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The relationship between physicians and the drug industry doesn't begin once you
have your MD
or your private practice, it begins the day you hit medical school.
Many medical students are given "gifts" on their very first day.
It's interesting that those gifts are never
things like a free dinner at a fancy restaurant or
free tickets to a basketball game. They're not even pens
or prescription pads. What they tend to be is things that
look like
they are about education. So they are a text book or
an opthamaloscope that you can look through and say "Oh my god I'm gonna be a doctor."
I think what that's about is establishing a relationship,
establishing good feelings
and
a dependency and a sense of entitlement that I work really, really hard
and nobody else is being nice to me, but these guys really nice to me.
And at the same time the notion
that we're all in this together. We're on the same side
the side fighting against disease.
(music) Money Talks: Profits Before Patient Safety
Accepting gifts and all sorts of entitlements from drug companies have
become
so prevalent had just become part of the culture in medicine
but nobody really talked about it. I started No Free Lunch in 1999 and
at the time the reason was we were we're moving to an offsite clinic across
the street from our main hospital
and I wanted the site to be a drug rep free zone. This meant though that we
wouldn't have access to free samples that reps often provider for use with
indigent patients without
prescription drug coverage. So
the initial idea really was a bake sale initially. I was gonna print out these
t-shirts and pens,
coffee mugs with no free lunch logo on them. Sell them to raise money
to buy drugs medications for these patients.
Of course out of that came the website, out of the website came the organization
and all that followed.
Prescription Access Litigation Project is a coalition of a over 100
consumer senior labor legal services women's health and health advocacy organizations
in 35 States and we fight
against illegal drug company practices that inflate the price of prescription drugs.
We do this using class action litigation - lawsuits
and public education.
I've been writing about the pharmaceutical industry for about five years now.
Largely from medical journals but also for the lay press.
And you know doctors started telling me these
stories about drugs and therapies that they were prescribing
and and they were shocked, they were horrified, because they find out that
these therapies - one after another, were actually causing more harm than good.
And they want to know how it happened.
They couldn't believe that they were giving medicines to people
that were actually in some instances killing patients.
So I started looking into where a lot of the physician education came from and
where a lot of the research was coming from and increasingly of course it
shows pharmaceutical influence.
I was a family doctor about an hour north Boston for twenty years.
And did all things the family doctor does
And there was this seminal moment when I talked to my partner, my family practice partner
who I'd practiced with for seven years and trusted
completely and said to him, "We can't even trust the New England Journal of Medicine
or the Journal of the American Medical Association anymore." And he looked at me
as if I was having a psychotic break as if I had said,
"The CIA put a bomb in my gas tank and if I don't blink five times the world's gonna
blow up."
The thought that...
that I could say the New England Journal and JAMA were being used by the drug
companies and we couldn't trust was in there was so
anathema to what he and all of us doctors
are taught. And yet the further I got into the research after that,
the more and more I saw that these journals now
are playing a major role in misleading physicians.
At the time that I was a sales rep I had a bachelor's
in finance and was working getting my masters
in business administration. So certainly that qualified me
to be a pharmaceutical school sales rep and tell doctors what they should or should not be doing.
I've been on the faculty at UCLA for
over 25 years now. Currently I'm a professor
medicine and emergency medicine. I also do research.
and of course I'm also responsible for some
supervision of patient care here in our emergency department.
In general the main character's experience is closely based on my own experience
and I worked in the industry for about 10 years.
Doctors will say that they get valuable information about drugs
from these pharmaceutical salespeople.
And that may be true at times, but they need to remember that they are there to sell a product
They're not giving a public service announcement.
The truth is
that they are so hurried and there are so many drugs out there now.
There are thousands and thousands of drugs that
simply to remember the right name of a drug
and the right dose alone is a task. And so frequently
they just want to know because they know that everyone around them is prescribing
a certain drug.
They just want to know the name of the drug and the dose.
It's a great way to spin it, in terms of selling verses you know is it -
am I selling a drug or am I
there as an information tool.
And it was sales. I mean, there is no question it was sales.
I don't think any of us, if we wanted, if we decided we wanted to buy a new car
would say well it's really hard to go out and search and learn everything about all
the new cars
so I'm gonna go to the dealer, the maker of a given car and asked them,
"Is it a good car?" We would understand that we really couldn't trust what that
person told us.
And that that wouldn't be better than no information, yet in fact in some ways it
would be worse than no information.
Let's be honest they're there to sell their drugs. They are not there to educate doctors.
They get paid. They get bonuses
on how much drugs the doctors prescribed, not whether the doctors prescribing
the most appropriate drug. So I don't think any doctor would
get their information from reps, if it wasn't for that the information came
with free food and other sorts of perks. If you took away all that stuff
in the 21st century I don't think too many doctors would be getting their
information from reps.
We've all seen the parade of drug reps that come into the doctors office.
I was just doing a radio interview the other day and the interviewer
had been sick a couple days before and was still fuming that
several drug reps got in to see the doctor before he did. And the doctor was
eighty minutes late by the time all the drug reps got out he got in see the doctor.
My least favorite part really is when you walk into a clinic
and you get the dirty looks from the receptionist who knows, oh boy here
comes another suit,
whose going to be peddling who knows what And you give 'em your business card they say,
"yeah, it'll be a couple of minutes."
And you turn around and you see 3 more suits sitting in a lobby with 2 patients.
And it was just a sickening feeling and more often than not, I would just leave.
I'm like, you know, I'm not gonna burden, you know, the doctors have no time for me that day.
You know, that's the part of the job that really bugged me.
There are over 80,000 pharmaceutical sales people employed by the drug industry in the
United States alone
My understanding is that's about 1 for every 4 doctors.
Their job is to sell drugs. Their job is not to educate doctors.
Their job is not to
provide medical information. They have one job than one job only -
to push their products, particularly against other competing products.
Doctors should not trust them to give them unbiased accurate information
about their drugs.
And frankly, doctors shouldn't let them in their offices.
The drug reps are amazingly inventive, oh the drug companies and
and the kinds of campaigns they would use
to get doctors to prescribe. And again just name recognition is a big thing.
When you've got a field of twenty different antihistamine for people to allergies,
you know which name comes to you first is important.
It's like you know the more times you see a message the more time
it was a marking ploy like anything else.
It's a lot of stuff that really has nothing to do with medicine.
I mean its baseballs and golf balls and chocolate
Kleenex boxes, frisbees, cooler cups,
coozies, napkins, plates
clocks and toy cars and cups and pens
golf ball, golf shirts, golf tees
bringing in a physician good lunches so you can have twenty seconds to give your pitch.
They will send hordes of reps into the offices
with everything from pens to meals,
to offers of tickets to special ballgames.
They employ all kinds of tactics both legal and illegal
many of which are very questionable.
At least most doctors are completely unaware of
is that they're being profiled by drug reps and that the drug companies
have these profiles on them that not only
keep tabs on every single pill every single shot
every single *** suppository that they prescribe
but they even keep psychological profiles on these guys.
So that they know how to seduce them with their sales pitches.
All doctors sort of in a non-specific way
get these fishing expeditions from time to time - would you like to be?
Since we know you're such an expert doctor ______ Let's see what's your name?
Dr. X
We'd love to hear your opinion on this, so that you can help us do better things.
Doctors again, have become
accustomed, entitled to accept all sorts of gifts from smallest to the largest and
certainly to the public with seeing doctors being
jetted off to the Caribbean for a weekend with the drug company paying
does not make the profession look very good.
There's the ski trips and there's the conferences and there's the fancy dinners and
the drug companies will do whatever they can to endear themselves to doctors. It's
hard to be angry at people when they're giving you good food, good wine.
You know taking them to ball games and taking 'em out to golf and
buying them lunch and dinner. And I'm thinking,
man, I really - I'm glad that we can do this stuff I'm enjoying this
and I hope that I'm getting this message out so that you know at least they're making
an informed decision.
But hope they're not doing it because they like me. Or that you know because I'm
giving him this stuff.
And I'm thinking if that is really what's
influencing them - that really is creepy to me
The worst things I think are some of the
smaller enticements. For example the
the mornings at Starbucks, the doctors come in and get a free latte,
in exchange for talking to the rep for 30 seconds.
That doctors would sell themselves so cheaply
and allow themselves to be influenced and really cheapen in the profession just for
a cup of coffee,
granted an expensive cup of coffee, but a cup of coffee none the less,
is I think very troubling.
I think it's high time that doctors basically, as a profession,
kick them out of their offices once and for all.
It's really hilarious, I mean I have friends who
are physicians, who know better. I mean they know that they shouldn't be seeing drug reps.
But they will actually come out and say, "but they're so good-looking."
And it's true, I mean drug reps are invariably gorgeous.
They are young beautiful things, male or female.
You think that there was a rhyme behind the reason as to why the people with,
that were pretty and smart and could tell a great story were selected
those with medicine backgrounds? Certainly there was.
You know, when you're working in an environment
where people are coughing up phlegm and puking
and feeling miserable, it's just wonderful have this lovely fresh
face, who comes in all perky and invariably stroking your ego
and you may think that you're resisting their message
and just enjoying a moment with a drug rep and getting a breather
and besides that you have to learn the name of the new drug anyway. But the truth is - it has an influence.
One of the lines that I often will say that always brings
a big chuckle, is I ask the audience, "Do you know any ugly drug reps?"
And the point of that is that, of course they don't know any ugly drug reps, because
drug reps are always not only handsome and beautiful but they're also well-spoken, thoughtful
smart,
reasonable, good listeners. They're lovely people.
They too, just like the opinion leaders
have to believe that what they're doing is a service for humanity -
doing good. I don't think any of them or certainly very few of them
could do the job well if they believe that this was really all about profits
and squeeze an extra dollar at the expensive the public health.
These things do influence physician behavior, despite the fact that if you
talk to any physician they will vehemently deny
that they would ever be influenced - that their prescribing would be affected by the
acceptance of any kind of gift from a drug company.
There's an interesting study that was done
that shows that generally speaking doctors think that their colleagues and the profession
is affected by drug marketing, but not them personally. It's a very interesting
disconnect between their personal thoughts about their own behavior and influences,
versus what they think of their profession. But studies have shown, also
that when you look at doctors prescribing patterns after they receive
you know visits and other marketing from drug companies
it does actually affect the way they prescribe.
So there is a fair amount of evidence that when you take lunches, when you meet with drug
reps recently, when you think highly of what they tell you,
when you go to sponsored education that you're less likely
to prescribe in an evidence-based way. You're more likely to do things
that are distorted and inappropriate and expensive and end up harming the public
health. When doctors here that
they many many of them respond in a way that I like to call the
"how dare you" response. How dare you think that I
would be influenced by a pen, by a pizza,
by a trip to the Lakers game.
There was a great study from the Cleveland Clinic
that showed that when you...
when they sent doctors on a junket and
educated them quote un quote by the drug company about the use of the drug. When
they return to their university or to their practices,
not only did they prescribe a lot more that drug, but all the doctors around them
at that institution began to prescribe greater
numbers at those drugs. So it has a downstream effect.
And it's not because doctors were individually educated it's because they
learned the name of the drug, the dose of the drug
and that the top dogs in their field were prescribing it.
Even if a physician is not influenced by the
three or four dinners that her or she goes to during the week, somebody
is paying for the cost of those dinners. And I would say that it's patients, in fact,
who are paying for those gifts in the form of higher drug costs.
And so it it took some time to be distanced from it to say my goodness
I was influencing them. And I was making them
alright, if I'm choosing between drug A and drug B, you know well
I'll give drug B a shot because you know so and so told me about it.
and what have you.
And I'm hoping that they're pulling the messages that were the facts.
And, the more I think about it, the less I
want to be thinking about it. Because
if I had that much pull and I had that much influence - that scares the living
daylights out of me, because I had no business telling anyone anything about this stuff.
I even had one physician,
who would often bring out a patient chart if she was having a difficult
patient or whatever the case is, she'd bring out a patient chart and be like
okay kathleen I've tried this, I've tried this, what do you recommend here in terms
of tweaking? And I'm sitting here thinking
I'm a political science major and you're asking me?
You know, what to prescribe for this patient?
The tactics used by the the pharmaceutical salespeople
rely on an entire system that is designed to manipulate what doctors
understand about drugs. And basically the the sales person is the last step in that.
We also have to look at how clinical trials are designed and conducted.
Right now clinical trials are designed by the companies that are seeking to
push a particular product in most cases.
And unfortunately they are frequently
able to manipulate the design of the study or how the results are presented
so that their drug comes out looking more favorable.
That obviously is not a good way for us to accurately assess whether a drug is useful and safe.
Before 1980 most clinical research was
funded by the National Institutes of Health.
Academic researchers quote, snubbed their noses
at doing commercial funded research before 1980.
When president Reagan came into office the economy was slow.
The ethos was small government and the NIH funding of clinical studies
went down dramatically. The drug companies were very happy
to come in and lend a helping hand. Nothing much changed until 1991,
because the studies were still being done in universities.
But during the 90s, most of that research got pulled out of universities
and was being done - was brought to
for-profit research organizations. There's nothing inherently unethical about that -
it was more efficient and quicker
for the drug companies. The problem is that that gave virtual complete control
over the research to the drug companies. They could design the studies.
They have control of data so that many of the authors of the most important articles
published in our best journals aren't even allowed to see their own data.
They don't get free access to their own data. And they have control over publication.
So the bottom line is that now 90% of clinical studies are funded by the drug companies.
The odds are five times greater that commercially funded studies will support their products.
Suffice it to say that when drug companies
set the research agenda - do the research
and design the research, have tremendous influence over the people who get to write it up
and in fact have tremendous influence over the journals that publish it
because they're very very beholden to drug companies
for their own financial well-being, then it's not surprising that
so much of what we think we are learning
is tremendously distorted.
We have studies that are a funded by drug companies and there have been studies of those studies.
And those studies of those studies repeatedly show
a tremendous bias. They repeatedly show that they will be far more favorable
for a drug, if they're funded by drug companies. And we have studies showing that
authors, who write about these drugs,
if they get money from the drug companies, they're going to write
far more positive information than doctors
authors and medical journal articles who don't get money from the drug company.
They may be right, they may not be right,
but I'd rather hear it from somebody who isn't getting money from one side.
And more often than not, you can't get the data. I think it would be a major
step forward if the drug companies who
sponsor research made their data available
to impartial scientists, to make sure that the conclusions
that have been drawn in the medical journals and that are driving our
medical care
really are supported by the research data. Right now that data is treated like
the recipe for Coke.
The data are so hidden and so complex whether it's gene therapy or whether
it's the number of people who die of heart attacks while taking Vioxx.
We have to rely on researchers to provide us with that evidence.
And I think the most shocking thing is to find
that that evidence is simply not available
or it is distorted and
some of it is hidden as trade secrets.
Federal trade secrets laws, commercial interests
allow drug companies to withhold some of this information.
And I just recently found out
for example that the Food and Drug Administration does not report
all the deaths it knows about, in patients who were on certain drugs,
because these are considered federal trade secrets.
One of the problems in the drug industry is that
studies are frequently either hard to find or
the results are manipulated by drug companies. We certainly heard a lot about that
in terms of Vioxx and the heart attack risk. But in the case of Nexium,
those studies were printed and reproduced the results
right in the package insert that the FDA requires
be accompany the drug in pharmacies.
So these were not secret, but you know, it's really fine print and
not something that most consumers can understand.
Whereas the ubiquitous television ads touting the benefits of the so-called
healing purple pill are very hard to miss. So this is a case where
I guess you could say it was hidden in plain sight.
The data that I found on the FDA's website
showed for Vioxx - that in the company's own study - in Merck's own study,
called the vigor study,
where Vioxx was compared to Naproxen or Aleve, sold over the counter.
Vioxx was no more effective than Aleve, but the important thing is that
cardiovascular complications: heart attacks, blood clots, and strokes
more than Aleve. And overall
Vioxx is a more dangerous drug than Aleve. So that if I as a family doctor,
prescribed Vioxx for 100 patients in a row
within the next year there will be 2.5 serious complications
because I treated those patients with Vioxx instead of Aleve.
The New England Journal of Medicine article that was published in November 2000,
that was supposedly based
on reporting that research, failed to include those two crucial pieces of information.
We need to look at how clinical trials are designed and adminstered.
But then we also need to look at how medical journals publish
results of clinical trials and other research.
Right now, unfortunately a lot of journal articles are written by physicians who either have a
financial interest in the company and the product that they're writing about
or have a consulting arrangement. And frequently journal articles are also written,
ghostwritten by companies that basically do this as a business and then sign up
a prominent doctor to put his or her name on the article.
There's a lot of evidence now that some of those articles aren't even written by
those physicians, but are actually
ghostwritten by the company's for the signature
of the opinion leader in medicine, who gets the credit and also sometimes gets paid
for an article that somebody else wrote.
And that gives a false credibility to the results
and creates a very incorrect impression for the doctors and other
medical professionals like read the article and rely on it.
I saw an article in the New England Journal Medicine in August 2000 about
Pravocol, which is a cholesterol lowering drug, reducing the risk of stroke.
And it seemed to be a biased article.
So, I went through very carefully. And then I got in touch with the research expert in Boston,
to review my critique of the article with him
to see if he agreed with me. So we went through it point by point and said yes,
he thought I was right. He didn't see anything wrong with my analysis.
So I asked him if he would be interested in writing a paper with me.
I thought it would be very powerful if a practicing family doctor
and a research expert wrote a paper together to help to immunize practicing physicians
from the growing commercialism in even our most respected journals.
He said to me, "Well, I'd rather not. I do a little consulting for the drug companies
and I'd rather not get involved."
And that really was a turning point for me, because
I naively had believed that the universities,
were the overseers of the integrity of medical science
and knowledge in general. And that
showed me that there is enough drug influence
in our best researchers so that the oversight function was no longer functioning.
And then a year later I saw a review article in the New England Journal again
about Celebrex and Vioxx and it seemed to be very clearly biased
in favor of promoting those drugs. I noticed that both of the authors
had financial ties to the drug companies.
And at the time that was against the editor editorial policy the New England Journal.
Now these journal articles are handed out by salespeople in doctors offices.
So now if they can't rely on the journal articles, they're even more hard pressed
to find out accurate drug information.
This transformation in the purpose of that knowledge has happened so quietly
that the watchdogs not only haven't been able to keep up with it,
but the watchdogs a largely drugged. So more than half of the
budget at the division at the FDA that proves new drugs and oversees drug safety is
funded by the drug companies.
90% percent of the clinical studies are funded by the drug companies.
59% percent of the experts who write the clinical guidelines
that create imperatives for us to follow
have an active financial relationship with the drug that's being considered in the
guideline process.
About 70% percent of our continuing medical education that the doctors
participate in, to maintain
their state license is funded by the drug companies. And we all know that there's now
one drug rep for every four and a half practicing doctors.
So the drug companies are spending about $30,000 per doctor
each year for marketing.
The pharmaceutical companies spend a lot of money on marketing its probably close to, in 2005,
probably close to twenty billion dollars.
It's well documented that the drug industry spends
roughly twice on marketing what they spend on research and development.
And this really demonstrates the drug industry's skewed priorities.
And though the industry will say the marketing costs
don't affect the cost of drugs, they do say that research costs effect the cost of drugs, so...
though I'm not an economist, I don't see how you can have one but not the other
And that in fact like the research costs may affect drug costs,
I guess that marketing costs probably affect them too.
They're more interested in marketing drugs of questionable
innovation to the american public then they are in researching genuinely
innovative drugs that will be real breakthroughs
for diseases, that not just Americans but people all over the world suffering from.
So the fact that they spend twice as much on marketing as they do on research
really undercuts their argument that they need the high prices that they force us
to pay in order to somehow pay for all this
supposedly innovative research that really isn't taking place.
First of all, they always claim that their prices have to be high because of
all the research they do. Well in truth most
their research goes towards "me too" drugs.
Those are drugs that just simply immitate
other drugs that are already on the market that do the same thing.
They're not saving lives.
They're not changing things. They're just a different drug company
trying to get a piece of the market.
The notion that we got to learn zillions of things because there are millions of journals been published every month,
is just not true. In fact, very little that comes out in the thirty years that
I've been a doctor
has really changed my practice - has really been important.
There have been a few things but you know what,
it wasn't hard to know about those things.
Those things were so dramatic
that you couldn't help but learn about them.
A good example in the ALLHAT study compared diuretics,
fluid pills, which are very inexpensive; beta blockers, which are very inexpensive;
and then three expensive classes of anti-hypertensive medications.
Well it turned out that the diuretic that costs only $30 to $50 a year,
was equal to or superior to all the other drugs in preventing the complications
of high blood pressure. So the British Medical Journal
published a wonderful article in which they interviewed a strategic
marketing consultant for the drug companies and the interviewer said well
isn't this going to be a problem - your expensive drug
is not as good as the drug that cost $30 to $50 a year. And he said, "No, this won't be a problem.
We have a ten billion dollar industry. We'll have 55 promotional events
and this data will go away. It'll fade away." And I believe he was right. It did fade away.
This is another thing that gets gross. When they come out with, because it's going to go off patent, right.
So it's going to be, a generic can be made.
While they just switch the formula ever so slightly so, oh
we get three more years of exclusivity to the drug and we can still charge premium prices.
Nexium we have all seen the TV ads for.
It's the so-called healing purple pill and many people know that it is a successor
to Prilosec, which was the original purple pill.
The main difference between Nexium and Prilosec is the yellow stripes
they added to Nexium
and the price. Now Nexium is seven times more expensive than Prilosec.
The piece of information that AstraZeneca is not too anxious to
publicize is that there is
basically little or no medical difference between those two drugs.
Basically Nexium is a chemical mirror
of the active ingredient in Prilosec.
It's called an isomer. They've taken pains to try and portray it as though it's different.
But they haven't really been able to do so. In fact, the main studies they did to
demonstrate that it was somehow superior
really didn't do a fair comparison. They compared a 40 milligram dose
of Nexium to a 20 milligram dose of Prilosec.
And even when they did that, the differences were really marginal at best
and in one of their studies no difference at all. When they put them head to head
20 milligrams of Nexium against 20 milligrams of Prilosec there was no difference.
If they were to say, "Look I'm making the 19th version of the same drug
that never worked in the first place. We have older drugs are even cheaper than all them
and they're just as good. And what's more it isn't even a disease, we're just making it up."
Shyness is now social phobia or something like that.
If they were to say that, "This is really just about making money."
They wouldn't make a lot of money. So, they're smart enough to know that the
way to make money is to convince us -
when I say us, I mean it all sorts of different levels -
that this is really about a noble search for science and health.
Objective cutting-edge science coming out of the top universities in this nation
is often marketing dressed up as science.
You know you can put lipstick on a pig, but it's still marketing.
Supposedly the web opens up medical information so
people can do their own research
but studies show that about 80% of the material that people
find on the web about medical care is commercially motivated.
whether or not it can be identifiable as such.
There are a number of groups on the internet that
look like these bona fide
disinterested patient groups that would only want the best thing that's right for them.
And you come to find out that they are 100% funded by a drug company.
Unfortunately the FDA currently only requires when you are seeking to have a new
drug approved that you show that the drug is better than a placebo.
In other words that the drug is better than nothing. That's really not very useful
information for the doctor.
They don't require the drugs be compared to each other.
And that's a huge gap in our medical system. And other countries
do require the drugs show that they're an improvement over what already exists.
And do research to show how they stack up against each other.
There are some publications and
research institutions that are doing this kind of research.
The biggest one, the most important right now
is the drug review effectiveness project at the Oregon Health Sciences University.
And this basically is a meta-analysis where they collect
all the different studies comparing drugs within the class to each other.
And they make conclusions about how they stack up and which ones
are really the most effective. Now for consumers much of that research gets distilled
on their website done by Consumer Reports. It's called Best Buy Drugs.
And they do essentially with for drugs what they've done for years for
refrigerators and vacuum cleaners and other products, which is tell you
within a particular say group of heartburn drugs which one is the best buy -
the most effective for the money. So things like that are really important resources.
And that website for Consumer Reports best buy drugs is
crbestbuydrugs.com
Even when physicians could see through some of this stuff, even when they could
say you know - this isn't right. The drug companies do an end run around
the doctors and go straight to the patients with direct to consumer advertising.
And patients would start demanding these drugs and
what they found was, I mean, a study clearly showed that when patients
ask for a drug, doctors will often yield to that request.
Even when they know that's not always the best choice.
I had been in practice for twenty years. I closed my practice ten years before
so all the patients in my practice I'd been working with
in a small town for at least 10 years. There were many of my own patients that I
could not convince
that these drugs weren't better. They would come in asking for Vioxx and Celebrex.
And I would say, "Look I know as much about this as
anyone in the country who is now working in the drug companies
and these are not better drugs. And my patients would say, "Well I saw them advertised."
Or even more emphatically, "My friend had them prescribed by specialist,"
implying you're just a family doctor. And many people said
if you don't prescribe them for me I'll go to another doctor who will.
And I could not convince people
that I was looking at the original research and that it showed that the drugs
were more dangerous.
The reason 20 million people to Vioxx and many millions more many millions more
took Celebrex was because of the advertising.
It's because consumers saw Dorthy Hamill skating around on their televisions in
those Vioxx ads we all saw,
all seen that so many people took Vioxx. So that's a perfect example of how drug advertising
totally skewed what drugs people took and how much they paid.
Because Vioxx was many many more times more expensive
than a bottle ibuprofen, which from most people would've been just as effective.
And not only would they not have paid more, they wouldn't have been heightened risk for heart attacks.
If there's anything in American or western society
that sort of dominates our cultural life
its advertising. Advertising costs millions of dollars for the Super Bowl
for a minute. And the reason it does is because it works.
Because by spending a few million dollars on advertising
you make billions of dollars. And the drug industry is very good advertising.
The ads are so beautifully designed to create an emotional connection
in a sense of needing these drugs that they really
capture a lot of people's interest.
God, you can name all these drugs nowadays.
Ten years ago you couldn't name unless you
were prescribed that prescription you could not name a drug.
And now you can name ten of the top your head. Isn't that crazy?
There is evidence that the best advertised drugs to consumers
are the best sellers. No surprise.
So drug advertising is really skewing the market and how much we pay.
It's not going to go away. I think that's very unlikely,
but it needs to be much more strictly regulated.
When president bush first came into office
there wasn't an FDA commissioner and he appointed Daniel Troy to be the chief
counsel of the FDA.
And one of the first things he did was make a rule
that all of the advertising infractions that had been responded to in a matter
of days previously because the committee that looks at them - the division that looks at them -
would send out warning letters or sanction letters
All of those problems would have to come to his office
and the delay in sending out warning letters, meaning protecting the public from
ads that cross the line, and that in some way
misrepresent the drug or overstate the drug's benefit or
understate the risks, was grossly delayed.
Right now the FDA does not require drug companies to submit
television ads or any other drug ads before they air.
They only have to submit them after the fact. So the ad will already be on TV
or in a magazine. And the FDA, if it eventually gets around to doing
something about an ad it considers deceptive,
may be too late. Representative Henry Waxman
has done studies about how long it takes the FDA to act on deceptive advertising.
And there are very lengthy delays, usually
four to six months i think is the average. By four to six months
many of these ads have stopped running. The damage is done.
The expression is closing the barn door after the horse is gone.
Well the FDA is at best shutting
the barn door halfway after the horse is long gone. So we need
better enforcement by the FDA of direct consumer advertising.
And we also need more disclosure within drug ads of
exactly what the drug is for, what its risks are,
who it should be used by and basically fuller information
so that people can make an intelligent choice. Right now drug ads are
basically a shameless promotion with a little bit a risk information at the end
that frequently people don't understand or that's obscured by
graphics, sounds, things going on in the commercial that make it hard for people to
take in that drug information.
It's shortsighted to think that this is a matter a bad drug companies
or bad people pulling things over on us. They're doing what they're supposed to do.
If we want it to be different we have to insist on it.
And the ways in which we insist on it is
multi-pronged but it includes our government, of course it does.
Right now our government is not terribly interested in making any reforms that
would be useful
because they're very beholden to the drug companies.
If we want to change that, we have to make them beholden to us.
We have to have the clout and the influence and the organization
to make it that they can't blindly go along making the FDA
be something that has been widely and famously called a servant
of the drug industry. We have to make that the FDA is a servant us.
Should doctors take drug samples well I took drug samples and I thought I was
being like a Robin Hood
because I had expensive drugs and some of the drugs are better than the alternatives.
I had expensive drugs that I could give to patients who couldn't
who had no insurance, who couldn't afford them. It was only until I left practice and started
doing research full time that I realized I thought I was being Robin Hood
and they were playing me like a violin. Because the real job is to get those drugs into my
drug closet, so that I would learn how to use the expensive drugs,
learn how to use their brand of expensive drugs - what the doses were, what the side effects were,
what the timing was of changing doses and following on patients.
So that I would get comfortable with their drug and then have it be one of
the two or three that I knew how to use in that class.
In fact industry spends over half its promotional dollar
on these on the retail costs of these free samples and its promotional costs not charity.
And it's not the charity budget these samples come from and for good reason because
these samples of course are always the newest most expensive drugs and
once the doctors and patients are hooked
on these drugs it becomes the drug that the doctor is most likely to use at a later time.
Well they never give samples of aspirin.
Aspirin is probably the most important drug that we use today in our society.
They don't have samples aspirin because aspirin is inexpensive and people can
actually use and it would be really, really helpful.
They give samples of the most expensive, fanciest
new drugs and they do that because they want us to use these drugs, so
And there's a lot of ways in which helps us use these drugs -
first at least you get used to using them and
handing them out. And you have to know exactly how you use them and what are
the terms and what's the dosage and all that stuff.
So you get familiar with them: that's good because the next time
you come to write a prescription
you're going to think about that new drug. In addition if you gave a sample to somebody
and now, the next time they need a prescription
well you don't want to change their drugs so you got to write the same sample.
I knew what a huge marketing tool
that the samples were. It was not just a a benevolent
act of kindness by the pharmaceutical industry. I, in fact, was evaluated
by how much I could push samples on my physicians because
we as reps we would often go into the offices and leave samples for the
physicians and we would check back maybe every two weeks
to see if they needed more samples. We would be sick to your stomach
if those samples weren't moving off the shelf because you know what
ultimately you know, if the doctor is using more samples, that means that doctor's
using one my competitors' it was a sickening feeling because
I knew that I was, you know, I wasn't performing my job.
There was this article where a group, I believe it was in Maine,
a small town in Maine, described a very different approach to samples.
They decided that it really, they weren't interested in meeting with the drug
reps anymore. It was taking too much at that time. They didn't like what was going on.
They didn't like the things they were given as samples, etc.
They didn't wanna be coerced into using these fancy expensive
new drugs. So what they decided to do instead
was they decided to each contribute $100 a year. For the $100 a year,
There were 9 physicians in this small town.
So they had $900 between them and they gave it to the one local pharmacy
that existed in the town.
And with the $900 here's what they bought: they bought all the samples
they could ask for
for a whole bunch of common diseases but the samples
weren't fancy new expensive drugs. They were things like aspirin and
hydrochlorothiazide, a very inexpensive diuretic, an inexpensive
beta blockers and nitroglycerin and all the drugs that really mattered but that cost nothing.
Inexpensive antibiotics, not the fancy new tremendously expensive antibiotics but
the simple ones that work.
So they got all the samples they could possibly have
for much less than the $900 because the $900 also bought them
education, because the pharmacy also agreed one night a month
to prepare a seminar which they would take someone's this $900 as profit.
And they would have one of their pharmacists prepare a seminar
on a drug topic of the physicians request.
The doctors said, you know what we really can trust this as education because this guy
was beholden to us - we were paying him.
Nobody else was paying him and he didn't have some other financial conflict of interest
Secondly, we got samples for things that are really useful and that we wanted to use.
Third of all for a hundred dollars a year each we saved all that time,
that we would have had to spend with these drug reps. I've told this story to groups of doctors
probably on 15-20 occasions and
over the years since I've told it I've had half-dozen
physicians come up to me afterwards and say you know I heard you say that
five years ago and we've started in our town and boy it's great.
I don't think you have to sell your soul to get these samples.
The reputation of drug companies is abysmal
It actually matches that of tobacco companies.
So the word is out, but the problem is
so entrenched in our institutions,
that without public action, where we actually separate
drug company influence from physician education,
from payments to the FDA,
from advertising in journals,
from research,
from patient advocacy groups,
from all these areas - we're not going to be able to get at the truth
because the actual data will be withheld,
scientific conclusions will be spun,
in ways in that we will not really learn the truth
And again as with Vioxx, we could have known years ago, before many people died but we didn't.
They don't want doctors thinking this is about selling
product no matter how useless. They want doctors to believe it's about curing disease.
So they advertise to doctors in all sorts of ways. They give us pens.
Not because they think we really care that much about a pen,
but because they think it'll create a relationship of friendship and
collegiality and trust.
And it's not just pens, it gets bigger and bigger depending upon who you are and
how much they need you.
And it's not just doctors, it's opinion leaders. And it's not just opinion leaders, it's
medical societies and famous
public medical societies and agencies.
I don't wanna name specific names, but anyone
of the big public agencies
or publicly known medical groups, they all have relationships with drug companies.
And the drug companies
spend a lot of time wooing them and giving them money.
And pretending that it really is all about science
and curing disease. And it's not just the societies,
it's the journals, which are tremendously beholden. And it's not just the journals,
it's the universities which have
taken enormous amounts of money from the drug industry.
And it's not just the universities, it's our government
and it's the NIH and it's the CDC and it's
the FDA and it's Congress and
the White House. All of these have very, very,
very powerful financial relationships with the drug industry.
The issue ought not to be a liberal
or conservative issue. The issue is one
of the benefit to society and not only is
our health care being compromised by this biased information,
and not only are 18,000 Americans dying every year because we're
the only country that doesn't have, industrialized country that doesn't have
universal health coverage.
But the market place itself is now being distorted
and now this, this crisis in the cost of medicine
is much like what we saw when there was a crisis in the confidence
the securities industry when the SEC had to step in
and be bolstered to restore confidence in the securities industry.
We now, it's a bipartisan issue to restore confidence in our medical knowledge.
And unless politicians from both sides of the aisle step up to the plate it's
not going to happen.
And that won't happen unless the public demands that their politicians do so.
Again I'm hopeful that we don't need more regulation that just getting doctors,
educating doctors getting them to do the right thing may be enough.
I do believe that ultimately the responsibility lies with the physician
who's gonna write the prescriptions
and that's why I feel that one of the biggest
things we can do, one of the biggest solutions we can provide here is to raise
this awareness with physicians and future physicians
about the tactics the industry uses to promote their drugs.
Drug companies will do whatever they can
to form relationships that they can the leverage into getting doctors to
prescribe their drugs.
In many ways it's us doctors
who are responsible for this because we oughta know
that they're not doing this marketing out of the goodness of their hearts.
They're doing this marketing to get us to use their drugs.
And that is more often than not going to take us away from truly evidence based medicine.
Making little rules about you should do this you or shouldn't do that or the size
of the gifted, it can be a pen, but it can't be a fountain pen.
That's all silly. If we really want to change then we have to separate out
functions. We have to go back to being
physicians who take care of their patients and don't get anything out of
meeting with proprietary sources. We as scientists have to be scientists
rather than people whose career is made or
not made by how much money we get from somebody who is trying to sell something.
We as editors should be beholden to the
to our readers rather than the people who are paying all this money for our journals.
I have one message for medical students and that is just say no.
No free lunch, no pens, no giveaways.
Remember why you went to medical school in the first place. Remember why
you're studying to be a doctor. It's to help people. It's to serve people.
It's not to serve the interests of pharmaceutical companies. It is work to find
independent information about drugs but take that extra time.
And don't allow drug reps into your office.
They'll start in on you in medical school and it just gets worse from there on in.
The sooner you say no, the easier it is to keep saying no.
But you also, not just in your own practice, you need to work for reform
in your profession, in your chosen profession, to ensure that it continues
to act with integrity and ethics
that characterize medicine. And don't let it be corrupted by corporate influence