Q: What do you do when the old stuff you have been saying seems not to be working so well any more--but you don't have anything new to say?
A: Say the old stuff over again, only louder.
At least that seems to be PhRMA's plan. Whenever something happens that challenges the main lobbying group for the nation's big pharmaceutical companies, you can count on a highly placed individual in the organization to appear in the media with a prominent opinion column, reciting the PhRMA party line.
The latest challenge was the Campbell et al. survey of physicians in the New England Journal (http://brodyhooked.blogspot.com/2007/04/new-england-journal-study-shows.html). The industry took quite a beating in the way the media covered that news. That 94 percent of physicians have contact with industry representatives is good, because those contacts provided valuable information about drugs, but don't unduly influence scientific prescribing--well, nobody was buying that story.
So PhRMA trotted out Scott Lassman, its senior assistant general counsel, whose op-ed, "Does a drug firm's free lunch influence doctors?" appeared in the Boston Globe on May 18. Lassman started off by briefly summarizing the Campbell survey, and added a point "ironically and rarely noted in the subsequent media coverage"-- that the investigators paid each physician $20 for participating in the survey. A standard measure these days as fewer and fewer folks respond to mailed surveys; but apparently in Lassman's eyes, it amounted to something sinister. After all, PhRMA gives physicians nice stuff, and then expects them to do what the drug industry wants them to. It only stands to reason that if somebody else is paying the physicians, they might go over to the enemy.
Lassman then proceeds to trot out all the familiar war horses:
"Who knows better about the scientific complexities of prescription medicines than the companies that create them?"
"...it seems to me to be insulting...[to say] that a meeting, a pizza, or a pen would inappropriately influence a physician's prescribing decisions."
A bit off the point, but have you noticed that whenever PhRMA is talking about gifts from drug reps being powerless to sway the scientific practitioner, the gifts always appear in the singular and never in the plural? A pizza. A pen. A doughnut. I guess that old ad was wrong; you can eat just one potato chip. No doubt if the doc ever took two pens, the industry could have its way with him. But the doc, being an abstemious sort of fellow, always takes only one pen, so everything is all right.
Back to Lassman. "This debate is really about trust." Yes, he got that part right. But whereas the media have for the most part drawn the logical conclusion that physicians become less trustworthy when they get their drug information, as well as a bunch of freebies, from biased commercial sources, Lassman wants to stand this idea on its head: "Just as patients trust their physician, it is equally important that physicians trust their pharmaceutical representatives."
Now, you might say that there is no reason on earth why physicians should trust a person who has one and only one job, who has been trained to do that job, and who is paid bonuses strictly based on whether or not he does that job--get the physician to prescribe more of the firm's drug, and push whatever physician's buttons have to be pushed to make that happen. But Lassman is now full of this trust thing, and so proceeds to tell us once again about the "strict" code of ethics imposed by PhRMA "more than four years ago" and that is in keeping with the AMA code of ethics. Now, referring to the PhRMA code of ethics is odd in relation to the Campbell et al. survey, since that survey is one of the most striking pieces of information to date on how widespread may be violations of the PhRMA code of ethics. If gifts are supposed to be modest and related directly to patient care, and some gifts are completely prohibited (such as tickets to sports events), then it would have been very hard for Campbell and company to come up with some of the figures that they came up with.
A few days before Lassman's op-ed appeared in the Boston Globe, a Seattle family physician, Steve Dudley, published a short essay in the Los Angeles Times ("The gifts that keep on giving," May 14). It's a bit hard to track what Dudley is actually saying in this ambiguous narrative. At the end, you don't know whether he has had an "aha" moment regarding how he is being corrupted by the free samples and free lunches the reps shower him with, or whether old habits rise up and drown out the "aha." But my point in bringing Dudley into this is that he has to hurry up to finish his clinic that day because he's due at the ballpark where box seats and free beer and brats await him, courtesy the drug rep. That is as clear a violation as you could wish of the PhRMA and AMA codes of ethics, and here's a doc writing about it in the LA Times as if it's the most normal thing in the world.
Just how well are the PhRMA guidelines being followed? If PhRMA would give us some hard data, instead of warmed-over smoke and mirrors such as Lassman's op-ed, we might actually know something. And don't tell me that the industry that manages to track every prescription written by every doc in the nation has no hard data.
Saturday, May 19, 2007
Saturday, May 12, 2007
Wake Up, Physicians: The Back Room Isn't Out of Sight Any More
The Tennessean (Nashville) had a forceful editorial last week, jumping off from the widely publicized study by Campbell et al. in the New England Journal (read about the NEJM study at http://brodyhooked.blogspot.com/2007/04/new-england-journal-study-shows.html):
http://www.tennessean.com/apps/pbcs.dll/article?AID=/20070509/OPINION01/705090427/-1/ARCHIVES
The editorial was pretty hard-hitting in condemning conflicts of interest that are destroying patient trust in physicians, but what especially caught my attention were the readers' comments posted on the website below the editorial. Here is a sampling:
***
The last three times I visited my doctor, Pharma Reps were setting up breakfast or lunch. Once while sitting in the waiting room, a Rep strolled in and asked the Receptionist if he could get "on the List" to provide breakfast or lunch to the office. She pulled out what I can only assume was an appointment log to keep track of lunch and breakfast appointments for the reps. She gave him a time and he happily went on his way. The office smelled of food all three times. I heard one of the staff say, "What's for lunch?" and another said I don't know but it smells like Mexican food. It appeared to be an everyday thing with this particular group. I stopped going in their office because I always came out with a handful of Rx that I didn't need.
***
I was recently at my doctor's office. A rep from a pharmaceutical company came in. He was ushered into the front office where he hooked his laptop up to one of the doctor's computers and did a download. After he finished, he thanked them and said, "I'll see you next month", then left. I am in the healthcare field myself and understand the pressures on health care providers to safeguard patient information. [HIPAA] has folks running scared. I had to wonder what kind of incentive would be strong enough to get my doctor to let someone walk in to his office and get unfettered access to one of his computers.
***
What most struck me about these postings was the way that I think my fellow physicians regard their relationships with drug reps. (I cannot document this with firm data.) It is my impression that physicians, over many years, have gotten used to thinking of what happens between them and the reps as occurring in the "back room." The giving of gifts, the providing of lavish lunches for the office staff, all supposedly happen out of sight of patients. The physician can have his cake (or his sandwich or his pizza) and eat it too. He gets all these freebies but never has to worry about patients seeing what is going on and asking embarrassing questions--or, worse, deciding that they can no longer trust this doc because he seems to be in bed with the industry.
Well, guys, wake up. There is no "back room" any more. All our shenanigans are now clearly visible to the patients. And an increasing number of them don't much like what they see. Check out the Tennessean editorial if you don't believe that.
http://www.tennessean.com/apps/pbcs.dll/article?AID=/20070509/OPINION01/705090427/-1/ARCHIVES
The editorial was pretty hard-hitting in condemning conflicts of interest that are destroying patient trust in physicians, but what especially caught my attention were the readers' comments posted on the website below the editorial. Here is a sampling:
***
The last three times I visited my doctor, Pharma Reps were setting up breakfast or lunch. Once while sitting in the waiting room, a Rep strolled in and asked the Receptionist if he could get "on the List" to provide breakfast or lunch to the office. She pulled out what I can only assume was an appointment log to keep track of lunch and breakfast appointments for the reps. She gave him a time and he happily went on his way. The office smelled of food all three times. I heard one of the staff say, "What's for lunch?" and another said I don't know but it smells like Mexican food. It appeared to be an everyday thing with this particular group. I stopped going in their office because I always came out with a handful of Rx that I didn't need.
***
I was recently at my doctor's office. A rep from a pharmaceutical company came in. He was ushered into the front office where he hooked his laptop up to one of the doctor's computers and did a download. After he finished, he thanked them and said, "I'll see you next month", then left. I am in the healthcare field myself and understand the pressures on health care providers to safeguard patient information. [HIPAA] has folks running scared. I had to wonder what kind of incentive would be strong enough to get my doctor to let someone walk in to his office and get unfettered access to one of his computers.
***
What most struck me about these postings was the way that I think my fellow physicians regard their relationships with drug reps. (I cannot document this with firm data.) It is my impression that physicians, over many years, have gotten used to thinking of what happens between them and the reps as occurring in the "back room." The giving of gifts, the providing of lavish lunches for the office staff, all supposedly happen out of sight of patients. The physician can have his cake (or his sandwich or his pizza) and eat it too. He gets all these freebies but never has to worry about patients seeing what is going on and asking embarrassing questions--or, worse, deciding that they can no longer trust this doc because he seems to be in bed with the industry.
Well, guys, wake up. There is no "back room" any more. All our shenanigans are now clearly visible to the patients. And an increasing number of them don't much like what they see. Check out the Tennessean editorial if you don't believe that.
NY Times: Docs Rake in Money, Prescribe More drugs
The article that appeared May 10 in the New York Times is very important because it addresses an issue on which current data is rather lacking--the "proof" that physicians are influenced by benefits received from industry. The hypohesis that physicians will alter prescribing behavior based on goodies, obviously, cannot be studied in a randomized, controlled trial. There is always the possibility of contamination. The available data strongly suggest that the hypothesis is true, and no good evidence tends to disprove the hypothesis. But any further data, even if of questionable quality, helps to make the case.
That is what the Times reporters seem to have done. They took advantage of the legal mandatory reporting system in Minnesota, requiring companies to report payments to doctors. They chose a small slice of medical practice--child psychiatry. They picked one variable that they could find in public data--prescriptions for atypical antipsychotics to children under the state's Medicaid program.
These prescriptions are especially important for a couple of reasons. First, most of these drugs are poorly studied in kids and some experts belive that they are now being greatly overused. (In defense of the docs, we should add that the average Medicaid patient will get a private audience with the Queen of England about as soon as he will get long term, competent psychotherapy; so the docs might reasonably feel that their only choices are to prescribe possibly dangerous drugs off-label, or do nothing at all.) Second, if these drugs are actually effective for anything, it is very likely that cheaper, older antipsychotics are actually just as good as well as being a lot cheaper--tho again, we are not sure when it comes to kids.
So what did the Times reporters find? Between 2000 and 2006, payments to MN psychiatrists from the manufacturers of these drugs rose more than 6 times; and the number of scripts written for these drugs rose more than 9 times. The docs who received at least $5000 from the drug makers appear to have written 3 times as many of those scripts as psychiatrists who received less or no money.
The article went on to describe at length the payment arrangements for these MN psychiatrists. Most of them are paid as members of company speakers' bureaus. From this article, it appears that virtually every child psychiatrist in MN is a member of one of these speakers' bureaus, leaving one to wonder who the audience is--maybe they sit in a big circle and pass the microphone around the table. Actually, it's not quite that bad; the article stated that "more than a third" of MN's licensed psychiatrists took money, so maybe more than half did not.
My personal sleaze award goes to Dr. Suzanne A. Albrecht, from Edina, MN, who earned more than $188,000 over a 3 year period for giving these talks. (She's nothing compared to Dr. Annette M. Smick, near Rochester, who topped the list by earning $689,000 over a 6 year period.) Dr. Albrecht defended herself to the Times by saying, "If someone takes the point of view that your doctor can be bought, why would you go to an E.R. with your injured child and say, 'Can you help me?'"
It's worth taking that comment apart word by word. What is Dr. Albrecht saying? That because all docs are like her, you should not take your injured child to an ER? (Like you have a choice?)Or that because you would take your injured child to an ER, that somehow proves that what she is doing is OK? Dr. A. seems oblivious to the logical conclusion, that if someday, people actually did so lose trust in physicians that they hesitated to take their injured kids to the ER, people like her could look themselves in the mirror and say that they were the reason for this distrust.
Another great quote in the article comes from Dr. Melissa DelBello, a strong advocate of the use of atypical antipsychotics for kids diagnosed with bipolar disorder. Dr. DelBello teaches at the University of Cincinnati, and since she is not from MN, the Times could not find figures on what she was paid as a speaker. "Trust me," she told the reporters, "I don't make much." In Hooked, I used a classic quote from P.G. Wodehouse, "When an Englishman says 'trust me,' it's time to start counting the spoons."
Gardiner Harris, Benedict Carey, and Janet Roberts. "Psychiatrists, Children and Drug Industry's Role." New York Times, May 10, 2007.
That is what the Times reporters seem to have done. They took advantage of the legal mandatory reporting system in Minnesota, requiring companies to report payments to doctors. They chose a small slice of medical practice--child psychiatry. They picked one variable that they could find in public data--prescriptions for atypical antipsychotics to children under the state's Medicaid program.
These prescriptions are especially important for a couple of reasons. First, most of these drugs are poorly studied in kids and some experts belive that they are now being greatly overused. (In defense of the docs, we should add that the average Medicaid patient will get a private audience with the Queen of England about as soon as he will get long term, competent psychotherapy; so the docs might reasonably feel that their only choices are to prescribe possibly dangerous drugs off-label, or do nothing at all.) Second, if these drugs are actually effective for anything, it is very likely that cheaper, older antipsychotics are actually just as good as well as being a lot cheaper--tho again, we are not sure when it comes to kids.
So what did the Times reporters find? Between 2000 and 2006, payments to MN psychiatrists from the manufacturers of these drugs rose more than 6 times; and the number of scripts written for these drugs rose more than 9 times. The docs who received at least $5000 from the drug makers appear to have written 3 times as many of those scripts as psychiatrists who received less or no money.
The article went on to describe at length the payment arrangements for these MN psychiatrists. Most of them are paid as members of company speakers' bureaus. From this article, it appears that virtually every child psychiatrist in MN is a member of one of these speakers' bureaus, leaving one to wonder who the audience is--maybe they sit in a big circle and pass the microphone around the table. Actually, it's not quite that bad; the article stated that "more than a third" of MN's licensed psychiatrists took money, so maybe more than half did not.
My personal sleaze award goes to Dr. Suzanne A. Albrecht, from Edina, MN, who earned more than $188,000 over a 3 year period for giving these talks. (She's nothing compared to Dr. Annette M. Smick, near Rochester, who topped the list by earning $689,000 over a 6 year period.) Dr. Albrecht defended herself to the Times by saying, "If someone takes the point of view that your doctor can be bought, why would you go to an E.R. with your injured child and say, 'Can you help me?'"
It's worth taking that comment apart word by word. What is Dr. Albrecht saying? That because all docs are like her, you should not take your injured child to an ER? (Like you have a choice?)Or that because you would take your injured child to an ER, that somehow proves that what she is doing is OK? Dr. A. seems oblivious to the logical conclusion, that if someday, people actually did so lose trust in physicians that they hesitated to take their injured kids to the ER, people like her could look themselves in the mirror and say that they were the reason for this distrust.
Another great quote in the article comes from Dr. Melissa DelBello, a strong advocate of the use of atypical antipsychotics for kids diagnosed with bipolar disorder. Dr. DelBello teaches at the University of Cincinnati, and since she is not from MN, the Times could not find figures on what she was paid as a speaker. "Trust me," she told the reporters, "I don't make much." In Hooked, I used a classic quote from P.G. Wodehouse, "When an Englishman says 'trust me,' it's time to start counting the spoons."
Gardiner Harris, Benedict Carey, and Janet Roberts. "Psychiatrists, Children and Drug Industry's Role." New York Times, May 10, 2007.
Tuesday, May 1, 2007
Welcome to a Non-Commercially Biased Psychiatry Newsletter
I had the pleasure recently of hearing from Daniel Carlat, MD, assistant clinical professor of Psychiatry at Tufts University. who describes himself as "a former drug company speaker who 'converted' in 2002." He's now the editor of The Carlat Psychiatry Report, a non-commercially-biased monthly newsletter:
www.thecarlatreport.com
As best as this family physician can tell, the newsletter looks like a very good source of thoughtful apprasial of psychiatric medications, and a potential corrective for marketing hype in a specialty that seems to attract more than its share.
www.thecarlatreport.com
As best as this family physician can tell, the newsletter looks like a very good source of thoughtful apprasial of psychiatric medications, and a potential corrective for marketing hype in a specialty that seems to attract more than its share.
Thursday, April 26, 2007
More on the Techniques Used by Reps
In HOOKED, I was able to use testimony from former drug reps to illustrate the various techniques that are used to influence physicians--almost always without the physicians ever having a clue as to how they are being manipulated. A recent paper that takes advantage of another former rep--the second author--is:
http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0040150
The article includes a long table that classifies physicians by type--"friendly and outgoing," "aloof and skeptical," "mercenary," etc.--and explains how the rep would effectively get each type to prescribe more of the company's drugs.
This paper has some of the most direct and unambiguous statements about how the rep system operates. As the former rep, Shahram Ahari, says, "During training, I was told, when you're out to dinner with a doctor, 'The physician is eating with a friend. You are eating with a client.'" The article covers the power of gifts, how the rep scopes out the doc looking for what buttons to push, how the reps use prescribing data to customize their detailing to each physician, and the use of samples.
Anari again: "[To constantly sway the doctors] is a job I'm paid and trained to do. Doctors are neither trained nor paid to negotiate. Most of the time they don't even realize that's what they're doing..."
http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0040150
The article includes a long table that classifies physicians by type--"friendly and outgoing," "aloof and skeptical," "mercenary," etc.--and explains how the rep would effectively get each type to prescribe more of the company's drugs.
This paper has some of the most direct and unambiguous statements about how the rep system operates. As the former rep, Shahram Ahari, says, "During training, I was told, when you're out to dinner with a doctor, 'The physician is eating with a friend. You are eating with a client.'" The article covers the power of gifts, how the rep scopes out the doc looking for what buttons to push, how the reps use prescribing data to customize their detailing to each physician, and the use of samples.
Anari again: "[To constantly sway the doctors] is a job I'm paid and trained to do. Doctors are neither trained nor paid to negotiate. Most of the time they don't even realize that's what they're doing..."
An Inside Peek: How Much the Drug Industry Supports Samples for Indigent Patients
Every time I have heard anyone representing the pharmaceutical industry's point of view defend physicians' cozy relationships with detail people, the case is argued that these relationships yield free samples for the docs, who then can give some of these samples to their indigent patients. In HOOKED, I discuss several reasons why this system is a flawed way of getting drugs for the indigent.
Whether or not this is a good way to provide drugs for those otherwise unable to pay, I found it interesting to compare the standard industry rhetoric with an insider's view of what the average drug company may think of this practice.
Thanks to Adriane Fugh-Berman and Shahran Ahari (see next post), I had my attention directed to an October, 2004 article in Pharmaceutical Executive: http://www.pharmexec.com/pharmexec/article/articleDetail.jsp?id=129291
The article, which is mostly about how to package sales reports so that the data make sense to the reps in the field, has a sidebar story, "Customization Case Study." (You have to click separately on that part of the story to read it.)
The sidebar tells how one drug company increased its market share by 86% using several techniques. Included in what they achieved were "reduc[ing] cannibalized prescriptions from oversampling," "reduc[ing] rep calls on low potential subscribers by 27 percent," "decreas[ing] sampling costs by 24 percent," "reallocat[ing] samples to high-opportunity prescribers most receptive to sampling as a promotional vehicle," "identify[ing] prescribers who were oversampled and take corrective action immediately."
If I translate all this into plain English, it seems to be saying: the reps were beat up by their managers to pick out the docs who actually gave a lot of samples to indigent patients, and who accordingly wrote fewer prescriptions for the drugs; those docs were given many fewer samples. Instead, the docs who used the samples "properly"--that is, as a prelude to actually writing prescriptions for well-insured patients who could afford the drugs--got more samples.
The report went on to conclude triumphantly, "No longer oversampled by reps, low prescribers cut back on giving patients free samples and began writing more prescriptions."
So much for the industry making it possible for docs to give free samples to the needy.
Whether or not this is a good way to provide drugs for those otherwise unable to pay, I found it interesting to compare the standard industry rhetoric with an insider's view of what the average drug company may think of this practice.
Thanks to Adriane Fugh-Berman and Shahran Ahari (see next post), I had my attention directed to an October, 2004 article in Pharmaceutical Executive: http://www.pharmexec.com/pharmexec/article/articleDetail.jsp?id=129291
The article, which is mostly about how to package sales reports so that the data make sense to the reps in the field, has a sidebar story, "Customization Case Study." (You have to click separately on that part of the story to read it.)
The sidebar tells how one drug company increased its market share by 86% using several techniques. Included in what they achieved were "reduc[ing] cannibalized prescriptions from oversampling," "reduc[ing] rep calls on low potential subscribers by 27 percent," "decreas[ing] sampling costs by 24 percent," "reallocat[ing] samples to high-opportunity prescribers most receptive to sampling as a promotional vehicle," "identify[ing] prescribers who were oversampled and take corrective action immediately."
If I translate all this into plain English, it seems to be saying: the reps were beat up by their managers to pick out the docs who actually gave a lot of samples to indigent patients, and who accordingly wrote fewer prescriptions for the drugs; those docs were given many fewer samples. Instead, the docs who used the samples "properly"--that is, as a prelude to actually writing prescriptions for well-insured patients who could afford the drugs--got more samples.
The report went on to conclude triumphantly, "No longer oversampled by reps, low prescribers cut back on giving patients free samples and began writing more prescriptions."
So much for the industry making it possible for docs to give free samples to the needy.
New England Journal Study Shows Widespread Relationships of Physicians with Industry
The Institute on Medicine as a Profession at Columbia University is rapidly establishing itself as the 800-pound gorilla of the forces in medicine concerned about pharmaceutical industry influence. Their latest salvo comes in the form of a survey of about 3100 physicians in six different medical specialties, published in this week's New England Journal of Medicine, and available on line: http://content.nejm.org/cgi/content/full/356/17/1742. For press coverage, see: http://www.latimes.com/news/science/la-sci-conflict26apr26,1,3419565.story (cannot guarantee how long this latter will remain up on the web).
The main take home message is that this is the first large-scale national survey of physicians conducted since the much touted PhRMA code of ethics went into effect in 2002, and supposedly put the kibosh on some of the more generous and outrageous forms of gift-giving. The authors of the study are appropriately cautious in drawing conclusions--after all, they did not do a before-and-after comparison survey--but imply that the "code of ethics" has not been very effective in altering the landscape of massive influence of the drug companies.
The major findings of interest: 94% of physicians surveyed took one form of benefit or another from industry; the most common were food in the workplace (83%) and "free" drug samples (78%). Twenty-eight percent received some form of payment, mostly for consulting or serving on a speaker's bureau. Among the specialties, monthly contacts with industry representatives ranged from a high of 16 by family docs to a low of 2 among anesthesiologists. Docs in solo or private group practices reported more contacts with industry than docs in hospital or staff-HMO settings.
My fellow family physicians had more contacts with the industry per month than any other specialty but were paid considerably less often than cardiologists. (Maybe we should up our rates.)
One message that I think comes through loud and clear from this survey, despite its various limitations (the response rate, for example, was 52%, which is about par for the course in trying to get harried physicians these days to fill out surveys), is the factoid of 28% being paid as consultants or speakers. Could it really be the case that fully a quarter of all physicians have so much specialized knowledge, and stand out so much from their peers, that they are appropriate recipients of company fees for these services? Or are such fees really a disguised way of giving company cash gifts to physicians who are both high prescribers, and willing to do the company's bidding by trying to persuade their peers to do likewise?
The main take home message is that this is the first large-scale national survey of physicians conducted since the much touted PhRMA code of ethics went into effect in 2002, and supposedly put the kibosh on some of the more generous and outrageous forms of gift-giving. The authors of the study are appropriately cautious in drawing conclusions--after all, they did not do a before-and-after comparison survey--but imply that the "code of ethics" has not been very effective in altering the landscape of massive influence of the drug companies.
The major findings of interest: 94% of physicians surveyed took one form of benefit or another from industry; the most common were food in the workplace (83%) and "free" drug samples (78%). Twenty-eight percent received some form of payment, mostly for consulting or serving on a speaker's bureau. Among the specialties, monthly contacts with industry representatives ranged from a high of 16 by family docs to a low of 2 among anesthesiologists. Docs in solo or private group practices reported more contacts with industry than docs in hospital or staff-HMO settings.
My fellow family physicians had more contacts with the industry per month than any other specialty but were paid considerably less often than cardiologists. (Maybe we should up our rates.)
One message that I think comes through loud and clear from this survey, despite its various limitations (the response rate, for example, was 52%, which is about par for the course in trying to get harried physicians these days to fill out surveys), is the factoid of 28% being paid as consultants or speakers. Could it really be the case that fully a quarter of all physicians have so much specialized knowledge, and stand out so much from their peers, that they are appropriate recipients of company fees for these services? Or are such fees really a disguised way of giving company cash gifts to physicians who are both high prescribers, and willing to do the company's bidding by trying to persuade their peers to do likewise?
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