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A Foolish Consistency

A foolish consistency is the hobgoblin of little minds, adored by little statesmen and philosophers and divines.
— Ralph Waldo Emerson (1803–1882)

It is odd isn’t it? Large numbers of quality studies published in the best peer review journals consistently showing the same or similar effect and no contradictory studies. Despite the emphasis on evidence-based medicine, the entire literature is dismissed as not relevant because personal experience suggests that the studies are wrong.

Curiouser and Curiouser. Coherent arguments as to the validity and scope of the literature are met with denial but never a critique of the primary literature. The facts of the research are never argued. The only argument is personal experience or blanket denial. Despite the published literature, practice continues the same, untouched by the facts.

How can practitioners routinely deny a preponderance of evidenced-based medicine? What is a doc who believes in the primacy of evidenced-based practice to do but roll their eyes and think, as Bugs Bunny so memorably said, “What a maroon”.

I’m talking about acupuncture? Homeopathy? Therapeutic touch?

Nope.

I’m talking about the interactions of physicians and the pharmaceutical industry.

This is a large literature on the topic. It is collated at www.nofreelunch.org where you find 70, seventy, references to support the following rant.

Good studies. Published in quality journals such as JAMA and The New England Journal of Medicine and the Annals of Internal Medicine. Offering a large, robust, consistent and routinely ignored set of conclusions.

I will summarize key points. Don’t want to trust me? The literature is there.

  • Pharmaceutical companies give misleading and biased information.
  • Physicians prescribing habits are influenced by drug company interactions.
  • Pharmaceutical reps and pharma sponsored lectures are often the number one source of continuing medical education.
  • Small gifts of food, pens, and other paraphernalia create an obligation that alters prescribing behavior.
  • The conclusions in published studies in peer review journals are in part determined by who provided the funding, and the more pharmaceutical funding, the more like the results will be in favor of the pharmaceutical company’s products.
  • Physicians often do not know when they are being manipulated.
  • Physicians deny that these interactions actually alter their practice. To quote one abstract “Although each physician is likely to consider himself or herself immune from being influenced by gift giving, he or she is suspicious that the “next person” is influenced.”

That is, I think, a fair summary of the literature. There are, to my knowledge, no published studies that contradict the above conclusions. It’s not like acupuncture where there are poorly done studies that suggest an effect. The literature on pharma-MD interactions is more akin to the literature on the use of penicillin and syphilis: overwhelming and consistent.

But unlike the penicillin literature, which everyone applies to their practice, there is this ongoing curiosity of a breakdown of critical thinking. Most physicians consistently deny that this literature applies to them.

It is like the issue of a physicist evaluating a psychic: the hubris of the advanced degree prevents the physicist from admitting they can be fooled. A physician can’t be fooled by mere advertising.

It more than branding and name recognition that guides advertising. It is manipulation.

An analysis of 174 advertisements for pharmaceuticals appearing in six Australian medical publications. Fewer than 8% of the advertisements contained quantitative data about the outcomes of therapy, and most of these framed the information in relative rather than absolute terms. Only 28% of the therapeutic claims in the advertisements conveyed clinical outcomes in any specific, substantive and unambiguous way. (5)

It is not what you say, but how you say it that often matters most. Spin, I believe they call it.

Physicians are susceptible to corporate influence because they are overworked, overwhelmed with information and paperwork, and feel underappreciated. Cheerful and charming, bearing food and gifts, drug reps provide respite and sympathy; they appreciate how hard doctor’s lives are, and seem only to want to ease their burdens. But … every word, every courtesy, every gift, and every piece of information provided is carefully crafted, not to assist doctors or patients, but to increase market share for targeted drugs. (6)

The proof of the pudding is probably in the tasting, as the pharmaceutical companies continue to spend billions (paid for, by the way, by our patients in higher drug costs, so don’t complain next time your patient has to pay $1500 dollars for a 10 day course on linazolid). Companies do not spend that kind of money and provide lunch and pen lights because it has no effect. It is estimated that for every dollar spent on drug rep detailing, there is a $10.29 return (2). AARP reports (unreferenced) that one minute with a drug rep increases physician prescribing by 16%; three minutes increases prescribing by 52% (3).

Does this marketing lead to worse outcomes? Or just more expensive treatment. I don’t have data. I will note that one of the driving forces of antibiotic resistance in bacteria is the overuse of broad spectrum antibiotics and choice of antibiotics is more often driven by marketing rather than science. Association or causality? The Xigris marketing lead to the use of the product for patients that, in subsequent clinical trials, had a higher mortality rate (4). How many died or were harmed due aggressive marketing beyond the limitations of the published clinical trials? No one knows. But if that number is greater or equal to one, than it is one too many.

My observation, with all the frailties and biases of the three most dangerous words in medicine (“In my experience”), is that antibiotics are given not because they are the appropriate choice for a given infection, but that somehow the choice is viewed as ‘strong’, ‘powerful’, ‘big gun’, or ‘broad spectrum.” Descriptors that have almost 100% sensitivity and specificity in identifying a physician that knows nothing about the treatment of infectious diseases and everything about their gullibility for marketing ploys.

I have been quoting this literature for years at my hospitals and I am always met with the same argument: I am immune to the wiles of big pharma, I can’t be bought, sold, fooled or manipulated. I’ll eat the food, but I don’t ever remember who is providing it. The literature doesn’t apply to ME. No one has ever argued that the literature is flawed, that the numerous and consistent studies are wrong. They do not point to studies that demonstrate a different outcome.

Nope. Never. Despite the data, there remains an intellectual blind spot in nearly all physicians I know. A complete inability, even after being given the data, to apply it. There is an increasing trend of institutions prohibiting reps at educational events. My institution (Legacy Health System) did it a decade ago, mostly because Housestaff questioned the propriety of mixing medicine and mammon.

I am curious. I assume readers of this blog are interested in applying evidence to the practice of medicine. Read the literature. Get back to me. Why is it wrong? Why am I misreading it? Or if you do find the literature compelling, why do you not apply it?

As an aside, I have not talked to a rep or taken anything from a drug company in at least 23 years. I attempt to apply all evidence to my practice. It is not without its downside. They provide pizza to our local Infectious Disease conference (where the reps can outnumber the medical students) and it is painful to sit there an smell the pizza and not partake. Mmmmmmmm. Pizza.

After one of my intermittent outbursts against the involvement of big pharma in our conferences (I am the lone voice in this argument), the head of my hospital received an anonymous letter complaining about my behavior. The letter was ostensibly from a member of the hospital staff. Accompanying the letter were copies of emails I had sent to the ID docs in the city complaining about the influence of drug reps at our conferences. It turns out when you print a page from Windows sometimes it will also print the path on the hard drive to the file. At the bottom of the page you will see, as an example, C:/folder/folder/bchristi/file. Curiously, and I am sure it was a weird coincidence, the name of the folder was the same as the email address of a local drug rep, bchristi@company.com. Weird, huh, how the folder and the email had the same name? What are the odds of such a serendipitous event? Also of interest was a copy of a private email I had sent to one of our local ID docs. How that personal email ended up in the folder of the writer I still have yet to determine.

If you think this kind of behavior is atypical, it is not. I suggest you read Surviving Sepsis — Practice Guidelines, Marketing Campaigns, and Eli Lilly in the NEJM of Oct 19, 2006. If I were prone to conspiracy theories, this would make for good supporting information.

In the interests of patients, physicians must reject the false friendship provided by reps. Physicians must rely on information on drugs from unconflicted sources, and seek friends among those who are not paid to be friends” (6).

References

  1. Halperin EC, Hutchison P, Barrier RC Jr. A population-based study of the prevalence and influence of gifts to radiation oncologists. Int J Radiat Oncol Biol Phys. 2004 Aug 1;59(5):1477-83.
  2. The Drug Pushers. Atlantic Monthly. April 2006. http://www.theatlantic.com/doc/200604/drug-reps.
  3. AARP Bulletin. Jan-Feb 2006. Page 26. http://www.aarp.org/bulletin/yourhealth/drugreptiesthatbind.html
  4. Surviving Sepsis — Practice Guidelines, Marketing Campaigns, and Eli Lilly in the NEJM of Oct 19, 2006.
  5. David A Newby and David A Henry. Drug advertising: truths, half-truths and few statistics. MJA 2002 177 (6): 285-286
  6. Fugh-Berman A, Ahari S (2007) Following the Script: How Drug Reps Make Friends and Influence Doctors. PLoS Med 4(4): e150. doi:10.1371/journal.pmed.0040150

Posted in: Pharmaceuticals, Politics and Regulation

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