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First of all, it would be useful to understand just what doctors are up against. According to some of the pharmaceutical industry's own numbers, there is one drug rep for every two to three doctors. Imagine how many drug reps come in and out of a doctor's office in a single week, vying for attention.
And they've done their homework. Before setting foot in a doctor's office, drug reps know how many patients he or she sees. They know what drugs the doctor prescribes and in what quantities. They know everything about the doctor's particular patient population. All of this information is available for purchase, of course. Pharmacies, Wal-Mart, your insurance company — all sell your information to third-party medical intelligence vendors such as IMS Health, which aggregate the numbers. And by information, we mean your body-mass index, your allergies, the prescription drugs you take, your last hospitalization, your zip code — everything but your name and address, a distinction that allows the vendor to remain kosher under the Health Insurance Portability and Privacy Act.
Even the American Medical Association gets a huge chunk of its yearly revenue from selling the information of its membership — specifically the Drug Enforcement Agency number that denotes an individual doctor. That number enables IMS Health to pair the prescription with the prescriber and the patient with the doctor, then to sell the whole package to Big Pharma. It's as close to omniscient as an industry can get without violating a whole host of federal laws.
As a result, drug companies know well what works and what doesn't. They can tell if prescriptions go up after bringing lunch to a doctor's office. They can tell if inviting a doctor to their speaker's lecture at Ruth's Chris Steakhouse (and picking up the tab while compensating them handsomely for their time) increases prescriptions — and it does, according to a number of studies in the Journal of the American Medical Association. Generally, JAMA researchers found that doctors who've been paid to speak for a pharmaceutical company or who have attended its promotional lectures are more likely to request that the specific company's drugs be added to the hospital formulary.
In fact, an internal Merck study obtained by the Wall Street Journal in 2005 showed the industry had quantified the "return on investment" of having a doctor speak for them down to the penny. According to the document, doctors who attended a promotional lecture led by another physician wrote an additional $623.55 in prescriptions of the Merck drug Vioxx — which has been voluntarily withdrawn from the market — than doctors who didn't attend. If the discussion was held in a more intimate venue over dinner, the figure rose to nearly $720.
If a drug rep led the discussion, on the other hand, the "return on investment" was far smaller. In pharmaceutical marketing, credibility is everything. Merck just put a price tag on it.
Dr. Terri Jerkins, a Nashville endocrinologist, takes issue with the perception that the money corrupts. Jerkins, who made $213,719 from her speaking engagements in 2009 and 2010, has relationships with five of the seven pharmaceutical companies currently disclosing physician payments — more than any of the top-paid docs in the country at the moment. She says she only speaks for drugs that she believes actually work. Being a solo practitioner, she says low Medicare reimbursement rates and high overhead make it tough to stay solvent. Speaking for drug companies pays the bills, she says.
"I'm not ashamed of it," Jerkins says. "All my patients know I lecture. I've got a waiting list six months long. If they're disturbed I lecture for pharmaceutical companies, bye. There are plenty of other people out there."
But patients could hardly be blamed for their fears, given the number of studies that suggest such interactions with Big Pharma influence which drugs doctors prescribe and how often. This worries the country's medical ethicists, who are unified in opposition to any unspoken quid pro quo — and to doctors acting as spokespeople, wittingly or not.
"I think what I'd ask them is, 'Do you think your opinion is getting influenced by taking all this money?' says Ellen Wright Clayton, a physician and attorney who teaches biomedical ethics at Vanderbilt. "And they're gonna say no. And the answer is: Of course it is."
To be clear, it's not as if the lecturer is getting up on the dais and making a snake-oil come-on for the wonders of Vioxx or Avandia — two hotly promoted drugs that did not exactly prove to be the greatest panaceas known to man. Doctors are educated sophisticates, not tent-show rubes — which is why peer-to-peer promotion works so well.
"They're talking to me, I'm talking to them," said Dr. Amanda Sparks-Bushnell, a psychiatrist and head of The Sparks Clinic near Centennial Medical Center. "It's a scientific exchange."
That exchange has been beneficial for Sparks-Bushnell. During 2009 and 2010, she made nearly $127,000 from Pfizer and especially Eli Lilly in speaking and consulting fees, the companies' disclosures indicate. She's also spoken for Sepracor, Wyeth and other companies, she says, which currently aren't required to disclose payments to physicians. Speaking for different companies, she believes, keeps her impartial.
"I think the appearance of that is important and not having all your eggs in one basket," Sparks-Bushnell says.
Sparks-Bushnell was first approached by a drug rep who informed her that she'd been chosen as a "key opinion leader," the industry's term for a cutting-edge medical luminary. She attended company speaker training, where she says she was brought up to speed on current research and federal guidelines for doctors who belong to industry speaker bureaus — one of the closest relationships a doctor can have with Big Pharma.
Why she was singled out as an opinion leader in the community isn't immediately clear. The industry often targets up-and-comers with academic appointments and published research. Yet Sparks-Bushnell admits she hasn't taken part in any clinical trials, and a search of the U.S. National Library of Medicine database doesn't turn up any medical journal articles under her byline. So why, then, was she chosen?
According to Dr. Adriane Fugh-Berman, a Georgetown University School of Medicine professor and director of PharmedOut, a research and education project examining the influence Big Pharma has on doctors, the industry chooses its speakers in a few ways. It might target a psychiatrist like Sparks-Bushnell with a bustling practice. The industry spends more money paying psychiatrists to speak than it does specialists in any other field, because psychiatry relies so heavily on prescription drugs.
As for the training given to those speakers, Fugh-Berman argues that it's little more than promotional indoctrination.
"They invite hundreds of doctors to speaker training, and they pay them hundreds at a nice resort, but it's not really speaker training," she says. "It's paying you to memorize marketing messages and thinking, 'I'm going to be one of the [key opinion leaders].' But what happens is, your own prescribing goes up."
It doesn't hurt if the doctors who hear their lectures prescribe more too. After attending speaker training, Sparks-Bushnell says she most often speaks to small groups of doctors, nurses and physician assistants at their offices and over dinner. For these talks, a speaker can make anywhere from $500 to $1,000. Sparks-Bushnell says she's there to discuss current research and the treatment of disease, not just to promote the drug developed by the company that sponsors the dinner.
But in a 2006 piece in The Atlantic written by Dr. Carl Elliott, a professor at the University of Minnesota's Center for Biomedical Ethics, a drug rep confided that if a speaker "didn't write (a bunch of prescriptions), he wouldn't speak." It's worth noting that nobody gets a continuing medical education credit — courses that are supposed to keep physicians current in their specialty — for attending such gatherings, though they do generally get paid.
No one — neither the speaker nor the attendee — thinks of it as unadulterated industry shilling. To Sparks-Bushnell, it's education: a chance for colleagues to share information on the latest treatments. To Fugh-Berman, that's the insidious part.
"Everything has to be camouflaged," Fugh-Berman says. "The bribes have to be camouflaged. The promotion has to look like education, even if you're not getting the CME credit."
The line between continuing medical education and promotion is already sometimes hard to discern. Dr. Jon Draud is the medical director of the psychiatry department and addiction medicine services at Baptist Hospital and Middle Tennessee Medical Center, according to his bio. He's also the highest-paid industry speaker in Nashville, making just over $240,000 during 2009 and 2010, the industry disclosures say.
Draud often lectures before a much broader audience than your average dinnertime promotion. He did not respond to repeated messages requesting comment, but a cursory Web search indicates — along with the Pharma speaker bureaus he belongs to — that he also speaks at continuing medical education functions for CME LLC., an education company funded by a who's who of pharmaceutical-industry players. Not coincidentally, that roster includes every company he speaks for.
It's quite common for companies that provide continuing medical education to choose speakers from a list supplied by the industry. According to testimony before the U.S. Senate Committee on Aging, some 90 percent of the funding for those companies comes from pharmaceutical providers. And because the industry money is delivered through a CME company, Draud does not have to disclose these payments, known as "honoraria."
"It's not just the money. It's not just the amount of the money," Fugh-Berman says. "It is part of a very multifaceted, very far-reaching, octopus-like campaign that includes every source of medical information physicians depend on." (It should be noted that Fugh-Berman is a paid expert witness on behalf of plaintiffs in litigation regarding pharmaceutical marketing practices.)
In 2007, the research firm Integrated Medical Systems estimated the drug industry was spending $20 billion a year to cultivate relationships with doctors. The National Institute of Medicine recently recommended that interaction between doctors and industry be curtailed — accepting gifts, meals and drug samples; making industry-funded and –controlled presentations — and to examine ways to provide industry-free CME. Harvard has forbidden its faculty from joining industry speaker bureaus. Vanderbilt toughened its conflict of interest policy in 2009, banning the acceptance of gifts, though it doesn't ban speaking and consulting for the pharmaceutical industry.
Already realizing the subtle influence Big Pharma has on what is supposed to be objective medical education, a handful of academic hospitals, medical schools and medical centers have banned or drastically reduced industry-sponsored CME: University of Michigan Medical School, Memorial Sloan-Kettering Cancer Center, East Carolina University's Brody School of Medicine and Kaiser Permanente's mid-Atlantic region.
But the CME-industry relationship is so firmly cemented that when Fugh-Berman gave a CME lecture to a hospital's assembled doctors on Big Pharma's influence, one incredulous cardiologist asked, "How did you get in here?"
"We responded, quite honestly, that the department coordinator thought we were drug reps," Fugh-Berman recalls. "And we paid for lunch."
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