The Medical Profession's Culture of Corruption, Part 2:
From Lancet: Just How Tainted Has Medicine Become? Another Top Medical Journal Asks a Tough Question about Doctors-Drug Industry Conflicts of Interest.
Lancet is one of the oldest and most prestigious medical journals in the world. So when a medical publication like Lancet questions the integrity of the medical profession, something is terribly wrong.
For years, many of us have objected to the drug companies providing gifts, expensive dinners, travel, vacations, tickets to Broadway shows, sporting events and golf courses, and other freebies to doctors. The American Medical Association and other organizations agree and have established voluntary guidelines that limit doctors' acceptance of gifts of more than token value. Unfortunately, these guidelines have not worked. Many doctors continue to accept drug company favors large and small, while maintaining that they can accept freebies without having their judgment swayed by drug company sales pitches.1 Studies have proven them wrong. Doctors' prescribing methods are heavily influenced by drug company inducements.
Because of increasing criticism, the drug industry has established voluntary guidelines about giving expensive gifts to doctors. The American Medical Association called these guidelines "a positive step," but loopholes exist. Doctors can still accept money as "consultants" to drug companies, which includes payments for attending drug-promoting seminars or all-expenses-paid trips to pricey resorts.2 The new guidelines do not impress Public Citizen's Sidney Wolfe. "This is a thinly disguised public relations campaign," he stated. "I don't trust the pharmaceutical industry or the AMA to practice what they preach because they have articulated similar guidelines for 11 years. And in the last couple of years alone we have found large numbers of violations of these.3"
Pharmaceutical Industry Influences in Medical Schools
The obvious question is: What is so lacking in medical education that so many doctors do not see a conflict of interest in accepting pharmaceutical industry favors? Aren't medical students taught ethics anymore? Aren't they educated about conflicts of interest? Today, drug company representatives frequent the halls of many medical schools, providing gifts and free lunches and seminars. And with more and more faculty members dependent on drug-company funding, it is unlikely that medical students hear much about the importance of distancing themselves from drug company influences.
The effects were revealed in a survey in which more than 90% of medical residents acknowledged that drug company marketing influenced their decisions about medications. The study also revealed that "approximately 50% of the items that residents carry have pharmaceutical company origins.4" No wonder patients complain that many doctors look like walking advertisements for the drug industry. Don't doctors realize how it appears when their tools, pens, pads, and posters in their examining rooms carry drug company logos? Can’t doctors afford to buy their own stuff?
The Pharmaceutical Industry Influences Medical Care
The fact is, the pharmaceutical industry influences the entire health care system. For example, most continuing medical education courses that doctors take to maintain their licensing are underwritten by the drug industry. In 2002, the Wall Street Journal published an article titled "When doctors go to class, industry often foots the bill: Lectures tend to feature pills made by course sponsors." The article stated:
"Doctors are learning a lot more about medical conditions that can be treated with expensive brand-name drugs and less [about] subjects from which manufactures can't profit. ... Many physicians view industry sponsored courses -- even those that follow the rules -- as verging on infomercials.5"
The drug industry's presence at some medical conferences is so pervasive, sometimes it is hard to tell whether they are medical conferences or pharmaceutical advertising conventions. The Washington Post reported:
"In the days leading up to the American Psychiatric Association's meeting in Philadelphia , pharmaceutical companies mailed attendees hundreds of free phone cards, as well as invitations to museums, jazz concerts and fancy dinners. ... And in several dozen symposiums during the weeklong meeting, companies paid the APA about $50,000 per session to control which scientists and papers were presented and to help shape the presentations.6"
This description was no exaggeration. I happened to be in Philadelphia at the time and wandered into the meeting. I was shocked. So were some attendees, according to the newspaper article:
"Concern over psychiatry's ties with industry was widespread enough to be the focus of several panels at this year's convention. Some psychiatrists said the association should simply sever all ties with industry." Many doctors agreed with one who stated, "It's totally out of control.6"
It is good to know that some doctors are disgusted with the situation, but can their voices halt the ever-increasing degree of drug company influence over the medical profession?
Beyond Mere Influences
The drug industry's methods go beyond mere influences. Because drug companies cannot directly promote their drugs for uses not approved by the FDA, drug companies seek other ways to extend the use of their products. In a New York Times article, a whistleblower described how the manufacturer of Neurontin, a drug for epilepsy, promoted the drug for unapproved uses, making Neurontin a multi-billion dollar success. The company's strategy included paying doctors to pose as authors of articles actually written by non-medical employees of the manufacturer. The company paid hundreds of doctors to attend expensive dinners and weekend retreats where speakers urged the use of Neurontin for off-label purposes. Doctors prescribing Neurontin were paid to encourage other physicians to do the same. Doctors were paid to enlist patients in clinical trials of Neurontin that were designed mainly for marketing purposes.7
This wasn't an isolated incident. The Wall Street Journal reported:
"Biovail Corp., a large Canadian drug company, has been paying as much as $1,000 each to thousands of doctors in the U.S. prescribing the company's new heart medication. ... The strategy, part of Biovail's effort to launch a medicine called Cardizem LA, underscores how some companies aggressively market their drugs to doctors. ... And some heart specialists say the Biovail is no more effective than much-cheaper generic versions of a similar drug.7A"
Biovail's marketing strategy was very successful because it not only paid doctors, but also office managers to help push its product. And, of course, Biovail did not require doctors to inform patients of the compensation they received. BMJ (British Medical Journal) challenged the practice of enrolling patients in studies without doctors disclosing that they had been paid by the drug manufacturers: "Consent obtained on the basis of withholding information ... is not fully informed consent.7B"
In February 2006 the New York Times described a lawsuit "alleging that Medtronic had paid tens of millions of dollars in recent years to surgeons in a position to use and recommend medical devices. In one particularly egregious example, a prominent Wisconsin surgeon received $400,000 for just eight days of consulting." This report was followed by another that described how "a Danish company paid a pharmacist, doctors' assistants and a drug store chain to switch diabetic patients to the company's high-priced insulin products.7C"
The Drug Industry's Primary Goal: Control of Medical Decisions
The drug industry has become the most profitable industry in the world year after year by understanding that its success depends on influencing the doctors' decisions about prescribing medications. All of the excesses described above have one common goal: to sway doctors to prescribe expensive, brand-name medications even when less expensive, equally effective medications would do or when non-drug methods such as diet or nutriceutical approaches are effective.
Many patients complain that their doctors answer every question with a new prescription. Patients understand that medications are often necessary, but they also know that there is more to quality medical care than pushing pills. Many doctors feel similar frustration that their therapeutic choices are often limited to drugs.
We have arrived at this point for a reason. Doctors make decisions based on information. If doctors' sources of information are dominated by the drug industry, then doctors' decisions will typically focus on drugs. The drug industry invests billions to accomplish this. Carefully selected information is provided to doctors at drug company-subsidized seminars, via advertising in medical journals, and via 90,000 drug reps who leave samples and studies at doctors' offices every day. Drug companies write the package inserts included with all medications, and they design and conduct or underwrite studies that are published in medical journals. Such studies are usually more favorable toward their medications that independent studies. Drug companies often do not publish studies with unfavorable results.8-12 All of these influences create an environment that is saturated with medication-friendly information.
The dominance of the drug industry on doctors' sources of information was described in the Washington Monthly:
"For the past two decades, medical research has been quietly corrupted by cash from private industry. ... Today, private industry has unprecedented leverage to dictate what doctors and patients know -- and don't know -- about the $160 billion worth of pharmaceuticals Americans consume each year.13"
Some doctors avoid drug company-oriented information and stick with the treatment guidelines produced by national committees. Yet even these doctors are unknowingly influenced by the drug industry. As Lancet reported, the vast majority of authors of the official clinical guidelines have financial ties with the drug companies. These ties are often not disclosed. Such revelations led Lancet to ask: "How tainted by commercial conflicts has medicine become?" Lancet answered: "Heavily, and damagingly so.14"
Consumers are also targets of the drug industry. Direct advertising of drugs is now a multi-billion dollar enterprise, and it is very effective in getting patients to demand a specific brand-name drug from their doctors. A more insidious drug company strategy involves directly influencing so-called consumer organizations. A report in 2003 warned:
"Pharmaceutical companies are pouring millions of dollars into patient advocacy groups and medical organisations to help expand markets for their products. Many groups have become largely or totally reliant on pharmaceutical industry money, prompting concerns they are open to pressure from companies pushing their products.15"
The influence of pharmaceutical companies over consumer groups is a big concern, according to Martyn Goddard, the health policy officer with the Australian Consumers' Association. "Drug companies find it very easy to recruit consumer groups and they do it very cheaply," he said. "There's almost no such thing as clean money for most consumer organisations.15" With this money comes drug company influence on what these organizations say and the treatments they recommend.
A Bold New Proposal: A New Chance for Medicine to Reform
In Part 1 of this 2-part article I discussed the new proposal by 11 respected doctors including Troyen Brennen (Harvard Medical School) and Jeffrey Kassirer (former editor of the New England Journal of Medicine). Their article in JAMA ("Health industry practices that create conflicts of interest: a policy proposal for academic medical centers") documented many of the abuses described above and called for strong, enforceable rules about doctors' relationships with the drug industry.16
Brennen, Kassirer, et al. called for a ban of all gifts, stipends, seminars, travel, and any other freebies provided directly or indirectly by the drug industry to doctors. They called for an end of free drug samples, which would be replaced by vouchers for low-income patients. They called for severing direct drug company funding of medical research. Instead, each medical institution would establish an office to channel the use of monies provided by the drug industry. Also, drug company representatives would be banned from the halls of medical institutions and from providing gifts, lunches and seminars to medical students, interns and residents.
In other words, the medical profession would reclaim control of its domain. Drug companies could continue to contribute to medical research and education, but only through proper medical channels, and all contributions and their uses would be made public. Drug companies would have no influence on the design of studies, the interpretation of results, or publication of findings. Studies with unfavorable findings such as inadequate efficacy or new adverse effects would not be suppressed.
Drs. Brennen et al. have offered a worthwhile plan. The question is, are there enough professionals at medical institutions untainted by drug company influence to embrace and implement it?
My view: I worry that the drug industry has been too successful in too many ways in influencing the medical and other healthcare professions. I worry that too many medical institutions and too many top experts receive too much drug company money to support the new guidelines. However, I hope that this plan is adopted. By doing so, the medical profession would be making a decisive statement that our highest priorities are our strict adherence to medical ethics, our objectivity, and our responsibility to provide patients with the best medical care without of influences or inducements from the drug industry.
It is interesting to note that Kaiser Permanente has already adopted many of the recommendations now offered by Brennan et al. Dr. Sharon Levine, associate executive director of Kaiser Permanente Northern California, said, "We thought it was critical for us that our patients never had a doubt that the decision made about a drug or a device was based on the best interests of the patient and not the financial interests of the physician.7C"
If Kaiser can do this, why not other institutions? I hope they follow, but for now I will remain skeptical. I am not alone. "I'm not very optimistic," said Dr. David Blumenthal in reference to the proposed guidelines.17 Dr. Blumenthal is a professor at Harvard Medical School and one of the authors of the Brennan article.
1. Brett, AS, Burr, W, Moloo, J. Are Gifts From Pharmaceutical Companies Ethically Problematic? A Survey of Physicians. Archives of Internal Medicine 2003;163:2213?]2218.
2. Brubaker, B. Drug Industry Adopts Guidelines on Giveaways to Doctors. Washington Post, Apr. 20, 2002:E3.
3. Wolfe, SM. Pharmaceutical companies offer doctors free trips, gifts for prescriptions. Worst Pills, Best Pills News, May 2004;10:38.
4. Sigworth, SK, Nettleman, MD, Cohen, GM. Pharmaceutical Branding of Resident Physicians [Letter]. JAMA 2001;286(9):1024-25.
5. Hensley, S. When doctors go to class, industry often foots the bill. Lectures tend to feature pills made by course sponsors. Wall Street Journal, Dec. 4, 2002:A1.
6. Vedantam, S. Industry Role in Medical Meeting Decried: Symposiums Sponsored by Pharmaceutical Companies Trouble Some Psychiatrists. Washington Post, May 26, 2002:A10.
7. Petersen, M. Whistle-Blower Says Marketers Broke the Rules to Push a Drug. New York Times, Mar. 14, 2002:www.nytimes.com.
7A. Zuckerman, G. Biovail is paying physicians prescribing new heart drug. Wall Street Journal, July 21, 2003:www.online.wsj.com.
7B. Rao, JN, Sant Cassia, LJ. Ethics of undisclosed payments to doctors recruiting patients in clinical trials. BMJ 2002;325:36-37.
7C. Seducing the medical profession (Editorial). New York Times, February 2, 2006:www.nytimes.com.
8. Prosser H, Almond S, Walley T. Influences on GPs' decision to prescribe new drugs -- the importance of who says what. Family Practice 2003;20:61-68.
9. Connelly DP, Rich EC, Curley SP, Kelly JT. Knowledge resource preferences of family physicians. Journal of Family Practice 1990:30(3):353?]9.
10. Cohen, JS. Over Dose: The Case Against The Drug Companies. Prescription Drugs, Side Effects, and Your Health. Tarcher/Putnam, New York: October 2001.
11. Cohen, JS. Dose Discrepancies between the Physicians' Desk Reference and the Medical Literature, and Their Possible Role in the High Incidence of Dose-Related Adverse Drug Events. Archives of Internal Medicine 2001:161:957-64.
12. Cohen JS, Insel PA. The Physicians' Desk Reference. Problems and possible improvements. Archives of Internal Medicine 1996;156(13):1375?]80.
13. Brownlee S. Doctors Without Borders: Why you can't trust medical journals anymore. Washington Monthly, April 2004:www.washingtonmonthly.com.
14. Just How Tainted Has Medicine Become? (Editorial). Lancet, Apr. 6, 2002;359:1167.
15. Hughes, G, Minchin, L. Drug firms fund disease awareness. Sidney Morning Herald, Dec. 13,
16. 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.
17. Harris G. In article, doctors back ban on gifts from drug makers. New York Times, Jan. 25, 2006:www.nytimes.com.
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