PharmaGossip: Dr Manoj Jain comes clean - Big pharma and patient care

About a decade ago when I was newly settled into private practice in Memphis, a representative for a drug company marketing a new and powerful antibiotic stood in my office and asked whether I would like to attend a consultants' meeting about the drug in Washington.
He told me I was a "thought leader" in the field and had been selected to join his company's speakers' bureau. Flattered, I agreed to go if my wife, who also is a physician, had no conflict with her on-call schedule.
The pharmaceutical company would pay for my flight, a two-day stay at the Ritz-Carlton, meals and a $750 honorarium.
It was an attractive invitation since my in-laws lived in the Washington suburbs and we were overdue for a family trip.
The drug rep warned me that his company would not be able to pay for airline tickets for my wife and kids. But then his eyes brightened. "Is your wife a doctor?"
"Yes," I said.
Well, then, she could be a consultant, too, he said. The company would pay for her flight and give her an honorarium, and "then you can have two rooms at the Ritz and invite your in-laws!" When I pointed out that, unlike me, she was not an infectious-disease doctor and had little cause to prescribe the kind of antibiotic he was marketing, he replied, "That's OK. I will talk with my manager." Sure enough, my wife and I received two airline tickets and two rooms at the Ritz and enjoyed our stay in Washington.
The relationship between doctors and the pharmaceutical industry has long been a cozy one. By offering up perks like my weekend trip to Washington, drug company reps have easy access to physicians' offices and the opportunity to influence the medications that doctors prescribe for their patients. But things are changing.

Voluntary pharmaceutical code
Under pressure from professional organizations concerned about possible conflicts of interest, the Pharmaceutical Research and Manufacturers of America (PhRMA) -- the industry's trade group -- published a voluntary code in 2002 that sets out guidelines for the companies' marketing staffs to follow in their interactions with doctors. The code, which was updated in 2009, says PhRMA is "concerned that our interactions with health care professionals not be perceived as inappropriate by patients or the public at large ... (Such interactions) are professional exchanges designed to benefit patients and to enhance the practice of medicine."
The code now prohibits giving physicians vacation trips or tickets to entertainment or sporting events, but allows drug company reps to provide "modest, occasional meals ... in the appropriate circumstances" to doctors and their office staff. It also allows pharmaceutical companies to compensate physicians who act as their medical consultants and pay "reasonable" travel, lodging and meal expenses for their consultants.
Consultants typically teach other doctors about the drugs pharmaceutical companies are marketing, provide feedback to the companies about their own experiences prescribing the drugs, and offer advice on how they can be marketed more effectively.
In 2007, Sens. Charles Grassley, R-Iowa, and Herb Kohl, D-Wis., introduced a bill to require large pharmaceutical companies and medical device manufacturers to disclose the value of dinners and of speaker and consultation fees they provide to doctors. The bill finally was adopted in 2010 as part of Congress' massive health care reform package.
Late last year, the nonprofit investigative news organization ProPublica published online the names of 17,000 doctors who together received $250 million from seven leading drug companies in 2009 and 2010 in return for speaking engagements and consulting services.
Looking through the list, I saw the names of many friends in Memphis and mentors from Boston, where I trained. In December The Commercial Appeal reported that two Memphis physicians, neurologist Stephen H. Landy and endocrinologist Samuel Dagogo-Jack, ranked second and third on the list of those who received the most money in speaker fees -- $302,125 and $257,012, respectively.
Mind you, it is completely legal for physicians to take money from drug companies for consulting services and giving lectures. Yet when I shared the ProPublica website with colleagues, they were startled by the amounts those doctors had received. One physician became defensive about taking speaking fees himself. Another told me sincerely, "I do it for the money, and I also provide service in teaching other doctors."
Mixed feelings on drug reps
Personally, I have mixed feelings about my profession's relationship with pharmaceutical companies. I must admit something gnawed at me during my stay at the Ritz 10 years ago. The "consultants' meeting" turned out to be a group of 25 doctors who were led through a slide presentation on the benefits of the drug being promoted. I realized that I was not in the company of "thought leaders" at all, but rather in a group of ordinary doctors who, like me, wanted a fun -- and free -- weekend in Washington.
I tried to convince myself that the trip and other perks I'd gotten before from drug companies, such as free tickets to Tigers' basketball games, did not influence my prescribing practices. Such rationalization is probably common. A 2000 study in the Journal of the American Medical Association found that the more gifts doctors received, the less likely they were to think that their prescribing behavior was being influenced.
Talks given by speakers paid by a drug company can in fact serve a valuable purpose. When I attend such events, I learn about new medications that can save my patients' lives. I also can discuss treatment options with other physicians, something I rarely have the opportunity to do in my day-to-day work. So I can justify paying doctors for their time and expertise when they agree to speak to their colleagues about how to use a particular medication.
But I still have an uncomfortable feeling about my frequent encounters with sales representatives for the drug companies.
A friend tells me how as a patient she resents it when well-dressed men or young women in skirted suits, carrying lunches for the doctors and their staff, get easy access to the back office, while she sits for hours in the waiting room.
According to a 2004 review in the New England Journal of Medicine, the pharmaceutical industry spent nearly a third of its revenue on marketing in 2002 through a sales force that numbered nearly 90,000. The marketing expenditures of the drug industry have been estimated variously at $12 billion to $15 billion yearly, or $8,000 to $15,000 per physician. Doctors in the 2004 study received an average of four visits per month from drug reps.
Meanwhile, other studies have shown that after such visits, doctors are more likely to prescribe a particular drug being offered by the sales rep, or to request that the drug be added to the formulary at the hospital where they practice.
Why is this the case? In my experience, a pharmaceutical representative humanizes a product and explains its use and benefits in a way that makes me want to prescribe it. Also, even if no gifts are given, I feel obliged to the rep for the courtesy he or she showed in visiting my office. And although the cost of a drug can be an important factor, it often seems almost irrelevant if a third party -- such as an insurance company -- is paying. In the end, if the drug sounds like it might help a patient, I tend to prescribe it.
But for me, something changed five years ago. One drug representative, a tall fellow with blond hair who carried an open laptop, politely but pointedly asked why I wasn't prescribing his company's HIV medicine. He was hinting that he knew what prescriptions I wrote. (I was unaware at the time that drug reps can access doctors' weekly prescribing patterns through a purchasable database.)
For a few seconds, I felt a little guilty about not ordering his product. But guilt was quickly replaced by a feeling I was being manipulated -- and in a way, violated. I asked him to leave my office and not come back. That afternoon I told my secretary to cancel all my appointments with drug reps and not to schedule any more.
My decision came with a price. I no longer have access to the free sample medications that I once gave to my low-income patients. Also, I am not updated regularly on new medications, as I had been through talks sponsored by the drug companies. A year ago, when a pulmonologist asked me about a new anti-fungal medication, I felt embarrassed that I knew little about the drug. A drug rep had briefed him in a visit, but not me.
With thousands of journal articles published each year, and with new drugs and new indications for old drugs regularly being approved by the Food and Drug Administration, it's almost impossible for a busy practitioner to keep up on his own. Doctors often rely on drug company reps to filter information -- a valuable service, but one that can pose its own problems.
Take the case of Vioxx, the painkiller made by Merck. In 2001, a study in the New England Journal of Medicine showed that patients on Vioxx were more likely to have a heart attack than those taking a generic pain medicine. According to a 2005 commentary in Slate, Merck's sales reps continued to market Vioxx and doctors continued to prescribe it until the company voluntarily pulled it from the market in 2004.
Impact on patient care
I am not alone in thinking that doctors' professional relationships with those who develop and market pharmaceuticals may have unforeseen consequences for patient care.
Columbia University researchers who studied the issue of conflict of interest between marketing and patient care concluded in 2007 that "only the prohibition of (doctor-rep) interactions will be effective" in reducing it.
But Eric Campbell, an associate professor at the Institute for Health Policy at Harvard Medical School, believes all such relationships cannot, and should not be banned. "If (doctors) severed all relationships" with drug companies, Campbell said, "we would never have a new drug" because doctors steer patients to the clinical trials that aid in the development of new medications.
Rather, he said, "certain relationships can be banned and others have to be reported and managed."
The American Medical Student Association has developed a "PharmFree" campaign to encourage students not to rely on drug company representatives for education, and to work to limit their access to medical school campuses.
AMSA also developed a scorecard at amsascorecard.org that grades medical schools on how well they limit the access and influence of pharmaceutical companies and drug reps on their campuses. The University of Tennessee College of Medicine in Memphis earned an "F" on its most recent scorecard rating in 2009, with AMSA noting that the school either had no policy on several issues concerning industry relationships and the educational activities of sales reps, or had a policy that is "unlikely to have a substantial effect on behavior. "
The drug industry's relationship with doctors needs transparency, regulation, enforcement and professionalism. Transparency can be achieved by such measures as ProPublica's list and the AMSA scorecard. Under the 2010 health care overhaul, beginning in 2013 a government website will list all doctors who take money from a pharmaceutical company.
We also need regulations and enforcement to bar doctors from taking excessive and inappropriate gifts and speaker fees.
And last, it is equally important that doctors seek inner guidance from their sense of professionalism whenever we face undue pressure to prescribe a particular drug, order fewer tests or scale back the frequency of a patient's care. No matter the source of the pressure -- the pharmaceutical industry, insurance companies or the government -- physicians need to remain true to the best interests of their patients.