Monday, November 26, 2007

Carlat's "Dr. Drug Rep"--Some Further Possibilities

Dr. Danny Carlat, editor of the Carlat Psychiatry Report and keeper of another great blog on the problems with industry influence in medicine, has written a must-read article in the New York Times Magazine. I'll let his blog entry tell you about it and guide you to the article itself:

Very briefly, the article tells about Dr. Carlat's saga into and out of the world of paid drug company speaker--how he was initially wooed, wined and dined; how he rationalied the message he was giving to his medical colleagues (while pocketing a cool $30K in extra income); how he began to have doubts about the ethics of his role as he saw new research data showing that the drug he was shilling for was not all that great; and how he eventually regained his integrity and parted company with the company.

It may seem like piling on to pick any holes in Dr. Carlat's riveting and well-told story; and indeed he provides an excellent model of how good doctors ought to read the medical literature with a critical eye. Here I just want to add an angle that he appears to have left out.

Dr. Carlat initially assumed that he was "hired" by Wyeth for one reason--they wanted to "educate" other physicians in his area about why Effexor XR was the best antidepressant and why they should prescribe it as their first choice. As a physician he could command more credibility than a mere drug rep, and so of course his talks were of great value to the company. That explains why it was worth $30K to them to have his services.

In what way did he come to change his mind? At first, Dr. Carlat was himself a true believer--the data seemed to support Effexor's superiority. Later, he became a relative skeptic about Effexor, and perceived that as his enthusiasm for the drug slacked off, his Wyeth handlers were quick to point out his deficiencies as a speaker. In other words, his opinion changed about the ratio between real education and pure marketing contained in the talks he was giving.

What no reader of the article will take away is the possibility that the real reason Wyeth hired Dr. Carlat was to pay him $30K in bribes to get him to prescribe more Effexor in his own practice.

That sounds crazy, right? How can it be worth it to a drug firm to pay a single doc $30K just to prescribe more to his own patients? But consider two facts.

The first fact is sort of buried in Dr. Carlat's article. He mentions that we do not really know how many physicians are paid drug company speakers; but some data are consistent with it being 25 percent. A quarter of U.S. physicians are paid speakers? A quarter of us are really talented and entertaining educators? A quarter of us are so good with statistics that we can make sense of the most complicated research studies? Get real. If fully a quarter of us are out on the road giving talks, who's staying behind to hear the talks?

How about nurses? See my earlier post about what happened in Minnesota when they actually clamped down on the free dinners to docs ( The drug companies could no longer get away with taking docs out to a lavish dinner to hear the spiel from one of their paid speakers. And without the free food the docs would not show up. So what did the companies do? Tell the speakers, sorry, we can no longer uise your services?

Hardly. They started inviting nurses to the talks instead of doctors. You might think, well, that makes sense; the nurses often have some influence over what medications the docs prescribe so this is a good indirect way of influencing the physicians. But Gardiner Harris, who wrote this up for the New York Times, made it clear that that was not the drug company's angle.

The point was, the speaker-docs were the local high prescribers of the company's product. It was essential for the companies to reward them for their good behavior. They were going to go on paying them to speak, come hell or high water, even if they had to fill the seats with life-size cardboard cutouts of people. (Harris, by the way, also pointed out that Dr. Carlat needed a better agent. The Minnesota top speakers easily pull down $100K a year.)

I know nothing about Dr. Carlat's own practice. But it seems reasonable to conclude that somebody at Wyeth added up the numbers and figured out that if they paid him to speak about Effexor a couple of times a week, somebody might listen to him and somebody might not. But the bottom line was that Dr. Carlat himself was going to find it very hard to prescribe anything except Effexor to his depressed patients. And those extra scripts were worth a certain amount to Wyeth.

And many of our colleagues still regard all this as "education."

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