Healthy Skepticism Library item: 1940

Warning: This library includes all items relevant to health product marketing that we are aware of regardless of quality. Often we do not agree with all or part of the contents.

Publication type: news

Cha S.
These Gifts Are Bad for Our Health
Washington Post 2005 Jul 24

Keywords:
gifts Vermont

Notes:

Ralph Faggotter’s Comments : The general public remains blissfully ignorant of the extent to which the pharmaceutical industry lubricates the affluence of the medical profession. This article shows that even with legislation it is difficult to cut this resiliant financial conduit, and asks the important question “What would the public or [our] patients think of this arrangement?”

Full text:

These Gifts Are Bad for Our Health

By Stephen Cha
Post
Sunday, July 24, 2005; B02

NEW HAVEN, Conn.
When it comes to accepting gifts from the marketing reps of
pharmaceutical firms, the American College of Physicians-American
Society of Internal Medicine suggests that its members apply a simple
litmus test: “What would the public or [our] patients think of this
arrangement?”

Most patients never find out. If they did, they’d probably go into
shock over the goodies doctors accept, like meals, travel, gift
certificates or parties. The pharmaceutical industry estimates that it
spends about $5.7 billion a year on marketing directly to physicians,
which works out to about $6,000 to $7,000 per doctor.
Three years ago, Vermont enacted a groundbreaking law intended to
remedy the situation by requiring the drug companies to publicly report
promotional gifts and payments to physicians. As in many areas of
government and business, the law was tailored with the idea that
sunshine is the best cure for the ethically questionable practices that
thrive in secret. If shame alone fails to curtail excesses, then at
least information about gifts and contributions can empower voters,
investors or consumers to make more educated choices, aware of
potential conflicts of interest.

Yet in the world of medicine, this is a new concept and, judging from
Vermont’s experience, legislation about it may require further surgery.
Not only have pharmaceutical companies and doctors circumvented the
disclosure rules, but it’s virtually impossible for patients to find
the information.

“It’s not surprising that this extraordinarily well-financed industry
circumvented the law,” says Peter Shumlin, the former Vermont
legislator who sponsored the bill. “The surprise is that we consumers
still take it.”

The scope of the problem in medicine is well known — at least among
doctors.

As a medical student, a colleague of mine once walked into the offices
of a practice where she was working and unexpectedly found herself at a
party. Food, trinkets, pens and coffee mugs were being handed out to
the whole office staff, about 20 people including med students and
doctors — all courtesy of Merck & Co. And to the physician who was the
number one prescriber of Vioxx in the entire region that year, a
marketing rep of the company awarded a pair of Philadelphia Eagles
season tickets.

That was almost five years ago, and the party for Vioxx has ended —
the painkiller got yanked from the market because it could cause heart
problems. Recent congressional investigations revealed that Merck
marketers had misled physicians, wrongly suggesting that Vioxx was
better for the heart than other pain relievers, even after research
suggested possible dangers.

Did Merck’s perks encourage that doctor to prescribe a drug that he
might otherwise have avoided? It’s difficult to judge. Like political
contributions, these gifts are not necessarily improper, and some
industry-physician collaborations can lead to important advances. But
research shows that such largess affects physicians’ prescribing
practices and may compromise their objectivity.

Certainly if I knew that my doctor was getting $5,000 to $20,000 a year
from the maker of Vioxx, I would wonder why the doctor was prescribing
it.

“I think the public would be outraged if it knew the extent of the
industry’s influence in prescribing decisions,” says Shumlin. “We hoped
to force industry to show the extent of these practices, and hoped to
embarrass doctors into changing their own practices.” Hoping that these
changes in practice would help stem the rising costs of prescription
drugs, 23 states have since considered, and a handful have adopted,
similar legislation.

So far, however, industry has exploited loopholes in the Vermont
legislation to avoid full public disclosure. For instance, the law says
that gifts under $25 or grants for “research” need not be reported. And
even when those gifts are reported to the government, the disclosure
can be withheld from the public if the industry designates its own
reports as “trade secrets.” And the reports of gifts are made to the
state attorney general’s office, which doesn’t keep a public database
with real-life physicians’ names and gift descriptions.

Instead, the attorney general issues annual overviews. In the May 2005
report, the most recent, the industry reported about $3.11 million in
gifts in Vermont. None of the state’s 2,200 doctors are named.
Nancy Chard, a Vermont state senator on the conference committee that
forged the legislation, says, “Doctors’ names should be out there. But
the bill got toned down to a point where it’s just a happy memory. I’m
proud of having done it, but it’s not a viable piece of legislation.
There are so damn many bad guys in this thing.”

Worried that Congress might spoil the party, some organizations have
begun self-regulation. The American Medical Association and the
pharmaceutical industry issued a set of voluntary guidelines on gifts.
For instance, gifts should be under $100 in value unless they are
payments as part of a formal consulting relationship. This gesture, and
$91 million in campaign contributions the two industries made during
the 2004 election cycle, have been enough to keep Congress out of this
dogfight.

Given the amount spent on marketing per physician, it’s clear that many
gifts are not within the AMA guidelines. In Vermont, many reported
payments to individual physicians ran into the thousands of
dollars. “I’ll tell you one thing,” says Chard. “There are still plenty
of [pharmaceutical] dinners going on at the local fancy restaurants.”

“It’s unconscionable that they’re spending $3 million on trinkets here
in Vermont when my patients can’t afford to pay for the medications to
treat their high blood pressure,” says Benjamin Littenberg, director of
general internal medicine at the University of Vermont. Littenberg
accepts no gifts, no drug detailers and no materials from drug
companies or their sales reps. (He’s also never written a single
prescription for Vioxx.)

Legislators in Vermont started with the simple idea that the billions
of dollars industry hands to physicians should be public knowledge. And
there are some simple ways to fix the rules the law established.

. Remove trade secret exemptions that subvert the entire point of the
law. Allowing a drug company to decide what is a trade secret is like
permitting John McEnroe to make his own line calls.

. Require disclosure of the identities of gift recipients. Imagine if
all political contributions had to be disclosed, but the public never
learned who received them.

. Improve data quality. More than half of the “name-identified data” in
Vermont contained only a last name and amount of gift.

“Do-not-call” lists that are made public could provide broad
recognition and encouragement for physicians who rebuff drug reps. No
Free Lunch, an organization that advocates a complete ban on
promotional gifts, also collects commitments to spurn industry gifts.
Already, more than 250 physicians have taken the pledge.

Littenberg says, “Taking anything from drug companies violates a trust.
They shouldn’t be allowed to offer [gifts], and we shouldn’t be allowed
to accept them, and it’s appalling it’s even an issue. It would be like
Consumer Reports taking money from the washing machine manufacturers.”
While people have criticized the pharmaceutical industry for promoting
less-than-desirable drugs, the fact is that for every dangerous or
inappropriate drug prescribed, there is a prescribing physician — one
who may have been unduly or unconsciously influenced by these quiet
billions in gifts. Physicians should serve as patients’ trusted
intermediaries, but that trust must be built on openness; the public
has a right to know about potential biases. Public disclosure may not
stop the distorting influence of money in medicine, but it should be
the first step.

Author’s e-mail: stephen.cha@yale.edu

Stephen Cha is an internist and a Robert Wood Johnson clinical scholar
at Yale University School of Medicine.

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