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Influencing Doctors
How Pharmaceutical Companies Use Enticement to "Educate" Physicians
By Brian Ross and David W. Scott

Feb. 21, 2002   " It was doctors' night out last June at the world-renowned Museum of Modern Art in New York City, and the Saturday night party, put on by Pfizer Inc., was lavish. The event was strictly private, closed to reporters, as the pharmaceutical company entertained a very select list of doctors and  their guests. But Primetime's undercover cameras saw the kind of big-money splurge that some say drives up the cost of prescription drugs and corrupts the practice of medicine.

Further investigation into the $6 billion spent by drug companies for what they say is a way to educate doctors showed that tactics like lavish gifts and trips are surprisingly common.

"It's embarrassing, it's extravagant and it's unethical," said Dr. Arnold Relman, a Harvard Medical School professor and the former editor of the New England Journal of Medicine. "It makes the doctor feel beholden it suborns the judgment of the doctor." But doctors seemed thrilled to have been invited for a weekend in New York City with some seminars along the way, with all expenses paid by Pfizer on behalf of one of its drugs, Viagra. 

Doctor gets $ 10,000 worth of "goodies". Few doctors were willing to talk publicly about their relationships with pharmaceutical companies, but one upstate New York doctor was willing to come forward."It's very tempting and they just keep anteing it up. And it's getting harder to say no," said Dr. Rudy Mueller. "I feel in some ways it's kind of like bribery". He is disgusted by how the free gifts and trips add to the high price of medicine, and moved by the plight of patients forced to skip needed medication". Mueller agreed to provide Primetime with a rare glimpse of the astounding number of drug company freebies he was offered by various drug companies in a four-month period. He was presented with an 
estimated $10,000 worth, including an all-expenses-paid trip to a resort in 
Florida, dinner cruises, hockey game tickets, a ski trip for the family, Omaha steaks, a day at a spa and free computer equipment. "It changes your prescribing behavior. You just sort of get caught up in it," said Mueller, who said he was offered a cash payment of $2,000 for putting four patients on the latest drug for high cholesterol. The company called this a clinical study; Mueller called it a bounty."I've never been offered money before," he said. "I don't remember that 10, 15 years ago."Though Mueller normally declines the offers, he agreed to attend a dinner, which Primetime secretly taped. Not only were the doctors wined and dined, but each was also offered a payment of $150 for just showing up to listen to a pitch for a new asthma treatment for children.  The company called it "an honorarium," but Mueller saw it differently. "Again, it's bribery," he said. "This is very effective marketing."There's a wide range in value of the free gifts offered to doctors "from lavish trips to free Mother's Day flower bouquets for doctors willing to hear a pitch about a new osteoporosis medicine.In the latter example, when asked whether a floral shop was the most effective place for a discussion on pharmaceuticals, one of the representatives said, "I'm sorry, we're not allowed to comment on anything." 

Detail Men
The goodies are dispensed by an army of drug company representatives known as detail men and women, of whom there are 82,000 nationwide.It's the job of the detail people to quietly befriend doctors, keeping close track of which doctors take the free gifts and then determining which drugs the doctors later prescribe."I think it's sleaze," said Relman. "Anybody who's been in that position knows that yes, those gifts, $60, $100, $40, again and again, do influence your attitude about that company and will influence the prescriptions that you write."And the multibillion-dollar drug company blitz extends throughout the profession, even at the yearly gathering of one of the most prestigious medical groups, the American College of Physicians. 

It was like a carnival. 
Doctors could be seen taking free massages, free food, free portraits, free 
Walkman players, free basketballs, and from one company pushing a new antacid drug, free fire extinguishers.  Many doctors say it's no different than any other business or convention, and that it doesn't affect their medical judgment. But that's not the view of the new president of the American College of Physicians, Dr. William Hall, who says anything beyond a pen or a mug could have an impact. "Whether we like it or not, it can cloud our clinical judgment," he said. "Unequivocally, I would say that."So why are some of the very practices Hall publicly criticizes permitted at his group's supposedly scholarly convention? "I think there it's a situation where every physician is going to have to balance what's right or wrong," said Hall. "We are concerned about it.," he added, saying that at some point the system may be changed.But right now, Hall's group receives $2 million a year from the drug companies to have their exhibition booths at the convention, yet another example of how the big drug companies spend billions to influence doctors in this country."The basic mistake we're making with our health-care system now is that we regard it as just another business. And it's clearly not just another business. Patients, sick patients and worried patients, are not like ordinary consumers," said Relman. "Doctors ought to be incorruptible."  That's the doctor's sacred obligation. They're being corrupted and undermined by this kind of salesmanship." 

Excerpts from Overdosed America by Dr. John Abramson, M.D.

The United States ranks 72 in the world when it comes to the efficiency which it's health care systems improve their citizens overall health. The United States spends more than twice as much per person on health care as the other industrialized nations. This excess spending on health care is like a yearly tax of more than $1800 on every American citizen. The combination of poor health and high costs puts the United States almost off the charts when compared to other countries. On most health indicators the United States relative performance declined since 1960; on none did it improve, according to researchers from John Hopkins.

Since 1900, the average lifespan of persons in the United States has lengthened by greater than 30 years; at least 25 years of this gain is attributable to advances in public health. These improvements include sanitation, clean food and water, decent housing, good nutrition and higher standards of living.

In 1900, tuberculosis was the leading cause of death in the United States. Over the next 50 years, the death rate from tuberculosis fell by 87 percent. This dramatic decrease in the tuberculosis death rate was entirely due to improvements in the social and physical environment such as healthier living and working conditions, better nutrition, more education, and greater prosperity. The first effective medical therapies were not even introduced until 1950, well after death rates for tuberculosis had plummeted. Throughout the twentieth century, similar patterns occurred in the death rates from many other infectious diseases, such as measles, scarlet fever, typhoid, and diphtheria. The vast majority of the deline in mortality occurred before the introduction of effective medical therapy, antibiotics or vaccines.

Rene Dubos, a French-born microbiologist who discovered the first two commercially manufactured antibiotics, wrote in his classic book "The Mirage of Health", "The introduction of inexpensive cotton undergarments easy to launder and of transparent glass that brought light into the most humble dwelling, contributed more to the control of infection than did all the drugs and medical practices."

Notwithstanding the barrage of news about major break-throughs in the diagnosis and treatment of cancer, the overall death rate from cancer was exactly the same in the year 2000 as it had been in 1971, when the "war on cancer" was declared.

People who had erratic heartbeats were prescribed antiarrhythmic drugs and these were routinely prescribed into the 1990s. The drugs decreased the frequency of extra heartbeats but they increased the risk of death. One of these studies was completed in 1980. The results, however, were not published until 1993. An article in JAMA in 2003 stated that "There are estimates that 20,000 to 75,000 lives were lost each year in the 1980s in the United States alone from inappropriate administration of antiarrhythmic drugs." Just think how much money the drug company made as a result of the 13-year delay in publication of these findings and how many people needlessly died.

The drug companies have no more responsibility to oversee the public's health than the fast-food industry has to oversee the public's diet. When the manufacturer of Paxil performs nine clinical studies on the treatment of adolescents for depression and finds that Paxil is no more effective than placebos and, in fact, significantly increases the frequency of "emotional liability" (including suicidal thoughts and attempts), it's no problem. The company publishes one study that shows a benefit, fails to publish the other eight, and markets away. 

A company doesn't like the way the study of an expensive drug for blood pressure is going? A non-issue -- just stop the study before the results reach statistical significance. Endovascular Technologies manufactured a $10,000 device to repair aortic aneurysms that dangerously malfunctioned in a third of the 7600 patients in whom it had been used. This malfunction did not stop Endovascular Technologies.The company reported 7 percent of the events to the FDA and sold on. According to a plea agreement entered into with the United States government in 2003, the company belatedly disclosed another 2628 serious malfunctions and 12 deaths. No problem. It agreed to pay $92 million to cover criminal and civil penalties and then picked up with business as usual on other products.

Your drug company just received an official warning letter from the FDA for the "false and misleading" marketing of Celebrex, Vioxx, Pravachol, OxyContin? No problem. The FDA's corrective action is unlikely to displace the false information already firmly planted in the public's mind.

Three of the top fifteen drugs for seniors are cholesterol-lowering statins. High-risk elderly patients with no previous history of heart disease have no fewer heart attacks when they are treated with a statin for three years. But they do develop significantly more cancer. Treating patients over the age of 65 with Vioxx is about four times more likely to cause a cardiovascular complication than a statin is likely to prevent one, even in patients who have already had a heart attack.

The third most frequently prescribed drug for seniors is Fosamax for osteoporosis. It does not reduce fractures when used to prevent osteoporosis. For women over 70 -- even those with severe osteoporosis -- Fosamax's cousin, Actonel, significantly reduces the risk of hip fractures only in women who have already had spine fractures. Meanwhile, how many women taking these drugs are aware of the research showing the significant benefits of exercise in preventing fractures and, more important, improving overall health and longevity?

"Quality of care" is now defined largely in ways that best serve the financial interests of drug and other medical industries rather than the health needs of the American people. Officials at the National Institutes of Health are allowed to participate in lucrative consulting contracts with the drug companies. Experts with financial ties to the drug companies dominate the FDA's Advisory Committees and the panels that write the clinical guidelines that define the standards of care for practicing doctors. The medical industry and drug companies even fund the majority of doctors' continuing education. The production and implementation of medical knowledge in the United States is by now so riddled with conflict of interest at virtually every level and every stage.

Drug companies earn higher profits when more people use expensive drugs, not when more people achieve better health. Doctors and hospitals are paid more for doing more, largely without regard for evidence of improved health outcomes (examples are the rapid increase in the number of MRI machines, excess capacity for neonatology and invasive cardiac procedures that lead to excess use, and the approximately 12,000 deaths that occur each year as the result of unnecessary surgery).

The areas of the country that have higher concentrations of specialist physicians have both higher health care costs and worse health care outcomes.

The recommendations about a healthy lifestyle may at first seem too simplistic, but the research repeatedly shows that this is the best way to stay healthy. Each person needs to have a willingness to accept responsibility for maintaining their own health and a willingness to let go of old habits to make room for growth.

The next time you hear about a medical "breakthrough," try to determine who sponsored the study and whether the experts interviewed disclosed any financial ties to the products being discussed. Protect yourself from the drug companies efforts to convince you that you desperately need their advertised products. There is a reason why drug companies spend so much money on advertising trying to brainwash people. Celebrex and Vioxx, two drugs of very limited clinical value, have become blockbusters in the United States but not in the rest of the world (nearly 80 percent of all sales occur in the United States). Drug company-funded continuing education is able to presuade doctors to prescribe certain drugs, not necessarily the best for the patient. Oftentimes patients come to their doctor demanding a certain drug because of seeing the advertisements and if their doctor won't prescribe it they will go to a doctor who will. Recommendations that guide peoples medical care are not nearly as "evidence based" as they claim to be.