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Bought and Sold: Who Should Pay for CME

There are two topics about which I am a crank. The first, as you might have guessed, is alternative medicine. The other is pharmaceutical reps. Drug companies are somewhat schizophrenic. They have amazing scientists who invent drugs that treat an astounding array of diseases. Then, they take these drugs and turn them over to marketing, to be sold with all the enthusiasm and truthiness of a late night infomercial.

In the spirit of openness, I will say that I have not talked to a drug rep in 20 years. As far as industry supported gifts and food, I have not taken a pen or eaten pizza from industry in almost 30 years, since I was a fourth year medical student. I have accepted one gift over the years. Years ago, when the Pfizer rep left, he sent me Fleets enema with a Unasyn sticker on it. I still have it in my office, unused. But you never know when it might come in handy.

Being an absolutist about industry gifts does have downsides. It is distracting to sit in an auditorium filled with the smell of pizza and not eat any; somehow the PB&J I bring with me doesn’t smell as sweet. Administration has received one letter complaining about me that was ostensibly from an employee, but curiously was printed from a windows folder that had the same name as the levofloxacin rep. Just a coincidence, I am sure.

As an Infectious Diseases fellow I was the on call physician for the hospitals antibiotic stewardship program where expensive or problematic drugs had to be approved before they could be released from pharmacy. It was curious how there would be spikes in approval requests, often for drugs that the surgical resident couldn’t pronounce correctly. Ain’t no drug called ciprofloxacillin, although there should be. Investigation revealed that these spikes often occurred shortly after a service was treated to a good dinner by the drug rep. Hmm. Funny thing, that. Probably just another coincidence. I remember once as an intern late at night trying to decide what antibiotic to give a patient and I decided to prescribe what was embossed on my pen. Turned out Bic was not on the formulary.

Over the years it has been rare to find a physician as extremist as I am. It is curious, since the literature supports the concept that interaction with pharmaceutical reps is detrimental to patient care: docs who interact with reps are more likely to prescribe expensive and/or inappropriate drugs after being detailed. When pointed out, every doctor tells me the same thing: That may be true of others, but I am not swayed by information provided by drug reps. It is the one area of science-based medicine to which most physicians are immune, and understandably so: who wants to jeopardize free pizza? Most of the literature on the topic is collected at nofreelunch.org, which appears to be under construction. It all may be publication bias, but I know of no reference that demonstrates improved patient care as a result of physicians interacting with drug companies.

So imagine my surprise when someone came out in favor of physicians learning from drug companies. Over at Slate.com is “Appetite for Instruction. Why Big Pharma should buy your doctor lunch sometimes,” by Jessica Wapner.

It starts out sedately enough “The war against industry-sponsored medical education is in full tilt.” War? It is an interesting choice of words. I might have started by writing “physicians are finally reclaiming their integrity after whoring for 50 years,” but I have a dog in the fight.

But with the mounting concern about ties between doctors and the pharmaceutical industry, commercially supported medical education is being axed from hospitals and university medical centers around the country. Not only is this change unfortunate for anyone with a doctor, but it also doesn’t make any sense.

It does make sense if you bother to read the extensive literature. The preponderance of data strongly suggests that medical practice and research is altered, and not for the better, by interaction with pharma. She quotes only one reference in her article in support of drug company sponsored education.

There is no substitute for a small group of people listening to a doctor talk about how to treat a disease. And there is no substitute for the commercial support required to run such programs. In a recent study, academic researchers were paid a modest honorarium to travel around the country teaching more than 14,000 doctors about new treatment guidelines for high blood pressure. Each researcher met with small groups of doctors to educate them about the latest advances. In counties where the most sessions took place, adherence to the guidelines rose by more than 8 percent. In counties with the fewest such sessions, adherence decreased by 2 percent. The approach that the pharmaceutical industry has been taking for years is actually an effective way to educate doctors.

The “recent study” refers to “Impact of the ALLHAT/JNC7 Dissemination Project on thiazide-type diuretic use.”

I pulled the article, and it does not say what the author thinks it says. What a surprise. The academic researchers were educating physicians about generic medications, it was “was supported by contract N01-HC-35130 from the National Heart, Lung, and Blood Institute (NHLBI), as well as an NHLBI mentoring award (RSS, K24HL086703),” not pharmaceutical money, and if they were paid an honorarium it is not mentioned in the reference.

Academic detailing, or counter-detailing, is what is done to try and give evidenced based, minimally unbiased information about treatments in an attempt to give practitioners information free from pharmaceutical company spin and bias.

Academic detailing incorporates many of the approaches used in pharmaceutical marketing. By using persuasive, individualized small group or one-on-one communication of key points, detailing can summarize findings, suggest concrete changes in practice patterns, and explore potential barriers to change. In addition, by targeting specific physicians recognized as opinion leaders, resources can be concentrated on locally influential prescribers.

Several systematic reviews have examined the effectiveness of academic detailing in changing clinical practice and found this type of intervention to be effective. The effectiveness of academic detailing is described as ranging from small to strong with results that are consistently favorable. The effectiveness of academic detailing in affecting prescribing practices is particularly prominent. In this situation, even small changes in prescribing may be important when the population affected is large or where large cost differences exist between alternative medications.

Academic detailing is the Spock without the goatee.

The effects of the intervention was modest:

The ALLHAT/JNC7 Dissemination Project was associated with a small effect on thiazide-type diuretic use consistent with its small dose and the potential of external factors to diminish its impact.

What external factors may have impacted the results?

…There was substantial questioning of the ALLHAT findings by recognized hypertension authorities, as well as by the pharmaceutical industry, that likely reduced the potential impact of the results on clinical practice.

So the authors suggest that using inexpensive, effective generic drugs for hypertension are being undermined by drug companies.

The take home message is that academic detailing, using the methods of drug reps but not their funding, is an effective alternative to pharma-financed education. It so irritates me when I read the original reference and discover it was almost completely misrepresented or misunderstood. I suppose she will be writing for Medical Voices next.

When Consumer Reports discusses cars, it is education. When Chrysler discusses cars, it’s an advertisement, even if they are having Dale Earnhardt Jr. as the discussant.

She also says the lack of pharmaceutical-sponsored education has lead to an increase in the misuse of drugs. No reference. So I went looking. Pubmed? Nothing. Google? The only reference is her article.

Stephen Hanauer, one of the clinical investigators who developed Remicade and who has been paid to speak to doctors about it, explains that as Remicade teaching sessions have been nixed, misuse of the drug has risen and Hanauer thinks that the two phenomena are connected.

The basis of the increased misuse is the experience of Dr. Hanauer. Well. Good enough for me. Lets get him back on the paid speaker trail, ASAP. Patient care depends on it. Even if the literature suggests that it is interaction with drug companies that more commonly leads to more medication mis-prescribing. Who are you going to believe, the published literature or the anecdotes of Dr. Hanauer?

He has been paid to speak. I wonder how much, because the money can be substantial.

However, the largest median payments were for research ($6593; range, $109-$922,239), speakers ($1430; range, $118-$154,188), consulting ($1000; range, $121-$334,180), and unspecified purposes ($1000; range, $100-$331,947).

I have always thought as part of mentioning conflicts of interest at the start of a talk, speakers should be required to give a dollar amount of direct and indirect (food, hotels, airfare etc) payments they have received. Does anyone think $154,188 isn’t going to buy something? I know if I were making that kind of cash as a speaker in this economy, I would want to keep the cash cow alive. But I really shouldn’t suggest others are subject to base motivations for their actions — I sound too much like Mike Adams.

Of course, if the drug company doesn’t provide food, no one will come to the talks.

But surely there must be other options. Can’t doctors meet with the experts in the absence of fancy cheese? Not necessarily. Teaching sessions often take place during the lunch hour. As Hanauer, who practices at the University of Chicago School of Medicine, describes, the elimination of paid lunches sent hungry doctors to the cafeteria instead of the lecture hall. “But the lines were so long that they missed the conference,” he says. “So attendance at our grand rounds conferences went to miniscule.” Now the doctor has a sandwich but isn’t up to date on how to treat a serious disease. That may sound silly, but it’s often the mundane reality. “There are sometimes times when residents have to choose between lunch and a conference,” Richard Goldberg, an oncologist at the University of North Carolina, wrote in an e-mail.

I just had to laugh. At my hospital system, administration takes education seriously and there is lunch provided at Grand Rounds. We get a sandwich and a lecture. University of Chicago is evidently not all that serious about the ‘school’ part of their title. Or, I don’t know, try planning ahead: it is Wednesday and we’ve had Grand Rounds every Wednesday at noon for the last 100 years, maybe I will pack a sandwich. Pu-lease. If my doc doesn’t have enough on the ball to plan for eating at conference, I don’t want them prescribing my Remacaid.

Of course, I don’t know how I manage to keep up in my field with no pharmaceutical support. I can’t read journals, can’t use websites like Medscape (I am a paid blogger for Medscape, so of course I suggest them), can’t go to conferences, can’t listen to podcasts, can’t attend meetings, can’t do the MKSAP. There is such a wealth of educational opportunities in medicine to keep up you have to be either lazy or stupid not to find them. It does takes discipline and time to keep up. I spend a minimum of 24 hours a month on CME. If you want job that requires no continuing medical education, perhaps you should be a naturopath or homeopath. Part of being an MD is the endless education it takes to stay current.

The problem is that drugs have more and different uses than the FDA approved indications and the only way that information can be disseminated is pharma sponsored education.

Only way? Sure worked for Neurontin.

…ParkeDavis executive reportedly told Franklin,

I want you out there every day selling Neurontin. . . . We all know Neurontin’s not growing for adjunctive therapy, besides that’s not where the money is. Pain management, now that’s money. Monotherapy [for epilepsy], that’s money. . . . We can’t wait for [physicians] to ask, we need [to] get out there and tell them up front. Dinner programs, CME programs, consultantships all work great but don’t forget the one-on-one. That’s where we need to be, holding their hand and whispering in their ear, Neurontin for pain, Neurontin for monotherapy, Neurontin for bipolar, Neurontin for everything. I don’t want to see a single patient coming off Neurontin before they’ve been up to at least 4800 mg/day. I don’t want to hear that safety crap either, have you tried Neurontin, every one of you should take one just to see there is nothing, it’s a great drug…

The Neurontin marketing plan consisted of both general strategies such as the promotion of Neurontin use among high-prescribing physicians and cultivation of thought leaders and tactical programs. Local physicians were recruited, trained, and paid to serve as speakers in “peer-to-peer selling” programs, which the company saw as “one of the most effective ways to communicate our message.” Academic leaders were solicited with educational grants, research grants, and speaking opportunities; some received up to $158,250 over a 4-year period. Advisory boards and “consultants” were convened so that the firm could cultivate relationships with them and deliver “a hard-hitting message about Neurontin.

Marketing “tactics” included education, publications, and research whose promotional intent was disguised, in addition to more transparent activities, such as advertising and sales visits. “Educational programs” reflected the belief that “medical education drives this market!” Teleconferences involving practicing physicians were moderated by physicians who were paid as much as $176,100 over 4 years. ParkeDavis formed speakers bureaus and sought “strong Neurontin advocates and users to speak locally for Neurontin.” “Unrestricted educational grants” were made to for-profit medical-education companies that produced programs to discuss unapproved uses of Neurontin and to grant credit approved by the Accreditation Council for Continuing Medical Education.

Yep. That’s what I want for continuing medical information, programs that resulted in payments “of more than $430 million to resolve criminal charges and civil liabilities.” Of course, industry has learned their lesson. I can trust industry, and my patients life and health, with information about off-label indications provided by an industry that stands to profit from giving me the information. “There’s an old saying in Tennessee — I know it’s in Texas, probably in Tennessee — that says, fool me once, shame on, shame on you. Fool me, you can’t get fooled again.”

She concludes:

But the entanglement caused by for-profit drug development can’t be undone by eliminating the free lunch. As one physician suggested, perhaps pharmaceutical companies should be required to pay for medical education. After all, if companies are going to unleash new drugs into the world, shouldn’t they be responsible for teaching people how to use it? Ousting commercial support is creating a huge chasm in medical education, leaving doctors not only hungry but also starved for knowledge.

No, but it is a start. Physicians can take responsibility for their own education. And lunch isn’t free. In the end, our patients pay for it. The price of drugs, in part, takes into account the cost of advertisement. Maybe you feel it is fine for the underinsured to pay $1500 out of pocket for a 10-day course of linezolid, but I can’t justify my patients indirectly subsidizing my pizza and education.

While we are at it, let’s have MacDonalds be responsible for teaching nutrition, Nintendo teach us about fitness, lobbyists determine congressional voting, tobacco companies provide research cancer and oil companies tell us the cause of global warming. “The only way that information can be disseminated is ‘fill in the industry’ sponsored education” indeed.

Perhaps as professionals, doctors should be responsible for their own education, especially when the lives and health of their patients may depend on it.

The conclusion of the only other journal article referenced sums it up:

… attending sponsored CME events and accepting funding for travel or lodging for educational symposia were associated with increased prescription rates of the sponsor’s medication. Attending presentations given by pharmaceutical representative speakers was also associated with non rational prescribing.

That’s the chasm being created by banning pharma-sponsored education: more rational prescribing, more physician integrity and patient trust, better education and information. I can live with that, and so can my patients.

Posted in: Medical Academia, Pharmaceuticals, Politics and Regulation, Science and Medicine, Science and the Media

Leave a Comment (68) ↓

68 thoughts on “Bought and Sold: Who Should Pay for CME

  1. Pizza? Really? When selling your soul you should at least hold out for a good deli sandwich and perhaps a brownie.

  2. Marge says:

    Could you please not use the word ‘schizophrenic’ as if it meant having multiple personalities? It’s not helpful to keep repeating a mental health myth – and to be honest I expected better from SBM!

    Great article otherwise.

  3. marcus welby says:

    Well said, and supported by facts throughout. Fortunately, the trend in U.S. medical education/industry funding is in line with the author’s wishes. May I have your permission to reprint in our county medical society monthly bulletin? We still have some talks with Pharma sponsorship.

  4. art malernee dvm says:

    I think the problem is not just who should pay but how to measure CME when its required by law. An hours of CE should be measured in time or measured some other way in the real world. Required by law CE not measured scientifically becomes little more than a tooth fair medicine restraint of trade practice.
    see
    http://www.ebvet.com/forum/viewtopic.php?f=12&t=405

  5. MKirschMD says:

    The crusaders who want to torch any industry funding of CME are over the top. Why is industry routinely demonized? While I wouldn’t want commercial interests to be choosing speakers or content, why shouldn’t they be permitted to fund educational endeavors? They could also contribute funds to the institution, rather than to the medical conference organizers. This would further insulate them from the conference and placate the crusaders.

    Similarly, some want to strike out any lecturer with corporate ties. While I recognize the potential conflict, even if disclosed, do we want to silence the views of the most knowledgeable and replace them with relatively inexperienced speakers?

    http://www.MDWhistleblower.blogspot.com

  6. rork says:

    Excellent. Thankyou.

    1) You could have plugged my institution more though.
    “The University of Michigan medical school has decided to stop taking industry money to support its CME activities. ” No kick-back for you today!
    2) NYT article reporting “The accrediting body for postgraduate medical education, for example, recently said it would no longer grant credit to doctors for attending medical meetings that feature industry employees presenting product research. ”
    3) Our glorious leader (Collins) quoted as saying “the breathtaking sweep to squash something that is really important to us, which is the science that’s going on in the private sector.”

    There’s more than one place to read about this, but the NYT’s one was this: http://www.nytimes.com/2010/06/24/business/24meded.html. It’s links are very poor.

    Sorry if that’s all ancient news, but I really haven’t heard enough expert opinion yet to make me think I know exactly where to draw any lines. I’ve rather liked it when some of the company folks talk about more basic stuff. Eric Shadt or Frederic de Sauvage to give just two examples – loved it, except that you’re not supposed to be that much smarter than me; take evil drugs or something. It’s possible we paid them rather than the reverse. Maybe some company plugging appeared with their talks – we plug our shops too when we speak.

  7. Calli Arcale says:

    Growing up as the daughter of a doctor, I learned that drug companies are so eager to give CME credits to doctors that they don’t mind giving them to random non-medical types as well. That is to say, I got to come along and get a free meal as well, even though at the time I was a college student going into a completely unrelated industry. And not just a meal, either. I don’t recall which proton pump inhibitor paid for me to have a very nice meal, listen to a lecture on acid reflux disease, and then go see “Rent” (in very good seats, I’d like to add). But I do recall it was Lymerix (the now-defunct Lyme disease vaccine) that paid for me to go pheasant and grouse hunting on a private game ranch in Prior Lake, have a very nice steak dinner, and listen to a lecture about the life cycle of B. burgdorferi.

    As a geek, I found the lectures interesting, but it was oddly discomfiting as well. The drug companies were willing to spend a heck of a lot of money. It wasn’t just the lecture they were paying for; they were wining and dining and entertaining, and they were quite happy to wine and dine relatives as well. Marketroids are not stupid. They would not spend this much money if they didn’t think it would generate enough sales to more than offset the cost.

    As I got into my professional career, I began receiving ethics training. My boss doesn’t care if a pharmaceutical rep wines and dines me, because it’s completely irrelevant to my business. But they do care if a supplier does, and they care if I offer that sort of thing to my customers, because that’s considered bribery.

    I’m curious: does anyone know if the government forbids VA doctors from attending pharma-supported CME sessions? Technically speaking, it could also constitute a bribe. That sort of thing could be considered criminal if it were a member of a program office in the military attending a contractor-sponsored lecture on, say, supersonic engine performance after a fancy meal and some expensive entertainment.

  8. windriven says:

    Information is as variable in quality as it is widespread in availability. As an example, much of the information on the internet is bogus. But then intelligent users of the internet browse with a critical eye. Are we to assume that physicians aren’t able to weigh the likely bias of information provided by pharmaceutical reps? Are we to believe that a physician who earns a six figure income is swayed by a slice of Domino’s pepperoni?

    Full disclosure: I own a small medical device manufacturing company. I am not a salesman and do not know much about pharmaceutical detailing. I do know that in the field of anesthesiology, device salespeople have been generally welcomed by physicians. The ensuing dialog has led to vast improvements in the instrumentation available to anesthesiologists. I say dialog because it is not a one way conversation; what clinicians tell salespeople finds its way back to those who design medical devices and ultimately results in the clinicians getting devices that better suit their needs.

    I have no idea if things work this way in pharmaceuticals. But let me finish by noting that there is a huge array of -cillins and -mycins and whatnot in the armamentarium because companies have invested staggering sums in research to produce drugs that improve – and sometimes save – lives. Some of these drugs work better than others and some of them cost more than others. There is waste and inefficiency here, no doubt about it. But without a broad marketplace the risk of developing a new drug or device would be so breathtakingly high that no one would take that risk.

    Dr. Crislip noted something about no free lunch in his blog. I heartily agree with him. The price gets paid one way or another.

  9. Mark Crislip says:

    reprint away, just give SBM credit.

  10. WilliamLawrenceUtridge says:

    I still think companies should be prohibited from CME courses and clinical research; funds should be delivered to a third-party like the NIH, who distribute them to researchers insulated from direct contact with drug companies.

    It’s funny, in the area I work it is well-known that companies have double standards – while marketing departments have nigh-unlimited budgets to wine, dine and wheedle clients and are encouraged to do so, purchasing departments are forbidden accept anything beyond a token amount or item – cheap lunch or mug with a logo on it.

  11. Windriven on assuming that physicians are as susceptible to the right marketing as anyone else: “Are we to assume that physicians aren’t able to weigh the likely bias of information provided by pharmaceutical reps? Are we to believe that a physician who earns a six figure income is swayed by a slice of Domino’s pepperoni?”

    My understanding is that no, we are not to assume any such thing. We are to look at the evidence and draw conclusions, as Mark Crislip has done. He pointed you here: http://www.drugpromo.info/read-reviews.asp?id=4 . Do you have specific concerns about the literature on the topic? On what basis do you call Mark Crislip’s conclusions about the role of marketing in generating non-rational physician behaviour an “assumption” instead of an “evidence-based conclusion”?

    I don’t think the point is that customers and suppliers must never communicate. Clearly they must. I think the point is that communication that is initiated by the supplier and driven by the supplier’s requirements is not driven by the needs of the end-user. The logical corollary is that the end-user will suffer to the degree that communication between customers and suppliers is supplier-driven. Which is exactly what the data support.

  12. pandora says:

    Dr. Hanauer certainly doesn’t speak for the entire University of Chicago. My section’s Grand Rounds are well attended, lunch or no lunch.

  13. chaos4zap says:

    Are the Pharmacutical companies able to track, in any accurate way, rather a specific doc is prescribing their med or not?

  14. weing says:

    ‘Are the Pharmacutical companies able to track, in any accurate way, rather a specific doc is prescribing their med or not?”

    Yes, they are and they do. Courtesy of the AMA. Unless the physician requests that this information not be divulged. I did this a while ago and, just to make sure, I notify the AMA yearly of my preference.

  15. windriven says:

    @Alison Cummins

    “My understanding is that no, we are not to assume any such thing. We are to look at the evidence and draw conclusions…”

    The conclusion that Dr. Crislip has invited is that in fact we ARE to assume that very thing.

    But your comment misses the point of mine: not all information comes in the form of published studies in peer reviewed journals and even if it did Ioannidis cautions that most of it is wrong. Further, not all information flows in one direction from industry to clinician.

    Information competes for attention. There is only so much time in a day. One could take the approach that the only valuable information is that which is found in peer reviewed journal articles. The world wouldn’t end. But it would certainly slow down.

    In this brave new world, if the Journal of Compact SUVs published a study showing that the 2010 Subaru Forester is the best compact SUV, the argument would be over. Others would simply withdraw from the market because the word has been handed down: they’re not The One. Of course if things worked that way there wouldn’t be much hope that the 2011 Subaru Forester would be any better than the 2010.

    What we have is a system that is messy, that uses every tool available to gain an edge and that sometimes crosses ethical lines (and should be slapped down hard) in the effort to succeed. We could change the rules and use another system. Just be careful because all systems come with a price.

  16. Who should pay for CME? Like us psychologists do, physicians could pay out-of-pocket. Physicians are about the only profession with CME requirments that get nearly all CME paid for by others. The rest of us have it in our budget as a cost of doing business.

  17. windriven,

    Where are we being invited to make assumptions? That’s the part I don’t get. Assumptions are independent of data, but Mark Crislip thinks we have data. He refers to the “preponderance of evidence.” Do you disagree that the evidence exists? (It might not. I didn’t read the extensive literature he says he linked to; I take him at his word because he looks so sweet in his picture.)

    What is the price that Mark Crislip’s patients are paying for his refusal of everything but enemas, and for his six hours per week of CME not driven by the requirements of pharmaceutical companies?

    Where did anyone say, “all information comes in the form of published studies in peer reviewed journals”?

  18. “Are the Pharmacutical companies able to track, in any accurate way, rather a specific doc is prescribing their med or not?”
    Yes. That is how the drug reps are evaluated. They have territories and specific drugs to market. The drug company buys data regarding number of prescriptions coming out of territories.

    I believe they can further identify by the prescribing doc.

    The reps can thus change strategy as they are able to judge how responsive the doc is. If a doc is not responsive, the rep may befriend the office staff by throwing a lunch for everyone, etc., while going easy on the hard sell. And so on.

    Sorry I do not have a link to this info that I can easily find. Hopefully someone else will post a decent link.

  19. SloFox says:

    Excellent article. My personal abstinence from drug lunches has thus far been without evidence. Now I’ve got some data to examine.

    A fundamental question to consider is why lunches, pens, sticky pads and the like are so effective as marketing tools. I find it unlikely (though not implausible) that physicians’ opinions are being bought for a slice of Domino’s. Is anyone aware of studies examining the consumption of food at drug lunches vs. just attending and not eating or accepting pens, etc. and prescribing habits?

    It seems more likely that it’s the increased exposure to a specific product that subconsciously undermines a physician’s objectivity. I know that most of my colleagues (me included) are not as diligent with their professional development as Dr. Crislip. Therefore, if your relative exposure to marketing is greater the more likely you are to slant your practice to favor filling the drug company’s coffers.

    I believe the advertising literature also shows that exposure is more important than the advertisement itself. There’s no such thing as bad press. The lunch just lures you in. After all fancy cheese is hardly a bribe. What they’re buying is your attention and your time.

    I’d be curious to see what would happen to drug company lecture attendance if they didn’t offer lunch. My guess is that it would drop off but I’d be interested in seeing it studied. I wouldn’t be surprised that if drug reps were allowed to give talks but NOT offer lunch, pens, etc. they’d find it less effective and might even drop it altogether if their profits dropped sufficiently.
    I’m not opposed to being offered education by the drug companies but less lucrative products that may be just as or more effective can’t compete for time and attention. Perhaps it’s time the hospital bought me lunch and an academic panel chose the topic and speaker. Until then I’ll keep having oatmeal for lunch and educate myself by reading the literature and going to meetings.

  20. weing says:

    Here is a link to the physician data restriction program on the AMA web site in case a physician doesn’t want this type of information to be passed on to drug reps. You don’t even have to be a member to restrict access.

    http://www.ama-assn.org/ama/pub/about-ama/physician-data-resources/ama-database-licensing/amas-physician-data-restriction-program.shtml

  21. Mark Crislip says:

    There is evidently an extensive literature on the importance of food as a way to win loyalty since most of time people lived in a food poor environment. The person who gives the food is owed, even at a subconscious level.

    I have only a cursory knowledge of the lit and did not have the time to do the research

  22. JMB says:

    If marketing of prescription drugs was outlawed, and tort reform was seriously addressed, I would think that costs of prescription medication in the United States would be closer to that in Canada.

  23. Dr Benway says:

    Meh. I like lunches with quality cookies and I’ll be sad if that is no more.

    Sure I can live without them –we only get about one of those lunches every 3 months where I work. But they are nice when they happen.

    I also like meeting the speakers. They’re usually someone within a two hour driving distance.

    People make decision contrary to their own immediate material benefit all the time (like the guy above foregoing delicious pizza for stale PB&J). Why? Because most people are not two years old. Most care about their relationships, about building trust, and about being good.

    I don’t think corruption is so much a function of what’s given as what might be lost if one were to say, “no.”

  24. Mark Crislip says:

    tort? a tort I would eat if offered. mmmmm.

  25. Samantha says:

    “…Nintendo teach us about fitness…”

    Hey! I get a better workout with my Wii than I do at the gym – mostly ’cause I don’t have to leave my house. ;)

  26. aaronupnorth says:

    Even those of us who have nothing to do with drug reps cannot avoid the insidious creep of non-ebm pharma info.
    The worst example of all has to be the advanced cardiac life support algorithms published by the American Heart Association. As an ER Doc I am required to use these algorithms as a standard of care though they are not based on evidence, and in some instances contrary to the evidence. The replacement of cheap old lidocaine with expensive amiodarone is a prime example, with the makers of amiodarone providing funding to the AHA.
    Even will intentioned physicians have difficulty keeping away from this sort of biased info because our professional associations are taking money from the same sources hand over fist..

  27. Dr Benway says:

    aaronupnorth, that is so f*cked up I find it difficult to believe.

    I took ACLS a hundred years ago and can only recall, “shock epi shock epi,” or something like that.

    I got stuff to do tomorrow and don’t really want to Google up the rationale for when amiodarone gets in there (is it not generic now?). So I will concede you are correct. But I hope Dr. Atwood will tell me that you are not.

  28. Dr Benway says:

    Oh one more point:

    Bias is assumed. Bias isn’t the problem. Shitty science is the problem.

  29. weing says:

    Who should pay for CME? I believe the patient pays for the CMEs and the cost of our medical school tuitions as well. In my case, the cost has to come from fees to the patient, as I am not independently wealthy.
    If drug companies stop funding CMEs, the cost of the CMEs will rise and has to be passed on. Where do we draw the line on pharmaceutical funding? I subscribe to the NEJM. Why do I have to wade through pages of pharma advertisements in order to read the articles? I used to tear those advertisements out until I learned that doing so focused my attention even more on the products advertised. Hmm. I wonder if they wanted me to do that? Would the subscription cost me three times the price if there were no advertisements? Where am I to get the money, if not from the patient?
    There is no free lunch. You don’t get something for nothing, ever. I learned that in high school physics.

  30. BillyJoe says:

    Mark, you are paying the price for your honesty.
    But that price is measured only in financial terms.
    The rewards to your integrity are much greater.
    I wish all docs were like you.

    I occasionally look into medical blogs locally and am amazed at the naivete displayed by most doctors who seem to think they are too intelligent to be swayed by the Drug Rep. Typical comment: “as if I’m going to prescribe their antibiotic just because they gave me a pen!”.

    Of course the multi million dollar marketing budget of the pharmaceutical companies says otherwise.

  31. wales says:

    Nice post MC.

  32. geridoc says:

    There is actually empiric evidence to support your observation that us of expensive antibiotics increase after a drug lunch. Check out this hilarious, yet very instructive case report that was published in JAMA a number of years ago:

    Shorr RI; Greene WL. A food-borne outbreak of expensive antiobiotic use in a community teaching hospital. JAMA;1995:273:1908.

  33. Draal says:

    So… If doctors are influenced by pharmacy education, does that make them, willing or unwilling, shills?

    I’ll take my answer off the air.

  34. windriven says:

    @ Alison Cummins

    you said, “Where are we being invited to make assumptions? That’s the part I don’t get. Assumptions are independent of data, but Mark Crislip thinks we have data. ”

    Assumptions are independent of data? On which planet? Assumptions that are independent of data are just guesses.

    I’m sure that we all hold the Pus Whisperer in the highest regard, I’m sure that the data he offered is real. But that leaves this a long way from settled. Are you familiar with the work of John Iaonnidis?

    A study may well show that physicians who attend a presentation about megamycin and while there consume vast quantities of pizza and Coke provided by the megamycin rep, write more megamycin scrips. Is it not possible that the megamycin presentation mounts a compelling argument that megamycin is a better therapy for, say, the creeping fung than other drugs?

  35. Calli Arcale says:

    windriven — yes it is certainly possible the megamycin rep has provided a compelling argument for using that drug, which leads to more scripts being written independently of what sort of food was offered during the presentation. But if that were really the case, why would drug companies continue spending money on the food, if it’s not assisting in the sales increase?

    Good, persuasive arguments will help sell products. Add free food and you sell even more. I think it’s safe to say that no (or vanishingly few) doctors are so incompetent that they’d write scripts for megamycin instead of something cheaper just because they’d had a very nice meal with the drug rep; they’re writing those scripts because they genuinely think it’s a better dug.

    But are they right? Did they arrive at that perception purely through a cold and impartial evaluation of the evidence, including the particulars of this patient’s case? Or did the free lunch factor in as well? There is plenty of research demonstrating that the free lunch does factor in, some of it by people opposed to the practice and a lot of it by marketing people who want to quantify and optimize the effect, to maximize return on the marketing investment. And this is why in industries with more fiscal oversight, such things are simply not allowed. It’s odd that the health care business is so resistant to seeing what other industries take as a fact of life: that fancy meals and other gifts will subconsciously influence people, even (and perhaps especially) people who feel that they are above such tawdry influences.

  36. BillyJoe says:

    Are you kidding me. It’s not only the free lunch, it’s also the spin they put on their product. You cannot arrive at an impartial evaluation of the evidence when all you have is what the drug company tells you.

  37. windriven says:

    I can’t believe what I’m reading!

    “it’s also the spin they put on their product. You cannot arrive at an impartial evaluation of the evidence when all you have is what the drug company tells you.”

    Well no sh*t. Anyone who buys anything based on nothing but a sales pitch is a fool. In the case of medical products, FDA requires package inserts with considerable detail for both drugs and devices.

    “why would drug companies continue spending money on the food, if it’s not assisting in the sales increase?”

    Drug companies (and device companies) provide food to attract clinicians in the first place. Before you can give a presentation you have to have an audience. The free food helps to draw the audience.

    These drugs are products, they are not holy amulets from the hand of god. Companies have a huge financial interest in convincing clinicians of the merits of their particular drugs. Should their presentations be required to be truthful? Of course. Should drug companies be prevented from hawking their wares to physicians? My argument, clearly against the tide here, is no. (But I would probably argue against hawking prescription drugs directly to potential patients who lack the tools to properly evaluate the pitches).

    We can have a system where presentations by drug companies to clinicians are strictly forbidden. As I’ve said before, the world wouldn’t come to an end. But the world would, in fact, be different. Be careful what you ask for.

  38. Dr Benway says:

    The onus is on the person making the claim to prove their case. That’s why drug companies *should* be the ones to argue for the benefits of their product.

    If we’re going to forbid drug companies from arguing their case, then some third party will have to do it. Who will pay them? How will we ensure that third party doesn’t become corrupted?

    Perhaps we’ll need a fourth party to keep an eye on the third party.

    But wait, what if the fourth party becomes corrupted?

    Oh, this is getting complicated.

    And why are we only targeting drug companies? What about surgical instrument manufacturers? Companies selling furnishings for hospitals? Companies selling electronic medical record software?

    There’s an awful lot of capitalism out there influencing people. We’d best get busy if we’re going to put a stop to it.

  39. wales says:

    But the problem is not the capitalist motivation of the pharma companies in promoting their products, it is the lines that pharma is willing to cross in that promotion that are disturbing (less than full disclosure, data manipulation or destruction, etc.) Pure capitalism is one thing, capitalism accompanied by unethical and/or criminal behavior is another.

    http://content.nejm.org/cgi/content/full/NEJMe1007445

  40. Mark Crislip says:

    The problem is not industry which is doing what they are supposed to: maximize profit.

    The problem is docs who think they that they are beyond manipulation and who think the literature does not apply to them.

    It is not that drug companies should be banned, its that docs should know better. Oh, yeah, there also needs to be world peace, an end to hunger and everyone should have a five dollar cigar.

  41. BillyJoe says:

    “The problem is not industry which is doing what they are supposed to: maximize profit.

    The problem is docs who think they that they are beyond manipulation and who think the literature does not apply to them.”

    Well put.

  42. windriven on assumptions: “Assumptions are independent of data? On which planet? Assumptions that are independent of data are just guesses.”

    Oh, I see the problem. You don’t know what “assumption” means. It’s exactly the opposite of a conclusion (which is based on data). It’s a premise upon which conclusions are drawn. (Axioms are also premises, but unlike axioms, assumptions are often invalid.)

    From The American Heritage Dictionary:

    3 The act of taking for granted: assumption of a false theory.

    4 Something taken for granted or accepted as true without proof; a supposition: a valid assumption.

    5 Presumption; arrogance.

    6 Logic A minor premise.

    In this article the author did not assume that accepting food from pharmaceutical companies influences prescribing; he concluded as much based on the evidence.

    Once he reached this conclusion, he used it as the premise for the argument that doctors should not accept food from pharmaceutical companies, but should do like him and bring a pb&j from home when attending pharmaceutical company lectures. Again, this is not an assumption because it’s the sole premise, not a minor premise.

  43. rwdrwd says:

    If I might make a couple of observations. First, regarding:

    ” why would drug companies continue spending money on the food, if it’s not assisting in the sales increase?”

    Although I personally agree that the food may assist in sales increase I am amused by that particular argument and find its frequent use among the pharmascolds somewhat curious. It doesn’t appeal to direct evidence and is like asking “why would patients spend money on woo by the droves if it didn’t work.”

    Regarding assumptions and evidence, yes, there is evidence that drug company promotions influence prescribing. But the notion that drug company promotions are, in the aggregate, harmful to patients is an assumption. An extremely popular assumption to be sure, and backed by key opinion leaders, but one devoid of supporting evidence.

    I responded to this article here:

    http://doctorrw.blogspot.com/2010/07/mark-crislip-on-drug-reps-and-industry.html

  44. windriven says:

    @Alison Cummins

    Perhaps you should reread the definitions you cite along with the first and second definitions, not just 3 through 6.

  45. Calli Arcale says:

    Dr Benway:

    The onus is on the person making the claim to prove their case. That’s why drug companies *should* be the ones to argue for the benefits of their product.

    If we’re going to forbid drug companies from arguing their case, then some third party will have to do it. Who will pay them? How will we ensure that third party doesn’t become corrupted?

    Who’s arguing that the drug companies be muzzled? I think Crislip and I and others are simply arguing that they ought not to get away with such egregious attempts to unduly influence people.

    I refer once again to my own industry: government acquisition.

    Let’s say Boeing wants to sell next-generation tanker aircraft to the USAF. (This is not a fictional example. I’m referring to the ugly case of the KC-X bidding war.) The KC-135 Stratotankers are getting old, so the USAF comes up with a plan to convert some 767 into tankers, which will be dubbed “KC-767″ and leased from Boeing. However, suspicions arise that this was not properly done. There was no competitive bid process, and the USAF declared Boeing the only capable company despite Airbus’s KC-330 tanker being offered as well. It was eventually revealed that one of the people involved in procurement for the next tanker was in the process of negotiating a job with Boeing at the time, an obvious conflict of interest. She was fired by Boeing, convicted at trial, and sentenced to nine months in jail. Boeing’s CEO also resigned, and the CFO was fired. But that wasn’t the worst price Boeing paid; the KC-767 contract was terminated as well, and the USAF issued and RFP.

    Boeing submitted a proposal based on the 767-200LRF (long range freighter, then in development) and a team of Northrup Grumman and EADS submitted a derivative of the A330 unofficially designated KC-30. The KC-30 won, and Boeing made the rare move of submitting a formal complaint, particularly risky considering that they’d already been severely tarnished by wooing a procurement officer involved with the KC-767 contract. The GAO upheld their protest, and the project is now in the process of being rebid, nearly a decade after the whole mess began.

    Now, obviously Boeing has a tremendous amount invested in winning this contract. They’ve spent a huge amount of money and also political capital (GAO protests are not a good way to make friends in the program office). So they will do a lot to try to win this. The law forbids them from trying to unduly influence the procurement officers (again). That includes taking them out to nice meals. Even cheap meals are forbidden. They can just about buy them a cookie, or maybe a t-shirt. They can’t offer to send them to a conference on, say, laminar airflow and its effects on efficiency in freighter aircraft hosted by Boeing themselves. After all, that conference might, with all the appearance of an academic lecture, point out that the 767-200 family has particularly good efficiency due to the design of their blended winglets, which are quite distinct from the Airbus winglets that would be found on, say, the KC-30 proposal. (Note: I’m not an aerospace engineer, so that was hypothetical; I have no idea whether 767 wings are superior to A-330 wings.) Boeing would likely get slapped if it did any of those things, though it would go worse for the procurement officers who accepted; the procurement officers would face the prospect of jail time, in addition to a basically destroyed career.

    So Boeing can’t (or at least shouldn’t) do the sorts of things pharmaceutical companies do on a regular basis in order to win this contract. So what *do* they do? Are they silent?

    Definitely not. In addition to putting their very best face forward in their proposal, they are also advertising the holy hell out of the KC-767. You may even have seen the tanker ads yourself, as they’re circulating around the Internet. If this site had Google ads, my mention of it here would probably summon the ad up. They’ve started advertising Boeing generically (though notably including pictures of the 767 freighter) on TV, playing up its American origin and how much they do for US defense. They make sure to have a presence at every industry trade show, and where applicable, they make a point of saying how great their tanker could be. And of course all industry trade journals will carry ads for them.

    So despite being forbidden from giving fancy gifts or paying for people’s education, Boeing is still managing to argue their case quite eloquently. The idea is to force them to do it based on its actual merits, rather than on who has the best meal tickets. Obviously this doesn’t always work out; corporations are not perfect angels, and will sometimes try and see how much they can get away with. And they sometimes find procurement officers with a looser set of ethics, and they do get away with stuff. But I think it’s a good ideal, and I really do not think the CME system will collapse utterly if doctors suddenly can’t get a drug company to foot the bill.

    Honestly, letting a drug company pay for your education isn’t all that much different from accepting a pay check from them. They’re paying for you to be employed. That’s pretty overt, in my book. If you were a government procurement officer, you’d be looking at criminal charges.

  46. windriven,

    Definitions 1 and 2:

    1 The act of taking to or upon oneself: assumption of an obligation.

    2 The act of taking possession or asserting a claim: assumption of command.

    I omitted the “to take on” definitions of assumption because they are irrelevant to the distinction between premises and conclusions. What do you think they add to the discussion of whether the literature supports the conclusion that accepting food increases irrational prescribing?

  47. Dr Benway says:

    I’m irked by the anxiety over pizza lunches, but not so annoyed that I’m willing to put up a fight.

    I’m irked because, seriously, occasional pizza and cookies are not going to make a material difference in the care my patients receive.

    Pizza, like superhero powers, can be used for good or ill. It can be used to get people to sit still for a few minutes to listen to lies or to facts.

    If a novel product is better for a certain patient population and the pizza helps more doctors learn about it, that’s good.

    Of course we don’t want doctors prescribing meds that aren’t as good as other options available, thanks to pizza. We should challenge someone prescribing Nuvablarg for, say, arthritis when Nuvablarg is twice as expensive as ibuprofen but no better at reducing pain, and no better from a side effect standpoint.

    I expect pizza has the most impact upon prescribing when the novel product is nearly equivalent to competitors from a risk-v-benefit standpoint –i.e., when we’re talking Coke verses Pepsi.

    Maybe someone gets Coke rather than Pepsi thanks to a pizza lunch. So what?

  48. Dr Benway on the effects of accepting food on prescribing: “I expect pizza has the most impact upon prescribing when the novel product is nearly equivalent to competitors from a risk-v-benefit standpoint –i.e., when we’re talking Coke verses Pepsi.”

    Mark Crislip quoting the literature on the effects of accepting food on prescribing: “… attending sponsored CME events and accepting funding for travel or lodging for educational symposia were associated with increased prescription rates of the sponsor’s medication. Attending presentations given by pharmaceutical representative speakers was also associated with non rational prescribing.” [emphasis mine]

    Dr Benway “expects” that the effect of free food has no negative clinical consequences. Mark Crislip’s review of the literature leads him to conclude the opposite.

    I prefer to go with the evidence base, myself. Interestingly, nobody who challenges Mark Crislip’s conclusions has challenged the evidence he used to reach his conclusions. They have simply said, “I don’t believe it.” And left it at that.

  49. Dr Benway says:

    They can’t offer to send them to a conference on, say, laminar airflow and its effects on efficiency in freighter aircraft hosted by Boeing themselves.

    I’ve never been offered a trip to a conference by a drug company. Do other doctors get such offers (excluding speakers or those employed by the drug company)?

    What I get mostly are faxes telling me about conference calls where I can listen to someone talk about a clinical issue. The speaker gets money from the drug company for talking. I might get a code that I can put on some Internet form for a thank-you gift like a mug or calendar. I dunno if that’s still the way it works because I stopped bothering with those; they’re not much fun and I don’t learn new stuff very well without a bit of emotional engagement.

    The “payment for education” I get is impersonal. Companies pay for “Industry Sponsored Symposia,” usually a panel of speakers covering some topic. They’re usually high quality presentations put on from 7:00 to 10:00 pm at a large hotel during our annual meetings. Dinner is included. You can get 3 CMEs for being there. I mean, you *could* get CMEs. They’ve been stopped due to fears of contamination.

    I would be less irked if everyone else on the planet were being protected from the same evil influences. As it stands, I feel a little picked upon.

    C’mon, you surgeons, cardiologists, and invasive radiologists. Let’s see *you* start holding your annual meetings at some teaching hospital with dodgy AV equipment and brown-bag lunches.

    I notice the upcoming American Association of Naturopathic Physicians is welcoming corporate sponsorship, lol.

  50. Dr Benway says:

    Alison, my personal impression could be wrong. I would have to review Crislip’s referenced study to see why it contradicts my own experience.

  51. Dr Benway says:

    Ok, I checked Crislip’s link and something there gave me an idea:

    CONCLUSION: Doctors who report relying more on promotion prescribe less appropriately, prescribe more often, or adopt new drugs more quickly.

    I prescribe new drugs pretty much never, lol.

    The last lunch I went to was for Saphris (#3 in the 2nd generation antipsychotics less likely to make you fat category). I had to actually Google to find the name. But I do remember the shortbread cookies with cranberries. And I remember the speaker, a nice guy working at a community mental health clinic in a nearby city. He’s using Saphris because he wants experience with it. Working with kids, I’m much more conservative.

  52. Dr Benway,

    That single article was one of the two cited by Jessica Wapner in support of her thesis that CME should be funded by pharmaceutical companies.

    Pointers from the body of Mark Crislip’s article:

    http://nofreelunch.org/reqreading.htm
    “Most of the literature on the topic is collected at nofreelunch.org, which appears to be under construction. It all may be publication bias, but I know of no reference that demonstrates improved patient care as a result of physicians interacting with drug companies.”

    http://www.drugpromo.info/read-reviews.asp?id=4
    “It does make sense if you bother to read the extensive literature. The preponderance of data strongly suggests that medical practice and research is altered, and not for the better, by interaction with pharma.”

  53. weing says:

    How about EHRs? I’m in the process of an expensive conversion to one right now. I am trying to find evidence that it leads to better outcomes and I can’t find any. This is being pushed on us by the government. I wasn’t wined and dined by any EHR vendor. Who was? Congressmen? Sebelius and her ilk?

  54. Calli Arcale says:

    Dr Benway:

    I’ve never been offered a trip to a conference by a drug company. Do other doctors get such offers (excluding speakers or those employed by the drug company)?

    Definitely they do. My father, a GP, got several industry-sponsored vacations — and he was allowed to bring his family along on two of them, though I believe he did have to pay travel costs (just not lodging). I don’t know how they decide which doctors to target with this sort of advertising, but I’m sure they do put some thought into it.

  55. Calli Arcale says:

    ADDENDUM: I don’t think he got any industry-sponsored vacations after about the early 90s. It could be that standards changed. I hope so. So it is possible that this sort of thing doesn’t happen anymore, or at least not as much.

  56. hokieian says:

    “ADDENDUM: I don’t think he got any industry-sponsored vacations after about the early 90s. It could be that standards changed. I hope so. So it is possible that this sort of thing doesn’t happen anymore, or at least not as much.”

    Ummmm….no. That sort of thing certainly doesn’t happen these days. It’s illegal to even give out branded pens or any other nick-nacks any more.

  57. Calli Arcale says:

    Illegal to give them out? I don’t think that’s correct. I’ve heard of plenty of facilities making it against policy to *receive* them, but that’s a horse of a different color. When was a law passed barring gifts of trivial value?

  58. weing – regarding EHRs

    I don’t want to spin to far off topic, but since I really dig EHRs, I thought I would chime in.

    I was under the impression that EHRs had been found to reduce medical errors and enhanced and expedited communication between doctor’s treating the same patient.

    I know my health network has EHRs and I really like how I can ask a question of one of my son’s specialists (even on a first visit) and they can very easily bring up the notes of all my son’s other doctors. It seems much more thorough.

    Being a science novice, I am not good at judging the quality of a study, but here is one positive report on EHRs.

    “Electronic medical records and mortality in trauma patients.”
    http://www.ncbi.nlm.nih.gov/pubmed/19741412

    Perhaps the related citations could offer others.

    Actually, the doctor’s in our office seem quite happy with their system. Hope you find one that you are equally happy with.

  59. I’m pretty sure my psychiatrist used to go on sponsored junkets. She’d say, “Oh, I can’t book your next appointment in March, I’m going to be in Barbados making a presentation about Ritalin.” I started seeing her in 1998, so this wasn’t the eighties.

    It’s entirely possible she overprescribed stimulants. She prescribed them to me, and I’m bipolar II. I’m pretty sure that amphetamines are not indicated for bipolar disorder. (I loved the stimulants… for about six weeks. Then I’d get too unbearably cranky and stop taking them.)

    She was a good psychiatrist. (She retired a few months ago.) I owe her my life. Even the stupid stimulant-related experiments were handled well. They didn’t harm me; they demonstrated that she was taking my complaints about my lack of concentration seriously; and they allowed me to feel that I had tried a bunch of different things and had settled for myself on what worked best for me.

    And this good psychiatrist I think so highly of was — as far as I can tell — unduly influenced by pharmaceutical marketing. I doubt she would have agreed if I’d suggested this to her.

  60. jpmd says:

    As a practicing physician, much of what has been said is outdated: no pens, no freebies, no trips. Occasional dinners and lunches are provided, but drug companies are now diverting most of their funds to congress and direct to consumer ads, both of which are far more qualified than physicians to evaluate the drugs.

    CME by drug company is non-existant, what with rule changes. There are talks, but they do not qualify for CME.

    Do lunches and so forth work? I am sure they do on some level. However, those drugs also pay for research that brings advances in medicine. Were it not for profit, there would be few new drugs brought to market, and advances in medicine would essentially stop at the the present level. Few if any drugs are developed independently of pharma.

  61. Dr Benway says:

    My laziness is probably showing, but I’m wondering if the study describing irrational prescribing contained concrete examples.

    I’m having a hard time imagining how I might find myself pizza’d into crazy land.

  62. hokieian says:

    “Illegal to give them out? I don’t think that’s correct. I’ve heard of plenty of facilities making it against policy to *receive* them, but that’s a horse of a different color. When was a law passed barring gifts of trivial value?”

    Maybe “illegal” was too strong a word, since a rep can’t be prosecuted for giving a pen to a physician (although providing certain gifts certainly is illegal in some states like Mass.), but there is an industry-wide ban on providing any gifts to physicians. PhRMA instituted the moratorium January 2009.

    Here’s a NYT story: http://www.nytimes.com/2008/12/31/business/31drug.html

  63. Calli Arcale says:

    Wow; they really did do it! That’s very encouraging to hear. The health care industry has finally embraced the ethical standards of other industries as far as that goes. It’s certainly true that it won’t stop the companies trying to influence people; there are many ways to do that. But it does force them to be more open about it, and that is a good thing.

  64. Scott says:

    The cynic in me wonders if it’s because they’ve concluded that direct-to-consumer advertising is more cost-effective and therefore wanted to score ethical points for doing something they were going to do anyway…

  65. hokieian says:

    If DTC advertising were more cost-effective every single brand would do it. As it is, only a small percentage of pharmaceutical products are advertised directly to consumers. I think PhRMA made this move to head off even stricter regulatory oversight that would have occurred if they had not done something to police themselves.

  66. wertys says:

    Pharma are always the bad guys in these conversations.
    For sheer blatant marketing scams with no evidence to support them you can’t beat orthopaedic prosthesis companies. Combining the self-belief of most sugrgeons with the flattery of the reps and the money the companies are playing for gives a perfect impression of the capitalist ideal in action. These companies make the pharmas look like rank amateurs.

  67. weing says:

    That physicians are influenced by advertising is no surprise. So is everyone else. Whether it is a drug company sponsored dinner, TV commercial, or advertisement in the journal you are reading, you are exposed to the commercial message. Does anyone really think that the drug companies will cut their marketing budgets? My paranoid side keeps wondering if this campaign against physicians getting cheaper CMEs, dinners, etc is not just about the money. Are medical schools, medical societies, and journals somehow immune to the influence that allegedly allows pharma to make puppets out of physicians? Are patients somehow immune to influence when they watch commercials, or see advertisements in magazines, or on billboards? I think they are not. The med schools, societies, and journals, magazine and TV executives, and billboard owners now get the dollars that were spent on dinners for physicians or lowering the cost of CMEs. The physicians are now as pure as freshly fallen snow and free from pharma influence because they never read journals, or magazines, watch TV, or pay attention to billboards while driving.

  68. Jessica says:

    I’m interested to hear what people think of the Physician Payment Sunshine Provision? Will this deter doctors or industry?

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