Healthy Skepticism Library item: 4622

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Publication type: news

Wahlberg D.
Outside income: UW's doctors needn't tell all
Wisconsin State Journal 2006 May 7
http://www.madison.com/wsj/home/local/index.php?ntid=82989

Notes:

Ralph Faggotter’s Comments:

“When you’re spending seven minutes with a patient, you might prescribe the first drug that comes to mind, not the best one,” Haber said. “A lot of it is subconscious when you have golf balls with a drug company’s name on it.”

This is partly how the process of influencing prescribing works.
The effect of constant drug advertising is like a golfer constantly practicing their swing- you keep doing it until the behaviour is unconsciously assimilated: until it becomes automatic.

Full text: SUN., MAY 7, 2006 – 1:22 AM

Outside income: UW’s doctors needn’t tell all

DAVID WAHLBERG dwahlberg@madison.com

Dozens of doctors at UW-Madison receive money from drug and medical device companies, but they generally don’t have to tell patients – even if they prescribe or implant the companies’ products.

And the university doesn’t know how much money the doctors get.

Ties to industry are pervasive in the UW School of Medicine and Public Health, according to university financial disclosure records reviewed by the Wisconsin State Journal.

The university oversees the activity, and administrators and doctors say the activity is beneficial. But campus conflict-of-interest policies allow much of the information to remain private, a State Journal analysis found.

The case of Dr. Thomas Zdeblick, UW- Madison’s chairman of orthopedic surgery, illustrates one of the gaps.

Zdeblick, whose university salary is $996,817, complied with campus disclosure requirements by reporting that he earned “more than $20,000” a year from the device company Medtronic.

What Zdeblick made was $400,000 a year from the company for a minimum of eight days of work. His contract with Medtronic captured national media attention this year after it was made public as part of a lawsuit.

Until the contract became public, the university didn’t know how much Medtronic paid Zdeblick.

University officials say off-campus work for industry, regardless of the amount of compensation, is an essential part of the “Wisconsin idea” – the century-old notion that knowledge at the university should improve the quality of life of all people in the state.

“It should be viewed as a great credit that our university has experts that businesses seek to improve their economic processes,” said Brian Fox, chairman of UW-Madison’s conflict- of-interest committee.

Patient effect

But studies suggest the financial ties can influence patient care.

In the Journal of the American Medical Association in 2000, Dr. Ashley Wazana of McGill University in Montreal published a review of 29 studies on the topic. The review found that doctors in the United States who receive free meals, travel or other money from drug companies are more likely to ask health insurance plans to pay for the companies’ drugs.

The doctors are also more likely to engage in “non- rational prescribing,” such as ordering stronger or more expensive drugs than needed, the review found.

The consumer watchdog group Public Citizen charged in a JAMA study in April that more than a quarter of the experts who advised the U.S. Food and Drug Administration in recent years had financial conflicts that affected their votes to approve drugs.

Darcy Haber, program manager for the social issues group Wisconsin Citizen Action, said even small gifts from drug companies can impact doctors, who must often rush through patient visits.

Relationships with industry are not necessarily more prevalent at UW-Madison than at other medical schools – or at community hospitals such as Meriter and St. Mary’s, although drug companies often seek consultants from universities.

But even as such activity has become commonplace in medicine, a groundswell of concern has started to arise among doctors themselves.

In January in JAMA, a group of prominent physicians called for stricter regulations on conflicts of interest. Policies should be implemented first at academic medical centers, they said.

The authors said doctors should be banned from accepting any money from drug companies for talks to other health professionals, for example, because such presentations “are an extension of the manufacturers’ marketing apparatus.”

UW-Madison’s conflict-of- interest policies don’t forbid most relationships with the private sector. They rely instead on the principle of disclosure, Fox said.

Undisclosed ties to companies can lead to questionable research results, Fox said. But faculty relationships with industry, if properly revealed, can be a reflection of the high quality of the institution, he said.

But some question whether the policies do enough to protect patients, at UW Hospital and elsewhere.

The university requires doctors with substantial ties to industry to disclose the relationships to staff and in papers and presentations. But doctors don’t have to tell patients unless they are being enrolled in studies.

“What’s the rationale for telling their colleagues about these connections but not their patients?” asked Bobby Peterson, executive director of ABC for Health, a public interest law firm in Madison that helps people get health insurance.

“It seems like the people getting the care are the ones most directly impacted by a doctor’s decision-making process,” Peterson said.

Fox said it’s not clear it would help patients to know about doctors’ ties to industry. Some might jump to the conclusion that their doctors are doing something wrong, he said. Others might be overly impressed that companies view their doctors as experts.

“What would the average person do with that information?” Fox asked.

Doctors’ defense

Cardiologist James Stein is among the UW-Madison doctors who reported the most money from industry last year, for activity in 2004.

But he doesn’t shy away from questions about the pay. “To be a successful clinical researcher, you’re bound to have conflicts of interest,” he said.

Stein, whose salary is $322,868, reported receiving more than $20,000 from Merck for the equivalent of three days of work and more than $20,000 from Pfizer for five days of work.

For both relationships, the university gave him “full management plans,” the highest level of scrutiny of conflicts of interest on campus.

Stein said the money from each of the two companies was for a dozen or so talks during the year about cholesterol management.

In the talks, Stein said, he helps doctors, nurses and pharmacists understand which statins and other cholesterol- lowering drugs are best for people at risk for heart disease. He said he also talks about diet and exercise.

Pfizer makes Lipitor and Merck makes Zocor. The drugs, both statins, were the No. 1 and No. 5 leading sellers globally last year, with $12.9 billion and $5.3 billion in sales, respectively, according to data collection company IMS Health.

Stein said he discusses the two drugs in his talks but also mentions others.

If Stein didn’t provide such education, he said, drug companies would send people from their headquarters to do it.

“We’d rather have it be people from UW doing it than some hired gun from New Jersey,” he said. “They’ve come to me because of my reputation at the university.”

Zdeblick, the spine surgeon who had the $400,000-a-year contract with Medtronic from 1998 to 2004, said he has invented six devices sold by the company. His contract involved eight days of work a year at a company site in Memphis, Tenn., along with numerous workshops for surgeons, he said.

“I have great ideas that make a difference in the marketplace, and (Medtronic) wanted access to those ideas,” Zdeblick said.

He wouldn’t say how much he receives from the company now; he continues to report more than $20,000. He said the money doesn’t influence which devices he uses in patients.

“It’s completely ethical,” said Zdeblick, who said he gave the keynote address on managing conflicts of interest at last year’s meeting of the American Orthopedic Association.

Making choices

Even though Zdeblick’s compensation from Medtronic was 20 times more than the cutoff on the university’s disclosure form, the amount is irrelevant, Fox said. The conflict- of-interest committee doesn’t seek specific amounts because faculty might view that as a threat, he said.

“Once something is significant, very significant is not really more significant than significant,” Fox said. “A lot of people are sensitive about their finances.”

Dr. Stuart Knechtle, a transplant surgeon whose UW- Madison salary is $484,196, has three full management plans for outside activity reported last year.

The plans are for work for Bristol-Myers Squibb, which sells drugs to prevent organ rejection in transplant recipients; TolerRx, a biotech firm studying similar drugs; and Renovar, a small company Knechtle founded in Madison six years ago to create a test of a patient’s immune response to transplants.

For TolerRx, from which Knechtle received at least $10,000 and some stock options for serving on a scientific advisory board, he used monkeys to test an antibody the company wanted to develop into a drug.

His test found the antibody ineffective, and the company dropped the project.

“It shows that just because I’m financially involved doesn’t mean I’m not willing to kill a drug,” he said.

Knechtle has long had stock in Bristol-Myers Squibb. The stock was worth more than $20,000 last year. When the company approached him to lead a study on an experimental transplant drug, university policies forced him to either give up the stock or turn down the study.

He kept the stock. Another doctor at UW-Madison is heading up the study, but Knechtle can enroll patients without telling them about his stock. Only one patient has signed up so far, not one of his.

Knechtle said a similar arrangement is planned for a study to start later this year by Renovar, his start-up.

Dr. Paul Anderson – an orthopedic surgeon, like Zdeblick – reported at least $80,000 in cash and stock holdings last year from four medical device companies: Medtronic, Stryker, Pioneer Surgical and St. Francis Medical Technologies.

Anderson, like Knechtle and Stein, would not say in an interview how much each company paid him. His university salary is $608,732.

Most of Anderson’s more than $20,000 from Stryker was for royalties for a cervical plate that he developed, he said. He has never used the device on a patient to avoid a conflict of interest, he said. For Pioneer Surgical and St. Francis, he has been a consultant.

For Medtronic, for which Anderson reported receiving at least $20,000 for six to eight days of consulting work, he wanted to also direct a study at UW-Madison of a new cervical disc. But the university wouldn’t let him, citing his ties to the company. The study went to other institutions.

Anderson said such restrictions are making it difficult for academic doctors to conduct research, especially in orthopedics, for which most studies are funded by industry.

“It has driven clinical research from university settings, where you have people skilled in doing research, into community hospitals, where they have fewer controls and less oversight,” he said.

Fox, the head of the conflict- of-interest committee, denied such claims. He said most public universities are implementing more rigorous oversight, with private institutions soon to follow.

At UW-Madison, Fox said, doctors now realize what they can and can’t do off-campus, and some are starting to change their behavior to avoid intense scrutiny.

Many doctors, for example, have reduced their outside compensation to less than $20,000 per company to escape full management plans, Fox said.

“People are beginning to know where the rules are,” Fox said. “They can make choices.”

Healthy Skepticism Library item: 4622

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