Pulse: A Message from Dean Edward C. Halperin

I invite you to 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 drugs or utilizing medical devices.

In the past 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.

The public listens 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, drugs designed to treat blood pressure or grow hair. The manufacturer is trying to get the patient to ask the doctor to prescribe its product. In many cases, the patient will not directly pay for the product. The interaction will result in an insurance company paying for the product.

All American physicians are familiar with the advertising that the pharmaceutical industry and medical equipment manufacturers target directly to them. This is referred to, historically, as “detailing.” In other words, a pharmaceutical company representative will provide information about the “details” of the product to the doctor.

Detail men/women are generally impeccably dressed and attractive individuals. There are 90,000 to 100,000 of them in the United States.

These detail men and women tell us about new medications and urge us to prescribe them. They may provide us with informational brochures or reprints of articles from the scientific literature. They often bring lunch or invite us to dinners where we listen to a speech describing the product being sold. The company sometimes provides medical textbooks as “gifts” or invites us on trips to a resort where, in return for a few days of sun and fun in the sand, we are asked to listen to speeches about the pharmaceutical company’s product.

A few doctors in the United States are paid spokespersons for the pharmaceutical companies. They are asked to talk to their colleagues during lunch breaks or at dinners and describe the benefits of the pharmaceutical company’s drugs. Often the drug company supplies the doctor with lecture slides. The doctor is paid at the rate of $1,000 per hour for this sort of work, and some doctors in the United States make between $15,000 and $100,000 per year as spokespersons for the pharmaceutical companies.

When you add up the entire cost of pharmaceutical company direct-to-physician marketing, it comes out to $15,000 to $25,000 per doctor per year. Each year in the United States about $22 billion to $25 billion is spent by pharmaceutical companies on direct-to-physician advertising and another $3 billion in direct-to-patient advertising.

There is, on average, one pharmaceutical representative charged with calling upon physicians for every five of us. If a physician is identified as a particularly frequent writer of prescriptions and a prime target for detailing, there is, on average, one pharmaceutical company representative for every 2.5 physicians.

The pharmaceutical industry, in collaboration with American pharmacies and the American Medical Association (AMA), mines vast stores of data on the prescriptions written by physicians.

The pharmaceutical industry acquires data-bases from clearing houses and pharmacies and can identify which physicians in any geographic area write prescriptions for which products, how often they write for specific products and how their prescription-writing behavior changes as a result of advertising.

The AMA helps sell these databases to the pharmaceutical industry. In 2005, for example, it made approximately $45 million selling this service — 16 percent of all net revenue. The AMA has recently allowed physicians to request that their prescription-writing practices be excluded from the database if they submit an internet application to the AMA.

Within the last month an article in the Journal of the American Medical Association asserted that the pharmaceutical industry has ghost- written many articles in the scientific literature and then affixed the names of prominent physicians as authors. This allegedly places a positive spin on the benefits of a company’s products.

Pharmaceutical company-sponsored medical research disproportionately leads to the publication of articles with favorable results about their products; pharmaceutical company representatives are alleged to have ignored articles that do not support their claims of improved efficacy of their products; and 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?

Patients trust their doctors to prescribe medications or medical procedures that are in their best interests. If a doctor makes decisions that are predicated not on evidence-based medicine but upon which salesperson most recently dropped off a free lunch and a gross of ballpoint pens, that is a relationship based on deception.

The American pharmaceutical industry and medical equipment manufacturers spend a large amount of money on continuing medical education (CME).They sponsor medical meetings and lectures.

Many people assert that, were this source of money to dry up, CME would suffer. Other people say that it is disingenuous to argue that individuals who can buy homes, cars and clothes are somehow unable to pay for their subscriptions to scientific journals or the tuition for CME.

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?

The pharmaceutical industry gives out $10 billion to $16 billion per year in retail-value free samples (or $2 billion to $3 billion per year in wholesale-value drugs). Those who express concern about this practice say:

(a) 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 that 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.

(b) A large proportion of free samples given out never end up in the hands of patients. They are used by people working in the doctor’s office, are resold or disappear without a trace.

(c) Samples are hard to recall.

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, to whom are these injunctions directed? Second, what constitutes a gift?

At first pass, these verses appear to be directed toward 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 21st century term: a person in a black robe sitting at the head of a court. These verses are, these writers say, directed toward 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 Medieval times respond by telling two stories.

The first is of two men walking toward a town. They come to a stream and must pass over the stream using a small plank bridge. One man extends his hand to the other to help him balance his way across the bridge. As they continue toward 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 away. 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 that even the smallest of gifts, for some people, might bias a decision. Simply stated: Doctors make a nice living. Buy your own pens.

Recently 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.

We will all face this issue in our practice of medicine.

Chapter 11 of the Book of Isaiah contains a list of the qualities that 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 that 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).

As we all consider the issue of gifts, I hope we will employ that wisdom, understanding, counsel, strength, knowledge and humility which characterize the physician.

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

Dean, School of Medicine