Some colleagues of mine on the Healthy Skepticism listserv have lately been commenting on some postings on the "Cafe Pharma" blog (warning: it's at least PG-13 if not R):
http://www.cafepharma.com/boards/showthread.php?t=226949
I am not sure just how this changes over time; but when I logged on, the discussion thread had to do with some reps sharing stories of how they had deliberately contaminated the food they brought into physicians' offices to "get even" with various people who gave them a hard time or who did not value their services. Others took issue with such behavior. One resident, who maintains his own blog, wrote to say that now he had yet another reason not to take any food from reps, thereby setting off a torrent of abuse from the reps directed at the resident, replete with suggestions as to with whom his wife was sleeping when he was on duty.
I was guided to this blog one time before by an in-the-know acquaintance, and after 10 minutes of reading gave up in disgust. I chose at that time not to mention this blog or its contents in any of my writing on ethics and the industry, as it seemed way too cheap a shot to take at the reps as a group.
On this occasion as I read the postings I am struck by the range. Some of the reps seem thoughtful and decent and trying to maintain integrity. Others are embarrassingly juvenile, obscene, and just plain mean in their postings.
I have tried hard in my own work never to villainize reps. As I see it, reps have an impossible job. From the company's point of view, they have one function only, to move product. I ask at every opportunity for someone to tell me about a single rep who was ever paid a single bonus for anything other than quantity of drug sales--and no one has ever given me an example.
The other part of their job is to lie about this. They have to lie to two people. First they have to lie to us, because we demand it. We will not easily and comfortably take all the goodies they shove our way, unless they keep repeating over to us the soothing rationalization, "It's education, not marketing." Second they often have to lie to themselves because they can live with themselves much easier if they can see themselves as educators and not as mere salespeople. Or at least they can lie to us more glibly if they lie to themselves first.
In one respect, I can concur completely with the blog postings, as much as I am repulsed by the packaging. If I sort through the obscenities, one basic idea seems to stand out. These reps despise docs and office staff who first scarf up their food and other goodies whenever they get the chance, and then believe that they can turn around the treat the reps who brought the stuff like dirt.
I agree totally. Whether that means it's ethical to deliberately sneeze in their lasagna is an issue we can take up at another time.
Saturday, November 10, 2007
Sunday, November 4, 2007
The Drug Industry: Business is Bad
In the Epilogue of HOOKED I reviewed evidence that shows that the glory days of the pharmaceutical industry may rapidly be coming to an end. Further evidence of this may be found in a recent article from The Economist (http://economist.com/business/displaystory.cfm?story_id=10026788&CFID=24605387&CFTOKEN=99289234).
The article describes the same tale of woe--many of today's blockbuster drugs are about to go off patent; Pfizer for instance is looking to lose a cool $13 billion in annual revenue when Lipitor goes off-patent around 2010. The pipeline that was supposed to be producing the next generation of blockbuster drugs has suddenly dried up--notwithstanding heavy new investments in research by most of the leading companies. More and more of the drugs the companies have been relying on for revenues have developed safety problems, either before or after FDA approval.
In an odd turn of events, The Economist reports that even safe drugs are being axed by the companies when their sales are disappointing. Exubera, for example, Pfizer's inhaled insulin, has been one of those poor revenue performers, but has shown no safety problems. Nevertheless Pfizer CEO Jeffrey Kindler decided to pull Exubera around mid-October in a bid to cut costs. (Just what do you say to thousands of patients who have been taking your drug, presumably doing fine with it, and having no bad side effects, when you suddenly yank it off the market?)
One thing that's new, says The Economist, is that the industry leaders have stopped bluffing their way through this downturn. You can now hear such folks as Novartis CEO Daniel Vasella admit openly that the industry has to change its business model in a basic way, and can no longer thrive solely on its top-heavy marketing operation.
But just what is this new business model that will come along and save the industry? The article is pretty thin on those details. Drug firms are starting to buy up biotech firms and medical-diagnostics firms in hoping of adding research muscle and diversifying. Beyond that there is really no news here as to what the industry might have up its sleeve--if anything.
In HOOKED, at the end, I try to make a case that these industry woes might provide an opportunity for meaningful reforms, in the direction of enhanced medical professionalism, if the companies feel vulnerable and are willing finally to admit that they have a problem. Certainly if the only result of these bumps in the road is that the industry goes down the tubes, that would be an outcome that cannot possibly help anyone. Poetic justice may be emotionally satisfying but never made a sick patient better.
The article describes the same tale of woe--many of today's blockbuster drugs are about to go off patent; Pfizer for instance is looking to lose a cool $13 billion in annual revenue when Lipitor goes off-patent around 2010. The pipeline that was supposed to be producing the next generation of blockbuster drugs has suddenly dried up--notwithstanding heavy new investments in research by most of the leading companies. More and more of the drugs the companies have been relying on for revenues have developed safety problems, either before or after FDA approval.
In an odd turn of events, The Economist reports that even safe drugs are being axed by the companies when their sales are disappointing. Exubera, for example, Pfizer's inhaled insulin, has been one of those poor revenue performers, but has shown no safety problems. Nevertheless Pfizer CEO Jeffrey Kindler decided to pull Exubera around mid-October in a bid to cut costs. (Just what do you say to thousands of patients who have been taking your drug, presumably doing fine with it, and having no bad side effects, when you suddenly yank it off the market?)
One thing that's new, says The Economist, is that the industry leaders have stopped bluffing their way through this downturn. You can now hear such folks as Novartis CEO Daniel Vasella admit openly that the industry has to change its business model in a basic way, and can no longer thrive solely on its top-heavy marketing operation.
But just what is this new business model that will come along and save the industry? The article is pretty thin on those details. Drug firms are starting to buy up biotech firms and medical-diagnostics firms in hoping of adding research muscle and diversifying. Beyond that there is really no news here as to what the industry might have up its sleeve--if anything.
In HOOKED, at the end, I try to make a case that these industry woes might provide an opportunity for meaningful reforms, in the direction of enhanced medical professionalism, if the companies feel vulnerable and are willing finally to admit that they have a problem. Certainly if the only result of these bumps in the road is that the industry goes down the tubes, that would be an outcome that cannot possibly help anyone. Poetic justice may be emotionally satisfying but never made a sick patient better.
Saturday, November 3, 2007
Are We at a Turning Point on Drug Company Gifts/Bribes to Docs?
Eric G. Campbell, PhD, of the Institute of Health Policy, Massachusetts General Hospital/Harvard Medical School, has published two major surveys of relations between physicians and pharmaceutical companies so far this year--first, on individual physicians (http://brodyhooked.blogspot.com/2007/04/new-england-journal-study-shows.html), and then on medical school departments and department heads (http://brodyhooked.blogspot.com/2007/10/academic-departments-lots-of.html). In the latest issue of the New Enland Journal, Campbell summarizes the current scene:
http://content.nejm.org/cgi/content/full/357/18/1796
Campbell first notes legislative efforts at both Federal and state levels to require reporting of all company gifts to physicians. Then, after reviewing the reasons why marketing influence can harm patients' interests, he notes the increasing number of academic medical centers that have enacted strict policies banning drug reps and their gifts. He offers the opinion that maybe we are coming to a turning point when more and more physicians and medical centers will choose to divest themselves from the industry gravy train, and that either new laws, or the threat of them, might stimulate more aggressive internal measures by medical groups.
In the end Campbell offers some suggestions to individual practitioners, to "maximize the benefit for patients and minimize the risks associated with their own industry relationships."It may be worth assessing the value of these recommendations by comparing to material discussed in HOOKED:
http://content.nejm.org/cgi/content/full/357/18/1796
Campbell first notes legislative efforts at both Federal and state levels to require reporting of all company gifts to physicians. Then, after reviewing the reasons why marketing influence can harm patients' interests, he notes the increasing number of academic medical centers that have enacted strict policies banning drug reps and their gifts. He offers the opinion that maybe we are coming to a turning point when more and more physicians and medical centers will choose to divest themselves from the industry gravy train, and that either new laws, or the threat of them, might stimulate more aggressive internal measures by medical groups.
In the end Campbell offers some suggestions to individual practitioners, to "maximize the benefit for patients and minimize the risks associated with their own industry relationships."It may be worth assessing the value of these recommendations by comparing to material discussed in HOOKED:
- Recognize that relationships with industry have one goal, to influence their prescribing behavior in industry-friendly directions, and assess the impact of these relationships on one's patients-- this is certainly good basic advice. I would add--all practitioners need to be regularly sensitized to the prevalent rationalizations that their colleagues use to justify the status quo and that industry sources are only too happy to reinforce vigorously: "it's education, not marketing"; "others may be influenced but I am a scientific reasoner and cannot be influenced"; "it's insulting to think that I can be boiught for a donut or a coffee mug"; and so on as we have extensively reviewed in this blog. After a while, no physician should be able to repeat these rationalizations without blushing.
- Be familiar with policies and codes of ethics of one's medical institutions and professional societies-- this will be good advice for docs who happen to work for the forward-looking centers that have banned reps and their stuff. If the doc works for one of the majority that are not yet that enlightened, instiitutional policy won't help much. Ditto, as HOOKED shows, for most association codes of ethics. Most are based on now-discredited ideas that gifts are OK so long as they are of low monetary value, are "modest" meals, are aimed at patient care, and so forth.
- Remember that ultimately the patients pay for all this junk--This also seems like good advice, and indeed, based on purely anecdotal evidence, this realization has provided the "aha!" moment for at least some physicians who ended up dissociating themselves from the reps' grip.
Thursday, November 1, 2007
How Pharma Pads Its Research Costs
In HOOKED I mentioned in passing that the drug industry claims that it spends more on research and development than on marketing, while virtually all independent economists put the figures at roughly 12% of revenues going to R&D while as much as 30% of revenues go to marketing. Besides that little white lie, the industry routinely pads its research numbers by slipping into the research column activities that really cannot be construed as research by any fair-minded criterion. The only specific example I was able to give, however, was "seeding trials"-- pretend post-marketing clinical trials which are really more disguised bribery, in which physicians are paid to give the drug to patients and to fill out meaningless "data" forms, the whole idea being to get practitioners to get used to prescribing the drug more and more.
I recently received from Donald Light, health systems professor at University of Medicine and Dentistry of New Jersey and an affiliate of the University of Pennsylvania Center for Bioethics, a copy of a recent book chapter he wrote. Among many other good things he provides a very handy list of these fake "research" budget items. Besides seeding trials, his list includes:
I recently received from Donald Light, health systems professor at University of Medicine and Dentistry of New Jersey and an affiliate of the University of Pennsylvania Center for Bioethics, a copy of a recent book chapter he wrote. Among many other good things he provides a very handy list of these fake "research" budget items. Besides seeding trials, his list includes:
- executive costs of negotiating with other firms for new product licensing
- costs for medical writers and PR staff to write media stories about trials while they are in progress, to stimulate market demand
- support for medical journal supplements and ads in those journals, as those are often the venue where lower-quality clinical trials can get published
- lectures and CME courses to inform practitioners about current research
- legal fees related to patents and licenses, and other research-related matters
- land and construction costs for buildings in which some research is done, even if only a small amount of space is devoted to research
- company-wide technical upgrades such as new computers or software
Today's Integrity Award: A Pakistani Psychiatrist
I cannot promise that each day I will issue an Integrity Award (let alone post a blog entry), but such as it is, today's award goes to Dr. Murad Moosa Khan, professor of psychiatry at Aga Khan University in Karachi, and author of "Why I declined an invitation to a drug company seminar":
http://www.bmj.com/cgi/content/short/335/7625/887?etoc
There are several reasons why Dr. Khan seemed to merit special recognition:
http://www.bmj.com/cgi/content/short/335/7625/887?etoc
There are several reasons why Dr. Khan seemed to merit special recognition:
- He referred to the invitation to the seminar, at a 5-start hotel in Pakistan, as "a form of bribery" (see my other post today on that topic).
- He is alert to the negative consequences of pushiong psychiatric drugs in his country, both for the patients who might be better served by a different form of treatment, and the excessive costs of the drugs that could better be invested elsewhere.
- Dr. Khan emphasizes the social circumstances of psychiatric illness. He notes that most of his patients with the worst mental health problems are poor, and that Pakistan has no effective public policy for dealing with mental illness. He also berates the medical schools in Pakistan for failing to teach most physicians about any form of psychiatric management.
Consumers International Report: A Must-Read
In my recent post on bribery I mentioned the new report from Consumers International:
http://marketingoverdose.org/documents/ci_pharma_2007.pdf
This 44 page report focuses on how drug marketing to physicians in the developing world seriously distorts health priorities. CI concludes that industry self-regulation is a flop, and calls for strict legal bans on "gifts" from drug companies to doctors in developing countries, with severe sanctions for violators.
ADDED 11/4/07: Here are a few more details from this important report. CI notes that most developing countries have effectively abandoned regulation of pharamceutical marketing to the industry. In turn, industry has blatantly violated many of its own claimed ethical codes. Advertisements to physicians in developing countries often leave out even the limited information that is required for the same drug in the developed world, and give blatantly misleading impressions about a drug. CI estimates that up to 50% of medicines in developing countries are irrationally prescribed. In these countries, people may pay a much larger percentage of their extremely limited health care dollars for medicines, so when an expensive drug does not work or is dangerous, the damage is doubled--both the direct effects of the drug, and the waste of money that could have been so much better spent on something else. While the amount of business done in the developing world by the major international drug companies is a small percentage of their total, this small sum is increasing much faster proportionally than most other sectors of the company's business, making it very tempting to keep on doing what drives the most profits. "Gifts" to physicians are often thinly disguised payoffs for the quantity of prescriptions written. Cars and televisions are not uncommon gifts received by high-prescribing doctors. (Popular gifts noted in a Pakistani survey included air conditioners, cars, cash, home appliances, and domestic cattle--the last a nice homey touch, don't you think?) Other popular gifts are air tickets, hotel and meal expenses to attend CME conferences, which are simply outside the affordability range of many practitioners in these nations without company funding.
CI notes that there are already laws and regulations against many of these practices; they need to be enforced. They call for a total ban on gifts; transparency in all industry marketing practices; and more government efforts at making CME and unbiased drug information available to their doctors.
A sad anecdote from Kenya--medical students have been spotted wearing white coats with drug company logos on them. When U.S. educators see residents going around with a lot of drug company pens and other gimmicks sticking out of all their pockets, they often try to shame them by asking, "Would you sell the company advertising space on your white coat?" In Kenya the answer seems to be "yes." CI reports that the same rationalizations that are in common usage among U.S. physicians to excuse taking company largesse are in evidence all around the world--only perhaps more understandable in nations where physicians are paid a relative pittance compared to their American income.
http://marketingoverdose.org/documents/ci_pharma_2007.pdf
This 44 page report focuses on how drug marketing to physicians in the developing world seriously distorts health priorities. CI concludes that industry self-regulation is a flop, and calls for strict legal bans on "gifts" from drug companies to doctors in developing countries, with severe sanctions for violators.
ADDED 11/4/07: Here are a few more details from this important report. CI notes that most developing countries have effectively abandoned regulation of pharamceutical marketing to the industry. In turn, industry has blatantly violated many of its own claimed ethical codes. Advertisements to physicians in developing countries often leave out even the limited information that is required for the same drug in the developed world, and give blatantly misleading impressions about a drug. CI estimates that up to 50% of medicines in developing countries are irrationally prescribed. In these countries, people may pay a much larger percentage of their extremely limited health care dollars for medicines, so when an expensive drug does not work or is dangerous, the damage is doubled--both the direct effects of the drug, and the waste of money that could have been so much better spent on something else. While the amount of business done in the developing world by the major international drug companies is a small percentage of their total, this small sum is increasing much faster proportionally than most other sectors of the company's business, making it very tempting to keep on doing what drives the most profits. "Gifts" to physicians are often thinly disguised payoffs for the quantity of prescriptions written. Cars and televisions are not uncommon gifts received by high-prescribing doctors. (Popular gifts noted in a Pakistani survey included air conditioners, cars, cash, home appliances, and domestic cattle--the last a nice homey touch, don't you think?) Other popular gifts are air tickets, hotel and meal expenses to attend CME conferences, which are simply outside the affordability range of many practitioners in these nations without company funding.
CI notes that there are already laws and regulations against many of these practices; they need to be enforced. They call for a total ban on gifts; transparency in all industry marketing practices; and more government efforts at making CME and unbiased drug information available to their doctors.
A sad anecdote from Kenya--medical students have been spotted wearing white coats with drug company logos on them. When U.S. educators see residents going around with a lot of drug company pens and other gimmicks sticking out of all their pockets, they often try to shame them by asking, "Would you sell the company advertising space on your white coat?" In Kenya the answer seems to be "yes." CI reports that the same rationalizations that are in common usage among U.S. physicians to excuse taking company largesse are in evidence all around the world--only perhaps more understandable in nations where physicians are paid a relative pittance compared to their American income.
The Framing Problem, and Physician Bribery
First, and apparently (but not really) off the subejct--if you do not know about the Rockridge Nation website and blog, you should. Here is a great recent piece on children's health insurance:
http://www.rockridgenation.org/blog/archive/2007/10/26/schip-and-the-rigged-health-insurance-game
The point of this "progressive" website is all about framing. As linguist and Rockridge founder George Lakoff has written about for some time, political discourse in the US has deteriorated because one side of the political spectrum has been amazingly successful in framing many issues in such a way that the words used to describe the issue pre-determine the conclusions. There cannot be an honest political debate because one side of the issue never gets under the spotlight for discussion. For that reason we must be extremely careful of the language used to frame any policy discussion, and to be sure that it enhances rather than retards understanding of what is at stake.
Now, back to Pharma. I thought of the framing issue yesterday when two headlines came across the ether:
Name and shame 'bribed' doctors
Tamara McLean, Herald Sun (Australia), Oct. 31
http://www.news.com.au/heraldsun/story/0,21985,22679124-5005961,00.html
Drug firms try to bribe doctors with cars
Sarah Boseley, The Guardian (London), Oct. 31
http://www.guardian.co.uk/print/0,,331116619-103681,00.html
(Both these stories relate to the recent Consumers International report, which I will address in a second posting.)
Did you say "bribe"?
I thought--in HOOKED, I refer all the way through to "gifts" given to physicians by pharmaceutical companies. The companies themselves try not to go so far as even to say "gifts"--they call the small stuff with company logos, like pens and mugs, "branding items" or "reminder items," and they try to label all the big stuff as some sort of "education" or other.
These recent newspaper headline writers, apparently emboldened by the tough new report from Consumers International, had no problem calling the practice by a more proper, accurately descriptive name. (Dictionary.com tells us that "bribe (noun)" means: money or any other valuable consideration given or promised with a view to corrupting the behavior of a person, esp. in that person's performance as an athlete, public official, etc. All we have to establish for "gifts" from the drug industry to physicians to become "bribes" is that the commercial influence has the view of "corrupting" and that the behavior of a physician is analogous to that of a public official with regard to public trust. I offer arguments in HOOKED to show that those things are so.
So, if the goodies dangled before physicians by the drug companies are in fact bribes, why have we been giving them a free ride for so long and using euphemisms?
(I cannot help adding as a footnote that when I showed my wife the headline from The Guardian, her reply was: "So--they are not trying to bribe doctors who don't have cars?")
http://www.rockridgenation.org/blog/archive/2007/10/26/schip-and-the-rigged-health-insurance-game
The point of this "progressive" website is all about framing. As linguist and Rockridge founder George Lakoff has written about for some time, political discourse in the US has deteriorated because one side of the political spectrum has been amazingly successful in framing many issues in such a way that the words used to describe the issue pre-determine the conclusions. There cannot be an honest political debate because one side of the issue never gets under the spotlight for discussion. For that reason we must be extremely careful of the language used to frame any policy discussion, and to be sure that it enhances rather than retards understanding of what is at stake.
Now, back to Pharma. I thought of the framing issue yesterday when two headlines came across the ether:
Name and shame 'bribed' doctors
Tamara McLean, Herald Sun (Australia), Oct. 31
http://www.news.com.au/heraldsun/story/0,21985,22679124-5005961,00.html
Drug firms try to bribe doctors with cars
Sarah Boseley, The Guardian (London), Oct. 31
http://www.guardian.co.uk/print/0,,331116619-103681,00.html
(Both these stories relate to the recent Consumers International report, which I will address in a second posting.)
Did you say "bribe"?
I thought--in HOOKED, I refer all the way through to "gifts" given to physicians by pharmaceutical companies. The companies themselves try not to go so far as even to say "gifts"--they call the small stuff with company logos, like pens and mugs, "branding items" or "reminder items," and they try to label all the big stuff as some sort of "education" or other.
These recent newspaper headline writers, apparently emboldened by the tough new report from Consumers International, had no problem calling the practice by a more proper, accurately descriptive name. (Dictionary.com tells us that "bribe (noun)" means: money or any other valuable consideration given or promised with a view to corrupting the behavior of a person, esp. in that person's performance as an athlete, public official, etc. All we have to establish for "gifts" from the drug industry to physicians to become "bribes" is that the commercial influence has the view of "corrupting" and that the behavior of a physician is analogous to that of a public official with regard to public trust. I offer arguments in HOOKED to show that those things are so.
So, if the goodies dangled before physicians by the drug companies are in fact bribes, why have we been giving them a free ride for so long and using euphemisms?
(I cannot help adding as a footnote that when I showed my wife the headline from The Guardian, her reply was: "So--they are not trying to bribe doctors who don't have cars?")
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