Monday, August 24, 2009

Friendly Ghosts--Why Should Academic Docs Get All the Credit?

Tracking this one back is a bit complicated--you can start with the post on Roy Poses's Health Care Renewal blog:

...which will take you in turn to an AP story by Matthew Perrone:

...and eventually, thanks this time to the PharmaGossip blog, you'll get to the original document from the drug company that's the subject of this little story:

Let's see what's going on here by first considering a town-gown problem--how unfair the standard practice of pharmaceutical ghostwriting is to practicing docs and the drug reps who sell to them, compared to their academic counterparts:
  • Academic physicians get to pad their vitae by the easy route of getting medical communication companies to write their journal articles for them, at drug company expense--because they have a name (or more often, the prestigious name of their medical school) the company wants to see in the credits of a journal article. The practitioner grunt out in the boonies? Who cares what he thinks about a drug?
  • The academic doc gets to put a minimum of a thousand bucks in his/her pocket (many say it's more but I'm still waiting for something in writing to back that up), all for the simple act of sticking a name on an article somebody else wrote. Where's the practicing guy going to lay hands on that kind of bread for trashing his own integrity?
  • Think of all the editorial assistance an academic gets from the communications company--the best editorial help, a thorough literature search free of charge, the nicest figures and tables, and most important, a well-researched strategy to match the article with exactly that journal whose editor is known to be dumb or negligent enough to print it. The practitioner, not being in a big medical center, needs that help even more--but gets none of it.
  • Finally think of it from the drug rep's point of view. The academic doc gets to pad his reputation and puts cash in his pocket too, and therefore feels even more beholden to the kindly drug firm that made it all possible. The drug rep is desperate for something she can give her prize prescribers, to keep them loyal and eager for future detail visits. But can she pass around the same goodies that the academic docs routinely get? NOOOOO.
Well, you drug reps and practicing docs out there in Haystack Junction, help is on the way--or at least it was in 2000, when SmithKline Beecham (now GlaxoSmithKline) introduced a new rep assistance program to boost sales of its antidepressant, Paxil. Somebody at headquarters must have had a real hoot when they were permitted to name the new program CASPPER (for CAse Study Publications for PEer Review). I'd personally be curious as to how many average drug reps got the joke; and of course, the practitioners to be reeled in by the reps presumably never learned what the program was called.

A sidebar-- we now know about CASPPER, says Matthew Perrone of AP, because the law firm representing hundreds of former Paxil users in a class action suit against GSK uncovered the document in its discovery process, and the judge approved its release. (More proof of the unfortunate adage that if drug companies were not regularly sued, we'd have no idea what the heck was really going on.)

CASPPER, according to its 14-page brochure, was cleverly designed to meet two needs simultaneously. Drug reps needed goodies to pass out to their best prescribers, or big-volume prescribers they thought could be turned into better ones. And the company needed more positive buzz about Paxil in the journals, especially of a sort that reflected the use of the drug in actual practice, even if the resulting papers appeared in smaller journals and were less impressive than major academic studies.

The drug rep was instructed to wait for docs, during detail visits, to mention experiences they'd had with Paxil that demonstrated significant success, or that countered claims by Paxil's competitors about side effects or other problems. (Hmm. Side effects. Could that possibly be why those hundreds of folks are now suing GSK?) The rep would then ask the doc if she ever thought of writing that experience up as a case report for a journal.

The doc would be expected to say--are you crazy, I'm a busy practitioner, look at how full my waiting room is (they are all waiting longer because I'm wasting my time talking with drug reps instead of seeing patients). How would I have the time to write an article, send it to a journal, and so on?

At this point the drug rep pulls the CASPPER rabbit out of his hat and tells the doc all the services that the drug company has contracted for, from a firm called Complete Healthcare Communications (CHC)--to the tune of a budget for 50 articles to be prepared in the year 2000 (the only year mentioned in the brochure). Once the doc suggests a topic and presumably describes his succesful case, CHC takes it from there--developing the topic, doing a thorough literature review, assembling sophisticated figures and tables, preparing the detailed first draft, noting all points at which the "author" must add information, revising based on "author's" responses, and finally developing the complete strategy for submission to the journal, even to photocopying the correct number of copies (recall the olden days of 2000 where journals were not yet demanding e-submission?). They only missed one beat that I could see. The office practitioner was given a sample cover letter to submit to the journal, that she was supposed to have retyped on her own office stationery. Obviously that was an oversight. CHC and the drug firm ought simply to have asked for a blank sheet of her stationery and written the cover letter on it themselves. I mean, if you are going to be a full service ghostwiting business, might as well do the thing right.

Ideal result--a case report touting the joys of Paxil appears in a low-level journal, but becomes a reprint that reps can hand out saying, "Here's a case report from a practicing physician just like you, telling us just how well Paxil works." The doc, who has the thrill of seeing her name in lights as a published author, is ever so grateful to the wonderful Paxil rep, and the rep can do no wrong so far as she is concerned from then on. The rep by the way never happens to let on that the academic doc up the street gets paid $1000 for that same service, so the practitioner has no idea that she's missing out on that little perk.

After admiring the sheer brilliance of CASPPER, we are actually rather let down to hear from GSK spokesperson Mary Anne Rhyne, "The program was not heavily used and was discontinued a number of years ago." Still, in its salad days, CASPPER produced articles in five journals between 2000 and 2002, including the American Journal of Psychiatry and the Journal of the American Academy of Child and Adolescent Psychiatry, not exactly chopped liver.

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