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Physicians, big pharma, and deception.

Recently, Dr. David McNeil wrote a guest editorial in these pages in which he argued that it is appropriate for doctors to give talks for pharmaceutical companies ("We Can Work With Pharma," February 2008, p. 11).

In that article, Dr. McNeil made several statements and arguments that I have often heard in defense of this practice. As the author of one of those critical "mass media" articles to which Dr. McNeil was apparently referring ("Dr. Drug Rep," New York Times Magazine, Nov. 25, 2007), I'd like to address some of these points.

Since Dr. McNeil says that he would like to know the agenda of the critics, I will begin by making my own disclosures. I own, write, and edit a non-industry supported CME newsletter, which is funded entirely by individual subscription payments from clinicians. I have a small private practice, and I write occasional articles for professional journals, consumer newspapers, and magazines--some of which pay me writer's fees. My take-home income from all these ventures is about $150,000 per year.

Some have argued that those of us who criticize drug company marketing tactics have a personal agenda, and use the issue to attract media publicity. However, as a medical educator and practicing psychiatrist, my interest is in helping patients to get better, which often requires the use of medications. I am not "anti-Big Pharma" by any means; rather, I am antideception. My agenda is clear. I aim to publicize an issue I care deeply about, namely, that pharmaceutical companies inappropriately use physicians to manipulate the prescribing practices of other physicians.

Make no mistake: When a drug company pays a doctor to speak to other doctors, the company is motivated by one thing only: to increase prescriptions of its product. It does not hire speakers like Dr. McNeil out of a sense of altruism. We know this is true from documents released in the setting of recent lawsuits.

For example, a few years ago, the Wall Street Journal reported that Merck carefully tracked the return on the money it paid physicians to give talks promoting Vioxx ("To Sell Their Drugs, Companies Increasingly Rely on Doctors," July 15, 2005).

According to Merck's own marketing research, when doctors targeted by the company met only with Vioxx drug reps, they wrote an additional $165.87 in Vioxx prescriptions over the next 12 months. However, when they attended talks given by other doctors, they wrote an additional $623,55 worth of the drug.

In short, Merck quadrupled its return on marketing investment by hiring doctors to do the speaking. It's no wonder that the number of physician-speakers has skyrocketed over the last decade, to a recent estimate that more than a quarter of all physicians receive drug company payments for speaking, consulting, or other marketing activities (N. Engl. J. Med. 2007;356:1742-50).

Dr. McNeil states that the money he is paid to give talks is actually not a meaningful incentive, and that "appropriately accounted, hourly income is higher in the office." When I spoke for Wyeth in 2002, I was paid $750 for 1 hour spent with physicians at their offices during "Lunch and Learn" sessions. Depending on the location, transportation would take an extra 1-2 hours. Therefore, my hourly rate varied from about $220 per hour to $375 per hour.

In my clinical practice, seeing three patients per hour for medication visits, I made about $130 per hour after my overhead expenses. Thus, by my accounting, I roughly doubled my hourly income giving drug company talks. Over the course of a year, I boosted my annual income by $30,000.

Other speakers have made much more. For example, in one highly publicized case, a psychiatrist made $556,000 in speaking and consulting fees in addition to his regular salary ("Drug Companies Enrich Brown Professor," Boston Globe, Oct. 4, 1999). In my opinion, money like this is a powerful motivator and could tempt doctors to favor the company's products.

Dr. McNeil denies that he ever slants the data he presents. In my personal experience, however, the pressure to subtly highlight the advantages of the sponsored product is enormous. The drug reps are listening to your every word, and they are the ones writing your next check. While speakers rarely, if ever, tell outright lies to the audience, they nonetheless promote the sponsor's product by giving short shrift to negative side effects or by downplaying the advantages of competing products (JAMA 2000;283:373-80).

Finally, Dr. McNeil argues that doctors should be entitled to industry perks and marketing consultancy opportunities just like those in other professions. Professionals in other industries, he points out, are accustomed to being plied with an array of financial perks by companies with whom they do business.

However, physicians need to be held to a higher standard. We are not selling cars, computers, or mutual funds. We are selling expertise related to the most precious commodity of all: health. Our patients rightfully expect that our decisions about their treatment are based purely on an objective reading of medical science and are not at all influenced by the promise of personal financial gain. Doctors who speak for drug companies and doctors who receive their medical education from such speakers stray dangerously away from this ideal.

Speaking for drug companies is lucrative, fun, and a relief from the rigors of practice. But that doesn't make it right.

DR. CARLAT is assistant clinical professor of psychiatry at Tufts University, Boston, and serves as publisher and editor of The Carlat Psychiatry Report. He has no financial ties to any pharmaceutical company.

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Title Annotation:GUEST EDITORIAL
Author:Carlat, Daniel
Publication:Clinical Psychiatry News
Date:Apr 1, 2008
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