Neither Shalt Thou Take A Gift, For A Gift Doth Blind The Eyes Of the Wise, And Pervert The Words Of The Righteous

 

Address to the Graduates of the University of Louisville School of Medicine at the Graduation Ceremony, May 10, 2008

 

Edward C. Halperin, M.D., M.A.

Dean

Madame Provost, Dean Pfeffer, Officers of the School of Medicine, Members of the Faculty, Alumni, Graduates, Family and Friends, Ladies and Gentlemen.

I invite you to join me this afternoon and think seriously about a major problem facing American medicine: the financial incentives offered to U. S. physicians by pharmaceutical companies and medical equipment manufacturers for prescribing their drugs or utilizing their medical devices.

We are all, of course, accustomed to marketing. When you decide which new dishwasher to purchase for your kitchen, you are likely to visit several stores, look at advertisements, read reviews of various products on line, listen to what the salesperson has to say at the appliance store or hardware super store, compare prices, and make a decision. When you find yourself in the market for a new automobile, you will listen to advertisements on television or radio, read the full page advertisements in the newspaper, get opinions from your friends, listen, once again, to the salesmen and women at the automobile dealerships, and then make a decision. Similar to the purchase of the dishwasher, you are deciding how and when to part with your money in return for the acquisition of a product.

 In the last 15 years the American consumer has been the target of a new form of advertising: direct to patient marketing by the pharmaceutical industry and medical equipment manufacturers. You in the audience are, of course, familiar with these advertisements. You have listened to exhortations during a “word from our sponsor” for “little purple pills”, all manner of products designed to treat problems that my generation did not discuss in polite company, cholesterol lowering medications, medications designed to treat blood pressure, or grow hair. The manufacturer is trying to get you to ask your doctor to prescribe their product. In many cases, you will not directly pay for the product. The interaction between you and your doctor will result in your insurance company paying for the product.

What all American physicians are familiar with, but I suspect few patients are familiar with, is the advertising of the pharmaceutical industry and medical equipment manufacturers direct to physicians. This is referred to, historically, as “detailing” i.e. that the pharmaceutical company representative will provide information about the “details” of the product to the doctor. I’ll bet that you have seen these “detail” men/women walking through the waiting room when you go to see your doctor. They are generally impeccably dressed, attractive individuals, wearing a nice nametag to identify themselves as a representative of the pharmaceutical company. There are 90 to 100,000 of them in the U.S.

 What do these detail men and women do? Sometimes they tell the doctor about their new medications and urge the doctor to prescribe them. They may provide the doctor with informational brochures or reprints of articles from the scientific literature. They often bring the doctor and the office staff lunch or take the doctor to dinner where, with all expenses paid, the doctor is well fed, provided with wine, and listens to a speech describing the product being sold. The company sometimes provides doctors with medical textbooks as “gifts” or take the doctor on an all expense paid trip to a resort where, in return for a few days of sun and fun in the sand he/she listens to speeches about the pharmaceutical company’s product.

Many doctors in the United States are paid spokespersons for the pharmaceutical companies. They are asked to talk to their colleagues during lunch break or at dinner and describe the benefits of the pharmaceutical company’s drugs. Often the drug company supplies the doctor with his or her lecture slides. The doctor is paid at the rate of $1,000.00 per hour for this sort of work and many doctors in the United States make between $15,000.00 and $100,000.00 per year as spokespersons for the pharmaceutical companies.

Indeed, when you add up the entire cost of pharmaceutical company direct-to-physician marketing in the United States it comes out to $15,000.00 to $25,000.00 per doctor per year in the United States. To put this in perspective, ladies and gentlemen, that means that for the graduates sitting in the audience in front of me this afternoon the American pharmaceutical industry will spend approximately 2.8 million dollars per year in supplying them with pens, notepads, books, trips, meals, and pizzas. Each year in the United States about 22-25 billion dollars is spent by pharmaceutical companies on direct-to-physician advertising and another 3 billion dollars in direct-to-patient advertising. When the pharmaceutical industry tells you that the reason that drugs are so expensive is because of the amount of money they spend on research, I remind you that they spend about the same amount of money on research as they do on marketing to physicians and patients.

In the United States there is, on average, one pharmaceutical representative charged with calling upon physicians for every five practicing physicians. If a physician is identified as a particularly frequent writer of prescriptions and therefore a prime target for detailing there is, on average, one pharmaceutical company representative for every 2.5 physicians. That means, young doctors of the University of Louisville, that there will be approximately 30 pharmaceutical company representatives assigned to market their products just to you.

One of the dirty little secrets of American medicine is that the pharmaceutical industry, in collaboration with American pharmacies and the American Medical Association, mines vast stores of data on the prescriptions we physicians write. The pharmaceutical industry acquires data bases from clearing houses and pharmacies and can identify which physicians in any geographic area write prescriptions for their products, how often they write for specific products, and how their prescription writing behavior changes as a result of advertising. If, for example, there is a psychiatrist in your community who is not writing prescriptions for a particular anti-depressant marketed by one of the large pharmaceutical houses, you can bet that pharmaceutical company representatives will specifically target that physician to promote their product and then monitor the doctor’s behavior through these data bases to see if their advertising techniques are successful. The American Medical Association helps sell these data bases to the pharmaceutical industry and in 2005 made approximately 45 million dollars per year selling this service – 16% of its net revenue. I should point out, in fairness, that the AMA has recently allowed physicians to request that their prescription writing practices be excluded from the data base if they submit an internet application to the AMA. I have done so and it is easy to do.

Within the last month an article in the Journal of the American Medical Association documented that the pharmaceutical industry has ghost written many articles in the scientific literature and then affixed the names of prominent physicians as authors - this places a positive spin on the benefits of their products. We have evidence in the peer reviewed literature that pharmaceutical sponsored medical research disproportionately leads to the publication of articles with favorable results about their products; pharmaceutical company representatives intentionally ignore articles which do not support their claims of improved efficacy of their products; and that doctors who are exposed to detailing from pharmaceutical company representatives frequently respond by requesting changes in the drugs available in their hospital formularies.

Why should any of us care? In my opinion, we should care because a economic buyer-seller relationship is based upon the exchange of information. I can receive information from advertising or from Consumer Reports about various dishwashers. I will then make the purchase of the dishwasher I wish to have in my home.  As patients, however, we do not decide what drugs we wish to receive nor do we decide whether our CAT scan or MRI will be done on a machine manufactured by the General Electric Corporation or the Siemens Corporation. We trust our doctors to prescribe medicaments or medical procedures that are in our best interest. When our doctors make decisions that are based not on evidence based medicine in the peer reviewed literature but upon which salesperson most recently dropped off a free lunch and a gross of ballpoint pens, that is an economic relationship based on deception.

The American pharmaceutical industry and medical equipment manufacturers spend a large amount of money on continuing medical education. They sponsor medical meetings and lectures. Many people assert that were this source of money to dry up, continuing medical education for American physicians would suffer. American physicians, however, are quite well paid. It is disingenuous to argue that individuals who can buy homes, cars, and clothes are somehow unable to pay for their subscriptions to their scientific journals or the tuition for continuing education in their own profession.

For many people the trump card is the issue of free samples. “Don’t pharmaceutical company representatives give doctors free samples and the doctors, in turn, give these samples to their patients?” Isn’t this an argument supporting the importance of drug detailing? My dear young doctors of the University of Louisville: To answer this question you must look at the data. There is no such thing as a free lunch or a free sample. The pharmaceutical industry gives out $10 - $16 billion per year in retail and $2 – 3 billion per year in wholesale free samples for the purpose of promoting their products. If you give a patient a three day supply of a free sample for an antibiotic and then write a prescription for the remaining seven days, you may be assured the price of the drug is being used to subsidize the free sample and that the free sample is being used as an inducement for you to write that prescription.

I must also confront you with the cold hard data that a large proportion of free samples given out in the United States never end up in the hands of patients. The data shows that they are used by people working in the doctor’s office, are resold, or disappear without a trace. They are hard to recall.

Over the last ten years the largest increase in market share of American health care dollars has not gone to doctors nor to hospitals. It has gone to the pharmaceutical industry which has increased its market share by 140%. The profitability of big Pharma is staggering and is joined by the profitability of companies that manufacture medical equipment such as stents for invasive cardiology, PET scans, CAT scans, and MRI’s.

Those of you staggering under the burden of your student loans to go to medical school might consider whether you would rather have $25,000.00 per year spent on each of you for pens, note pads, and box lunches or whether you would rather have that money infused into the health system and used to pay down your loans.

You may say that it is hard to believe that the loyalty of an American physician can be purchased for a slice of pizza. The data is, however, what the data is. Randomized trials show that if a waitress leaves you a few mints when she drops off your check at the end of dinner, you leave a bigger tip. If you send strangers Christmas cards they often respond with a Christmas card. Gifts of all sorts, no matter how small, tend to engender a positive response. Whether you want to believe it or not, the data is what the data is: the American pharmaceutical industry is distributing all of this largess not out of altruism but because it increases sales.

If I have not yet persuaded you about the seriousness of this problem using arguments based on health policy or economic grounds, let me ask you to consider it from the philosophical, moral, or religious context. We read in the Book of Exodus, 23:8, “And thou shalt take no gift; for a gift blinds them that have sight, and perverts the words of the righteous.” We find this sentiment again in Deuteronomy 16:19, “Thou shalt not rush judgment; thou shalt not respect person; neither shalt thy take a gift; for a gift does blind the eye of the wise and perverts the words of the righteous.”

As we analyze these verses we must consider two issues. First, who are there injunctions directed to? Second, what constitutes a gift? At first pass, these verses appear to be directed towards judges. The reliability of a system of justice depends upon judges being unbiased and unswayed by gifts. Some Biblical commentators, however, assert that these injunctions cannot be thought of as referring to judges in the 21^st century term: a person in a black robe sitting at head of court room. These verses are, these writers say, directed towards anyone in a position of social responsibility who has control over the lives and safety of others; including physicians.

And what does a gift mean in these Biblical verses? Biblical commentators stretching back into the Medieval times respond by telling two stories. The first is of two men walking towards a town. They come to a stream and must pass over the stream over a small plank bridge. One man extends his hand to the other to help him balance his way across the bridge. As they continue towards the town one asks the other “Why are you going to the town?” He says that he is the judge on his way to hold court. The other man points out that he is a litigant about to bring a case to the court. The judge throws up his hands and says, “I am disqualified from hearing your case because you have done me too great a favor.”

In the other version of the story litigants are sitting before a judge when a piece of dust falls on the judge’s lapel. One of the litigants rises and brushes the dust from the judge’s lapel. The judge announces, once again, that he can no longer sit in judgment because one of the litigants has done him too great a favor.

The point of the story is even the smallest of gifts, such as extending a hand for balance or brushing away dust might bias a decision.  And, young doctors of the University of Louisville, the message for you is even the smallest of gifts might bias your judgment. Doctors make a nice living. Buy your own pens.

Last week the Association of American Medical Colleges recommended to U. S. medical schools that they halt all gifts from the pharmaceutical industry to medical students, house staff, and faculty: no pizzas at lunch, no box lunches, no direct sponsorship of lectures, nothing. You will all face this issue in your practice of medicine. This afternoon is a good time to think about how you shall respond.

I urge you to respond as members of a learned profession that is self governing, has a high standard of ethics and is in possession of a large measure of public trust. There are names for people who sell parts of themselves for money or who facilitate that process. Don’t let those be your names. Let your name be doctor.  Take you name off the list that allows the pharmaceutical industry to tap into your data base on prescription writing, obtain your medical education from independent sources, and when people offer you a gift that is intended to persuade remember that the dictionary definition of that is a bribe. Turn it down.

My dear young doctors of the University of Louisville. Last week I read Chapter 11 of the Book of Isaiah. It contains a list of the qualities which distinguish the ideal person of social prominence.  “The spirit of wisdom and understanding, the spirit of counsel and might, the spirit of knowledge and of humility.” The qualities which distinguish the ideal person of social prominence are related to their intellectual attainments (wisdom and understanding), administrative skills (counsel and might), and spiritual attributes (knowledge and humility). I wish, for all of you in your practice of medicine, that wisdom, understanding, counsel, strength, knowledge, and humility which characterize the physician.

Godspeed on the next part of your life’s journey, young doctors of the University of Louisville.

 

References

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NEJM 2006; 354: 2745-47.

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Carlat D. Dr. Drug Rep. NY Times Nov. 2007.