"Real lobbying reform must end the practice of corporate lobbyists writing our laws," said former Massachusetts Congressman Marty Meehan. While most people know about the practice of corporate lobbying, few realize that lobbying may be a big problem not only in politics, but also right in the doctor's office. Meehan's statement would be equally as true had he said, "Real medical reform must end the practice of pharmaceutical lobbyists determining what prescriptions doctors write."
Last month, the pharmaceutical manufacturing giant Pfizer disclosed that it paid more than $20 million to 4,500 doctors and other medical professionals for consulting and speaking on its behalf in the last six months of 2009. In other words, those 4,500 doctors gave talks that forwarded the interests of drugs sold by Pfizer, and they performed consultations with an eye to selling Pfizer products in the deal. The sales angle did not necessarily need to be announced, meaning that attendees at the talks given by these doctors and those accepting consultations thought they were getting unbiased help. During that same period, Pfizer also paid $15.3 million to 250 academic medical centers and other research groups to sponsor clinical trials of their products. It doesn't take a Ph.D. in pharmaceuticals to realize that if somebody pays your bill, you're going to be kindly disposed towards them.
Why would Pfizer admit to paying out all that money to influence medical practice? According to Pfizer spokeswoman Kristen E. Neese, most of the disclosures were required by an integrity agreement that the company signed in August to settle a federal investigation into the illegal promotion of drugs for off-label uses. As I've written before, off-label prescribing refers to the practice of doctors ordering up a medication for a purpose other than that originally approved by the FDA, even though there may be absolutely no clinical evidence supporting the efficacy or safety of the off-label application. Currently, off-label prescriptions account for a stunning 21 percent of pharmaceutical sales, if not more.
Dr. Freda C. Lewis-Hall, Pfizer's chief medical officer, said that the disclosures were part of a larger disclosure effort that the company started in 2002. Other major pharmaceutical companies including Eli Lilly, Merck, and GlaxoSmithKline all have made similar disclosures, and all four companies have established disclosure websites. Pfizer, however, is the only company to include how much it paid out for clinical trials on its site.
Do these confessions indicate that the Pharma giants have been chastened and moved to alter their behavior? Not necessarily. According to Eric G. Campbell, director of research at the Mongan Institute for Health Policy at Massachusetts General Hospital and an associate professor at Harvard Medical School, the companies may simply be trying to look like they're cleaning up their acts as a way to influence public opinion. Plus, says Campbell, "I think it's a good thing to do, but I put absolutely no trust in what drug companies voluntarily disclose to the public when those things are un-audited."
Campbell is the lead author of several studies on this issue. In 2007, he led a survey of department chairs at 125 U.S. medical schools and the 15 largest independent teaching hospitals. In the end, nearly 460 department chairs completed the survey. The results showed that an astounding 67 percent of departments and 60 percent of department chairs have some kind of relationship with the pharmaceutical industry. The respondents either received payments from a drug company for consulting, or research grants underwritten by the drug company, or funding to support continuing medical education. The department chairs admitted concern over "restricted grants," or grants for a specific purpose. Campbell and his team were quick to point out that other studies have shown that even small gifts of little or no monetary value can leave recipients feeling a sense of obligation, and that is really the central issue. When companies with a very evident self-interest support medical research and medical education, can the results of that research be truly objective and can the education be free of a sense of obligation for those who take part?
But as worrisome as the ties between pharmaceutical companies and medical schools may be, the real eye-opener comes in looking at how individual physicians fare once they graduate from medical school. According to a survey published in the New England Journal of Medicine in 2007, 94% of the 3,167 doctors queried had some sort of relationship with the pharmaceutical industry. The survey canvassed physicians in six specialties, including anesthesiology, cardiology, family practice, general surgery, internal medicine, and pediatrics. The physicians admitted receiving food or drug samples at work, receiving reimbursement for continuing medical education expenses or to attend professional meetings, and payments for consulting, lecturing, and enrolling patients in clinical trials.
The survey also showed that the Pharma folks gave special treatment to those physicians most likely to influence the prescribing behavior of other physicians. For instance, cardiologists were much more likely than other types of doctors to receive direct payments from drug companies because they are perceived as influencing the prescribing patterns of non-specialists. The survey points to a separate Dutch study that bears this influence out.
As Susan Goold, MHSA, bioethicist at the University of Michigan Medical School and a coauthor of Dr. Campbell's survey of medical schools and teaching hospitals says, "Although many respondents felt that relationships with industry could compromise the independence of research or education, such relationships were nonetheless quite common."
In conclusion, the next time your doctor offers up a prescription for you, you might want to keep Geena Davis' advice from The Fly in the back of your mind, "Be afraid. Be very afraid."