The Medical Professions's Culture of Corruption, Part 1:
Respected Physicians Call for End of Conflicts of Interest with the Drug Industry
There have been many calls for reform of the broad influence of pharmaceutical industry money on doctors and other health professionals, hospitals, and medical centers, but few have been so sweeping as the recent article in the Journal of the American Medical Association by Dr. Troyen Brennen of Harvard Medical school, Dr. Jerome Kassirer, who was an editor of the New England Journal of Medicine, and 9 other authors.1
The drug industry has been roundly criticized for its intense, diverse, and unrelenting efforts to influence doctors and sell more drugs. The criticism has accomplished little, and drug sales have soared. The analysis by Brennen et al. focused on the medical profession, acknowledging that "physicians' behavior is a large part of the problem," and that the stature of the medical profession and the trust of patients have been jeopardized by medicine's many conflicts of interest with the drug industry.
Approximately $19 billion is spent annually by drug companies for marketing to doctors. Tens of thousands of sales representatives descend on doctors' offices every day. Patients in doctors' waiting rooms are often outnumbered by drug reps (typically young, female, attractive). Many doctors deny that gifts and other freebies influence their decisions about medication treatment. Drs. Brennen et al. disagreed:
"Social science research demonstrates that the impulse to reciprocate for even small gifts is a powerful influence on people's behavior. Individuals receiving gifts are often unable to remain objective .... Receiving gifts is associated with positive physician attitudes toward pharmaceutical representatives. ... The rate of drug prescriptions by physicians increases substantially after they see sales representatives, attend company-supported symposia, or accept samples."
Indeed, studies have shown that the drug company influences on doctors often lead to irrational decisions and have a negative impact on the treatment of patients.1 I am not surprised by these findings. Decades of research have allowed marketers to learn how to influence anyone without his/her knowing it. Doctors are not immune. Moreover, drug companies are subtle. They not only provide gifts and dinners and seminars, but also leave behind carefully select studies that support the use of their drugs. The overarching goal is to control the information that doctors receive about medications.
Drug companies write the package inserts of all drugs, carefully including the information they choose and omitting information they want to avoid.2 Drug companies underwrite a large percentage of continuing education courses for doctors. In doing so, they make sure that the speakers represent the company view. Drug companies design studies that are meant to produce favorable results and then publish the studies in medical journals. Studies with unfavorable results are not published. Drug reps typically bring stacks of studies, all favorable, which impress doctors, who no longer have the time or motivation to search the medical literature themselves. Drug reps do not include independent studies with less favorable conclusions. Many doctors never see these.
A Call for Strong, Clear, Enforceable Rules
More forcefully and clearly than any before, Drs. Brennen et al. have called for strong, mandatory rules including the outright banning of any gifts or payments for meals, shows, sporting events, travel or meetings. They call for a system in which drug samples are replaced with vouchers for low-income patients. They call for an end of all drug company underwriting of doctors' continuing education, thereby ending drug company influence on the speakers (who are paid directly or indirectly by the drug companies) and on the content of such "education."
The doctors go even further. They call for a ban on the hiring by drug companies of university doctors and other healthcare professionals as speakers for drug companies and their products. Brennan et al. rightly assert that university experts have a special obligation to avoid any appearance of conflict of interest because these experts conduct important research that affects patients and also train medical students. Academic centers would also ban drug company representatives from meetings, lunches, presentations, and the corridors of medical centers. This is a very important proposal, for another aspect of the pharmaceutical company onslaught has been to embed themselves into all aspects of medical education. Today, young doctors learn that it is perfectly reasonable to accept drug company gifts, partake in drug company lunches and seminars, and to accept drug company selected information. This is a distorted ethic that doctors carry into their practices, and it may explain why so many doctors have opposed efforts to curb drug company influences.
Brennan et al. are realistic. In this era of shrinking government with reduced abilities to support research, drug company money plays an essential role in funding research. Under the doctors' plan, drug companies would be allowed to continue this, but rather than giving money directly to individual researchers, drug company contributions would be channeled through a special office at academic institutions that would determine the actual use of the funds. This would prevent drug companies from exerting direct influence (and, often, control) on the work of the researchers.
Will True Reform Take Place?
The proposals of Brennen et al. make sense and are long overdue. But will they work? Will they even be implemented? Many calls for reform have been issued previously. Some reforms have been implemented, but they have been largely ineffective. So far, medical institutions have balked at implementing strong, enforceable rules. Doctors are independent sorts, and many still insist that they are entitled to receive gifts and other benefits if drug companies want to provide them. Academic institutions do not want to have to police their medical faculty members.
Worse, many academic institutions have become dependent on drug company money and have long become inured to drug company influences. This was best described in 2000 by Dr. Marcia Angell, then the editor-in-chief of the New England Journal of Medicine. Her astonishing article ("Is Academic Medicine for Sale?") described a situation that has not improved:
Academic medical institutions are themselves growing increasingly beholden to industry.... Some academic institutions have entered into partnerships with drug companies to set up research centers and teaching programs in which students and faculty members essentially carry out industry research.... When the boundaries between industry and academic medicine become as blurred as they now are, the business goals of industry influence the mission of the medical schools in multiple ways....3.
With so many high-ranking doctors having financial ties to the drug industry, are there enough doctors who are independent financially or at least in conscience to consider reining in this compromised system? Maybe not. Drug companies are smart. They long ago realized that if they hired as consultants all of the top experts in every medical field, they could sway the entire medical profession with their slant. The result is that today, few independent experts remain. For example, when the FDA convenes medical advisory committees to discuss problems involving medications, it is usually impossible for the FDA to find enough independent experts to outnumber or even equal the experts with drug company ties. At some meetings, 90% of the experts have financial arrangements with drug companies.4
So the main question is not whether the proposals of Brennen et al. make sense. They do. Absolutely. The question is whether there is enough objectivity, independence, and will in the medical community to follow through. Or has the deliberate strategy of the drug industry to influence medical science and medical experts and medical institutions as much as possible already proceeded beyond control? This brings us to a question raised by another top medical journal, Lancet: "Just How Tainted Has Medicine Become?" I will discuss this article soon in Part 2 of "The Medical Profession and the Culture of Corruption."
Finally, there is an irony in the publication of the Brennan article at this time when corruption in Washington has led to the resignation of the majority leader of the House of Representatives, and scores of politicians are trembling in anticipation of revelations by indicted lobbyist Jack Abramoff. Washington will enact reform, but will it be serious or window dressing? The same question applies to the medical profession and its conflicts of interest with the drug industry.
1. Brennan TA, Rothman DJ, Blank L, Blumenthal D, Chimonas SC, Cohen JJ, Golden J, Kassirer JP, Kimball H, Naughton J, Smelser N. Health industry practices that create conflicts of interest: a policy proposal for academic medical centers. JAMA, Jan. 25, 2006;295(4):429-433.
2. Cohen, JS. Over Dose: The Case Against The Drug Companies. Prescription Drugs, Side Effects, and Your Health. Tarcher/Putnam, New York: October 2001.
3. Angell, M. Is Academic Medicine for Sale? New England Journal of Medicine 2000;342:1516-18.
4. Cauchon, D. FDA Advisors Tied to Industry: Approval Process Riddled with Conflicts of Interest. USA TODAY, Sept. 25, 2000.
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