Physicians, medical schools, and professional organizations have no… excuse, since their only fiduciary responsibility is to patients. [Their] mission… is not to enter into lucrative commercial alliances with the pharmaceutical industry. As reprehensible as many industry practices are, I believe the behavior of much of the medical profession is even more culpable.
Marcia Angell, former editor-in-chief, New England Journal of Medicine (NEJM).
How could physicians have allowed this to happen? No doctor I know started with the idea of money above patients. We all wrote that essay in school about how we wanted to save the world. But we are now pawns of moneyed interests, and we often betray our patients’ trust.
Physician training is brutal, and our expectations are high. Most of us have little income through our mid-30s, and we often take out huge loans. We may be responsible for spouses and children. Everyone around us seems to be squeezing a fortune out of healthcare: older surgeons, radiologists, hospital administrators, and even the lawyers suing us. We want to claw our way up the pay scale.
The best marketers on the planet are spending billions of dollars trying to get us to channel whatever resources we control towards their companies. We know this, yet we still connect with our patients, inspire their trust, and try to do our best. They are dependent on us, especially the sick ones, and this makes us responsible for all consequences.
I am by turns reverential and contemptuous of my peers. Some are true mensches. This Yiddish word means they are honorable, modest, and outstanding mentors. These real physicians are with us still, and you will hear their angry and sorrowful voices here. Others sacrifice their patients’ health to make more money.
Most of us are somewhere in between. We are trying to make a living in a system where the industry has rendered the science murky. Most of our misdeeds are not intentional, and few of us admit to ourselves that we ever take advantage of patients. We are blind to our faults, but to the patient on the receiving end, it is a moot point.
Doctors imagine their scientific training and professionalism allow them to walk through this jungle without bias. But we are profoundly vulnerable, the more so because we believe little can sway us. Nothing excuses us for ignoring patients’ best interests—not fatigue, confusion, ignorance, or even cowardice.
Salespeople begin our seduction in medical school, where they supply free food. Gangs of them later invade our offices. The corporations teach them the “three Fs of sales:” food, flattery, and friendship. Relationships are everything; the sales reps occasionally even use the fourth F. The target rarely understands what is going on, and the profits from blowing up prescribing are enormously larger than corporate marketing expenses.
Gifting has a considerable effect. Accepting a single pharmaceutical industry-sponsored meal produced higher rates of prescribing. The more expensive meals had bigger effects. Doctors who accept money prescribe brand-name medications twice as often. Recipients of industry funds write more costly prescriptions. A JAMA review (2000) entitled “Is A Gift Ever Just a Gift?” looked at 538 studies about lectures and gratuities sponsored by drug companies. Gifts transformed physician behavior. How could they not?
An analysis at Worstpills.org, published by the Ralph Nader group Public Citizen, concluded that this situation produces staggering overprescribing. In 2018, US patients filled 4.19 billion prescriptions, over 13 per person. Since many of us take no medications, the rest are consuming a freakish quantity.
How can presents have such a profound effect on professionals? The answer lies in “influence theory,” a foundational field of psychology that corporate marketers have weaponized to boost sales. Any time we give a gift or favor, substantial leverage occurs. This is “reciprocity.” It seems obvious, but we are easily fooled.
People who help you have the favor returned. Turning down gifts is antisocial, and we think of those who do not give back as “moochers.” Larger presents make a bigger difference, but small ones can be powerful as well.
Reciprocity is likely a fundamental evolutionary survival trait. Giving and receiving meals with strangers locks in relationships. In the past, this allowed a tribe or person to support others during hard times when starvation loomed. Food, from sandwiches for office staff to lavish dinners for doctors, is one of the most potent weapons in the corporate drive to increase drug and device sales.
Outside medicine, business people recognize reciprocity. They scramble to gain an advantage by delivering favors, even as small a consideration as holding a door. The impulse to return gifts is reflexive and powerful. This is unlike negotiated exchanges.
Restaurants that give free samples of food can make purchases seem irresistible. Drug companies provide samples of expensive drugs to doctors who then gift them to patients. The process bonds everyone to eventual purchase—which is often painless because insurance pays.
At one time, Hare Krishna’s followers were handing out flowers at many US airports. This worthless gift often triggered an automatic contribution. The beggars would pocket the money, and the travelers would throw the flowers away. The Krishnas would then pick them out of the wastebaskets and reuse them. Another example: restaurant tips significantly increase when the waiter leaves candy with the check.
After reading about influence studies, I understood why drug companies give away all that plastic junk. Besides reminding us of brand names, free pens and coffee cups start reciprocal relationships. Later, dinners, trips, and even substantial research grants may be available. A few prescriptions of stratospherically priced drugs will pay for nearly anything. Congress recognized how potent this is and banned large presents for physicians—yet loopholes still abound.
Industry representatives overwhelm busy doctors with these influence techniques. Reciprocity or returning favors is only one type. Others include:
✪ Authority (if the physician leaders do it, it must be right)
✪ Liking and identification (what a nice drug rep, he plays golf just like me)
✪ Social proof (my competitors are doing it)
✪ Scarcity (the product is nearly gone, buy or prescribe it now)
The best reference for this process is Dr. Robert Cialdini’s Influence (1984). This book has been regarded as a bible of sales by generations of business people.
We idolize celebrities, giving them credit for almost anything, even sound judgment. The companies flood TV, movies, and the Internet with their endorsements. These combine authority, liking, and social proof. For example, Bob Dole helped create a new category of disease, erectile dysfunction. In 2002 Kathleen Turner discussed rheumatoid arthritis on Good Morning America and directed listeners to a website. She did not disclose that she was working for Wyeth, the manufacturer of the rheumatoid drug Enbrel. Cases like this have been in the news for over a decade.
Ninety-four percent of US physicians accept drug and medical device companies’ gifts. Most of us only receive a few dollars a year for an occasional sponsored lunch at medical meetings. But twelve percent of US physicians get paid for research—or sham research—and the money is substantial. According to ProPublica, the total industry gifts to physicians were over $2 billion a year in 2018, including gifts, meals, speaking, travel, and consulting. They did not count research grants, but openpaymentsdata.cms.gov did. This website said the total was $9.35 billion for 2018 alone. You can look up how much each doctor received on either website.
There is now one pharmaceutical sales representative for every five doctors in the US. They call the big prescribers who like and use their drugs “whales.” Companies often pay them to lecture about products at meetings. Hawking physician credibility like this has built many a summer home.
Jerome Kassirer, former editor of the NEJM, described all the payoffs in On the Take (2004). Some consultant physicians get free trips to Florida, some get $1000 for attending one-day meetings, and some get paid for allowing their names on ghostwritten articles.
Psychiatrists receive more money from corporations than any other US specialty. Many hide the payments. Lisa Cosgrove studied the highly influential psychiatric diagnostic “bible,” the Diagnostic and Statistical Manual of Mental Disorders (DSM IV and V). She reported that three-quarters of the authors had financial ties to corporations.
Pharmaceutical companies know which of us is prescribing each medication. Here is how they find out. Although pharmacies will usually refuse to sell the names of doctors who prescribe, they will sell their Drug Enforcement Agency (DEA) numbers. The American Medical Association (AMA) then sells the doctor’s name that matches each number back to the corporations. The companies find out precisely how much medication each physician prescribes. This allows them to pressure doctors to sell more and target those who are small prescribers or who do not use their products at all. Including this, the AMA made more than $56 million from database sales in 2018.
I know a family physician who gets a free dinner nearly every week. He recently had his housewarming party catered by a drug company. Specialists usually control more sales, and they often get the most. Everyone thinks this is harmless, but it is not.
Other industries criminalize this kind of behavior. For example, the Securities and Exchange Commission has clear rules about disclosure when raising money for investments. An investor needs to know conflicts that could effect returns, just as a patient should know if a corporation has paid the doctor to prescribe. Law, business, and governmental groups forbid outside relationships that produce financial gain, professional advancement, or family advantage. Ethical conflicts like these may provoke a lawsuit or criminal prosecution.
Lawyers can be disbarred for concealing conflicts of interest (COIs). Judges recuse themselves or are recused by their supervisors from involvement where they have personal or monetary relationships. Federal judicial and executive branch bureaucrats must sell their ownership in companies of industries that they might affect. The federal government prohibits its employees from accepting anything with a value of over $20. Reporters “may not take any payment, gift, service, or benefit… offered by a news source…[in order to] maintain accuracy, balance, and the truth.”
Physicians’ organizations are also being bought. The medical industry gives them trinkets, research grants, outright grants (sometimes in the millions), speaker's fees, and substantial exhibitor fees for their meetings. Free ghostwriting is part of it. All this ensures favorable guidelines, prescribing, and publications. One reviewer called the conferences “unprofessional conduct” and wrote that the impact of the system was overwhelming.
Nearly all the societies’ websites state that they are “funded by an unrestricted grant from company X.” Each physician group has policy statements saying they have no commercial bias, however. Their physician leaders vehemently proclaim objectivity with editorials in the journals.
For example, the Endocrine Society says in its Code of Ethics: “The Society actively seeks outside financial or in-kind support… from pharmaceutical, device, or biotech companies… [and they] maintain complete independence between industry support of any and all of its programs… [and] objectivity and credibility are not compromised in any way.” However, for their “Endo2015” national meeting, they advertised the industry perks, from “therapy dogs” to raffles, to prizes, to local jazz artists. Posters on their website proudly stated (caps in the original):
WITH MORE THAN 5800 ATTENDEES, ENDO DELIVERED ON IT’S PROMISE TO PUT YOUR COMPANY AND BRAND IN FRONT OF THE LEADERS IN ENDOCRINE PRACTICE
They have over a dozen corporate sponsors. Implausibly, their “Statement on Industry Relationships,” reminds us: “Sources of commercial support do not influence the scientific, educational or public policy decisions of the Society.”
Companies now spend at least twenty percent of their vast marketing budgets on the physicians who have the most influence. They call them the “key opinion leaders,” using the acronym KOL. Since routine gifts to physicians have been progressively restricted by federal law, the companies focus on things like study funding, which has few rules. This research money is used to induce top doctors to corrupt science, produce favorable conclusions, and advocate for products.
Many of these physicians conceal the sources of their money. For example, the dean of Yale’s medical school, the director of a cancer center in Texas, and the incoming president of the most prominent society of cancer doctors all published articles in medical journals without disclosing financial ties to pharmaceutical and healthcare companies (New York Times, 2018). José Baselga, MD, chief medical officer at Sloan Kettering Cancer Center, took millions from industry, published frequently, but mostly kept the payments secret. When this came out, he resigned (NYT/ProPublica, 2018).
Industry pays the KOLs to write favorable guidelines for physician practice. Hundreds of these statements now command doctors to perform in ways that jack up drug sales. Four of five authors of these “standards” have financial relationships with the corporations, with an average of ten conflicts of interest (COIs) per contributor. One study looked at 431 guidelines. Eighty-eight percent had no disclaimers and did not even reference the relevant literature. A JAMA review of 279 guidelines produced by 69 authors concluded their methodological quality was atrocious. Unfortunately, these “standards of care” have the weight of expert testimony in court.
Gilbert Welch told how the corporations made it happen in Overdiagnosed, Making People Sick in the Pursuit of Health (2011):
The head of the diabetes cutoff panel [which established standards] was a paid consultant to Aventis Pharmaceuticals, Bristol-Myers Squibb, Eli Lilly, GlaxoSmithKline, Novartis, Merck, and Pfizer—all of which made diabetes drugs. Nine of the eleven authors of recent high blood pressure guidelines had some kind of financial ties… [to the medication manufacturers]. Similarly, eight of the nine experts who lowered the cholesterol cutoff were paid consultants of the drug companies making cholesterol drugs. And the first osteoporosis standard was established by… a panel… whose corporate advisory board consisted of thirty-one drug and medical equipment companies.
The industry has even infiltrated medical schools, home to some of the most influential physicians. Eric G. Campbell, Ph.D., studied 459 department chairs of US medical schools. Two-thirds of them and two-thirds of their departments had close ties to industry. An overwhelming majority of these chief doctors believed they had no biases related to this.
In another study, he discovered that a third of the Institutional Review Board members who approve studies had corporate COIs. Thirty-five percent of them had conflicts regarding issues they voted on during the past year. Federal guidelines require recusal in these situations, but they are ignored.
Disclosure is used to launder conflicts of interest, but this gets nothing clean. Elsevier, the largest medical publication house, requires its authors to confess their payments in writing. But this does not disinfect payoffs. No matter how strong an argument, if it comes from a paid advocate, a balanced view is impossible. Sponsors punish actions contrary to their interests by cutting off their consultants’ money.
Joseph Biederman, MD, has one disclosure statement of 364 words, an article in itself. He was censured for failing to disclose some of his many sources of corporate pay, and the NY Times asked whether he was an “expert or shill.” He is Chief of Clinical and Research Programs in Pediatric Psychopharmacology and Adult ADHD at the prestigious Massachusetts General Hospital. Here is another disclosure statement:
Dr. Gertz reports personal fees from Ionis/Akcea, personal fees from Alnylam, personal fees from Prothena, personal fees from Celgene, personal fees from Janssen, grants and personal fees from Spectrum, personal fees from Annexon, personal fees from Appellis, personal fees from Amgen, personal fees from Medscape, personal fees from Physicians Education Resource, personal fees for the Data Safety Monitoring board from Abbvie, personal fees from Research to Practice, speaker fees from Teva, speaker fees from Johnson and Johnson, speaker fees from Medscape, speaker fees from DAVA oncology, roles on the Advisory Board for Pharmacyclics and Advisory Board for Proclara outside the submitted work, royalties from Springer Publishing, and Grant Funding from Amyloidosis Foundation and International Waldenstrom Foundation; NCI SPORE
Everyone respects doctors, particularly those with fancy degrees and university affiliations. Credibility based on credentials seems dependable. Unfortunately, influence works on them the same as on the rank-and-file. After money changes hands, the recipient’s recommendations about drugs, treatments, and surgery are biased. Pretensions of objectivity citing authority are much worse than nothing because they fool us. Patients and doctors alike are blind to this.
Neither physicians nor patients are tough-minded enough to believe that powerful effects—essentially bribery—now command nearly every move in healthcare. In theory, doctors and other caregivers put patients before finances, but corporations are designed as money-making machines. For them, patient outcomes are a distant consideration.
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