps find me sufficiently persuasive? But the day after my talks, I would get a call or an e-mail message from the rep saying that I did a great job, that the doctor was impressed and that they wanted to use me more. Indeed, I started receiving more and more invitations from other reps, and I soon had talks scheduled every week.
The entire process is fishy, no doubt. But why I’m posting on it is the role organized medicine is playing in such. The level of detail the drug companies have on what your doctor is prescribing is pretty remarkable. Don’t fret, they don’t have info on patients or on who is getting what. But they can certainly tell that this doctor prescribes Zoloft 80% of the time for depression, then a drug rep from the maker of Effexor busts in and tries to convince the doctor that Effexor is better than Zoloft.
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The same old question: how do drug companies influence physician prescribing habits? The New York Times looks at “payments” for anemia drugs.
Industry analysts estimate that…payments — to cancer doctors and the other big users of the drugs, kidney dialysis centers — total hundreds of millions of dollars a year and are an important source of profit for doctors and the centers. The payments have risen over the last several years, as the makers of the drugs, Amgen and Johnson & Johnson, compete for market share and try to expand the overall business.
Let’s be clear what we’re talking about here. The physician practices aren’t getting a big check with you know, the word “Commission” on the Re: line.
Federal laws bar drug companies from paying doctors to prescribe medicines that are given in pill form and purchased by patients from pharmacies. But companies can rebate part of the price that doctors pay for drugs, like the anemia medicines, which they dispense in their offices as part of treatment. The anemia drugs are injected or given intravenously in physicians’ offices or dialysis centers. Doctors receive the rebates after they buy the drugs from the companies. But they also receive reimbursement from Medicare or private insurers for the drugs, often at a markup over the doctors’ purchase price.
Medicare has changed its payment structure since 2003 to reduce the markup, but private insurers still often pay more. Combined with those insurance reimbursements, the rebates enable many doctors to profit substantially on the medicines they buy and then give to patients.
No matter how they’re earning profit off these deals, you imagine it provides a pressure to overuse the drug. But I think there is a functional difference in between getting discounts on the drugs and…getting paid to use them.
Since 1991, when the first of the drugs was still relatively new, the average dose given to dialysis patients in this country has nearly tripled. About 50 percent of dialysis patients now receive enough of the drugs to raise their red blood cell counts above the level considered risky by the F.D.A.
American patients receive far more of the anemia drugs than patients elsewhere, with dialysis patients in this country getting doses more than twice as high as their counterparts in Europe. Cancer care shows a similar pattern. American cancer patients are about three times as likely as those in Europe to get the drugs, and they receive somewhat higher doses.
The fact not addressed adequately by the NYT’s article is that for smaller practitioners Medicare’s reimbursement scheme for these drugs mean they lose money on them. Much like the complaints PCPs have about some vaccines - it simply is not profitable for some smaller hem/onc and nephrology practices to stock and dose these synthetic erythropoietins. Yet they have to for their patients.
It is for those practices that the rebates are defended.
The biggest problem in the abuse of these drugs may lie with the big boys:
DaVita, one of the two large dialysis chains, and the most aggressive user of epoetin, gets 25 percent of its revenue from the anemia drugs — and even more of its profit, according to some analysts.
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The NYT goes over state laws requiring drug companies to report their payments to physicians.
There is nothing illegal about doctors’ accepting money for marketing talks, and professional organizations have largely ignored the issue.
But research shows that doctors who have close relationships with drug makers tend to prescribe more, newer and pricier drugs — whether or not they are in the best interests of patients.
A New York Times/CBS News poll last month found that 85 percent of respondents thought it “not acceptable” for doctors to be paid by drug companies to comment on prescription drugs. Eighty-five percent also said such payments would influence the decisions that doctors made about patient care.
In addition to Minnesota, legislators in Vermont, Maine, West Virginia, California and the District of Columbia have passed laws requiring some level of disclosure of drug company marketing efforts. In Vermont, the state has collected three years of data on payments to doctors, but drug makers are allowed to keep the records private by declaring them trade secrets.
Ah The Allure Of Getting Paid…
What does one state’s database show?
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How thoroughly do conflicts-of-interest permeate clinical trials? An LA Times article from last year looks at one study,
More than one-third of experts charged with overseeing clinical trials at medical schools and research hospitals have financial ties to companies that sell pharmaceuticals and medical devices, according to survey results released Wednesday.
The report found that nearly 7% of experts discussed or voted on clinical studies sponsored by companies they had relationships with or by competitors of those companies — a conflict of interest under federal rules.
The problem isn’t that these exist…
Eric G. Campbell, a health policy expert at Massachusetts General Hospital and lead author of the study, said it wasn’t possible to eliminate relationships between academia and industry.
Scientists rely on companies for research funding, and companies rely on academic centers to test new products.
…but that academics don’t recuse themselves or report the conflicts. Of course, unfortunately for ranting advocates of mandatory disclosure, it doesn’t seem like this is high on the list of concerns of patients,
In a related report in the journal, patients in cancer-research trials said they would not have changed their minds about participating in the studies had they known in advance about the financial ties between researchers and drug companies.
Recently, the International Federation of Pharmaceutical Manufacturers & Associations, banned its members (including some notable big pharma members) from lavishing gifts on physicians.
“What we’re trying to do is prevent as many of the activities as possible that have not helped the reputation of the industry,” said Harvey E. Bale, director general of the federation. “We need to make sure the product is the best product for the patient and it’s not influenced by gifts and it’s not influenced by hospitality or vacations.”
However,
This Isn’t Covered…
The federation’s new code limits companies to gifts that are work-related and of modest value, such as stethoscopes or medical dictionaries, Bale said.
What I didn’t know was how far some academic medical institutions have already gone to limit sales rep’s influences.
Stanford’s ban extends to free meals, drug samples, pens and sponsorship of continuing medical education, according to the university’s website.
I wonder if any Noble Laureates have looked at the labs, grants, practice and research opportunities, their new Chair, and lavish staff offered in Stanford’s contract but shaken off the deal because their free meals would be cut off…
I’ve had my share of free lunches working in doctors offices (and all I did was put charts away and take fundus photos), and I’ve been around physicians my entire life. But these are the most extreme examples of pharma gifts I’ve ever heard of,
[S]oon I hit the harder stuff: a trip to Italy in exchange for attending a symposium, tickets to a Mets game for my sons and me (and a chatty drug rep). Et cetera. There’s a moment when each of us knows we have gone over the edge. For me, it was a trip to California where I met with a pharmacist for 30 minutes to talk about antifungal medication.
I’m not saying that isn’t “common,” but certainly not common enough for me to have run into it; even growing up with physicians as parents, and working through high school and college in multiple private surgical subspecialty offices. Tickets to a Mets game?
The thing is, there are no apologies in the article.
I don’t feel that much shame for my former behavior, at least the money-grubbing part. I just don’t think that the financial hanky-panky between drug companies and doctors constitutes the central crisis in American medicine or, for that matter, the most corrosive aspect of the entire messy doctor-drug relationship. They need us; we need them. We do the studies they can’t do because they aren’t doctors. They invent the drugs that we can’t invent because we aren’t chemists. It’s pretty straightforward, really. A symbiosis.
No, the real problem is…well, the physician kind’ve gets lost defining the real problem. But this is all light hearted so I won’t take him to task.
[Doctors] feel unappreciated by our patients and by the public. The way we see it, we’re just a bunch of blue-collar Joes with a degree, traveling through rain and sleet and snow trying to keep people healthy. Like the president, we think it’s hard work and, also like Mr. Bush, we are genuinely shocked that everyone doesn’t love us.
Enter the drug reps. Those guys love me; they really love me. I have my own personal troupe of professional grovelers who are paid to laugh at my jokes. You should join me when a few are in my office. It is a laugh riot. And you should hear the compliments I get after giving a paid lecture. My back is patted. I receive countless business cards and compliments.
So the problem isn’t the freebies or the drug reps. It is the physician ego. But not really because…
It’s not our fault, really. We’ve been working in a drug-company haze for far too long.
Ah, we’ve made a circle in our reasoning. Still, I’m not shy saying while I have a personal problem with pharma gifts, I do not think it is something that needs, nor should get, regulation.
I’m trying not to be hypocritical here. Let people pitch their products. Physicians, or many of them, don’t take pharma reps to task on a large scale. The same can’t be said about medical students and the younger crowd, who doth protest in greater numbers (they just haven’t been flown to Italy yet). Certainly, the drug rep-physician relationship draws less vocal calls for reform than say Direct To Consumer advertising.
At least that is my observation.
But the similarities between the two are there. Let’s protect the right to speech…even for apparently soulless corporations.
You don’t want to see pharm reps, don’t see them. You don’t want to give your patient a script for that blue pill he saw on television, have the gall to tell him. And yeah…I know - “you don’t have the time,” “they’ll just go to someone else,” etc. Those sound an awful lot like assholes excuses. Everyone has one.
A beautiful example of the just teeny-weeny hypocrisy of such positions is found at Mexico Medical Student’s blog as he discusses both issues. I’m not picking on him, it was just too good an example (and I found it while I was writing…I didn’t write these comments because of the post) to pass up.
And Yeah, If I Had My Way Joe Could Still Be On TV…
…I Await The Response Where Every Small Cell Carcinoma Is My Fault For That Position
Whatever the speech rights for pharm companies and their reps doctors certainly don’t have to listen. Some very good points.
My pharmacology lecturer today told a story.
Now that I have your attention with that compelling opening line to this post…
He was chatting up one of our primary teaching hospital’s Merck reps, down on the ground floor with several guys carrying platters of food behind him. Okay, your typical free lunch. The rep was on his way up to the 8th floor and the trauma/crit care surgical division.
A few hours later he gets a call, from the in house Pharm.D. covering the orders from the SICU.
“You’re not going to believe this, but I just go three orders for entrapenem in like four hours.”
Entrapenem is the carbapenem that isn’t. Also known, according to my pharm lecturer as a cross dressing cephalosporin. My pharmacology professor claims that one of the orders was for an acinetobacter infection.
Well, what’s the problem here?
It is true that carbapenem as a class is a highly effective choice against resistant acinetobacter. It certainly varies by physician and hospital whether they’re the drug of first choice or last resort (you don’t want to overuse it) But entrapenem doesn’t function like a typical carbapenem. It doesn’t cover acinetobacter.
A Merck rep sold the virtues of entrapenem over lunch and my pharm lecturer sees an increase in use within the same day, some of it inappropriately. I’m not going to take a single second hand story as hard core evidence of the massive influence gifts have on physician decision making. Still, stories like this are a little disturbing.
