Thursday, October 21, 2010

NPR Reveals How Big Pharma Influences Your Doc, and Fires Juan Williams, Too

This entire week, National Public Radio--that known haven of insane Marxist-Socialists--has aired a series of reports illustrating in lurid detail the extent to which physicians are manipulated by pharmaceutical companies into becoming unwitting accomplices in their efforts to generate profits. When you see how the game is played (or more accurately, how doctors are played in the game) you can't help but a) cringe, and b) wonder about the amount to which your own doctor is manipulated. I am a doctor and these stories (along with other books and articles I've been reading) are making me question just how much my own prescription practices have been influenced by these tactics, and that's in spite of the fact that I have assiduously avoided drug reps since I was a fourth-year medical student. How many times have I heard lectures from senior physicians--even those from within the academic medical centers where I was trained--where some large corporation's money had influenced the speaker, who may have been unknowingly acting as a shill? How many times have I taken these lectures at face value, assuming they were given by disinterested academics who took only the best evidence into account when preparing their slides? The more I learn about these practices, the more I realize I have no idea. Just follow the link, listen to the stories, and have some scotch at the ready. It ain't pretty.

Today's installment on All Things Considered brought a new twist to the game. I have long known that the cozy little dinners at nice restaurants sponsored by drug companies were not likely to be places where one could get unbiased information. Today's story, however, explains that sometimes the drug reps target not the audience, but the speaker in order to generate revenues. The recipe: find a practicing physician with a large patient base and prescribes a large volume of drugs. (Companies have access to the prescriptions made by doctors because of arrangements they have with pharmacies. It's perfectly legal and any doctor's prescription habits, down to the last valium tablet, can be tracked.) Approach the physician and explain that he or she is a "thought leader" and welcome them to come give these dinner talks. Provide them with slides about your wonderful drug. Watch them speak. Follow that doctor's prescription patterns--not the ones who come for the cabernet and prime rib, but Dr. Thought Leader Himself/Herself--and watch the money roll in as your company's drug sales shoot through the roof for the month or two after the gig.

Mind you, this is all above board: there's no quid pro quo as part of these speaking gigs. There doesn't have to be one. Beyond the speaking fee (which is typically around one grand: very nice money to be sure) there is no explicit arrangement as to the content of the talks. Indeed, the overwhelming majority of docs would be seriously indignant if there were any implication that they should explicitly endorse drug X at someone's instruction before a talk. No, the key to the scam (let's call it what it is) is that such docs are manipulated through a psychological trick that allows them to succumb to influence precisely because they think they're above influence. "[Doctors] come to the table with the belief that because they have gone through this rigorous academic training that they are somehow impervious," says Dr. David Switzer, a doc who blogs about the interactions between drug reps and physicians. "I don't think that we're as good at that as we think that we are."

According to one former drug rep quoted in the story, a $1500 investment in the speaker's fee plus, undoubtedly, a whole ton of flattery to a high-prescribing doctor could result in a bump of $100,000 to $200,000 for the drug in question--all from just the speaker. One can't draw too many conclusions from just one example, but the yarn is enough to make me believe that various drug companies would make it part of their marketing arsenal. Indeed, if it's legal and other companies are out there doing it, they'd be fools not to.

One of the only humorous moments of the story was when one of the drug reps had to explain what to do with some of the less stellar "thought leaders." Recall, the game is to try to target the doctor who prescribes a lot. Such a doc might not be charismatic, might be unattractive, might not even be a very good doctor, but all of that is beside the point. If they are all of the above, that's clearly a bonus and you want to have the added benefit of that speaker's influence on the audience. But if those qualities are not in play and all you are trying to do is to get the doc to push your drug, you want to limit the damage, and you book the gig at a fast-food style restaurant to ensure low attendance. (Doc Rubin, no doubt, would do no better than top billing at a parking lot outside the local coffee & donut shop!)

If you are a political junkie, you may also have seen how NPR got Big Media to pay attention to it briefly, for firing Juan Williams, their longtime news analyst. Williams, who lived the weird double-life as a commentator for both NPR and Fox News, has slowly and inexorably been moving toward this moment for some years probably. I have been unimpressed by Williams's thoughts on NPR for a very long time (not unlike its other major political commentator, the even more vapid Cokie Roberts), but his stellar performance on Fox was a piece of work, and NPR couldn't abide by it, leading to a he-said-she-said (literally) trading of accusations documented at NPR.

In case you hadn't followed all this, the brouhaha started when Bill O'Reilly opined in a guest spot on The View that "Muslims killed us on 9/11," causing the usual media flap (to say nothing of hosts Joy Behar and Whoopi Goldberg's emphatic reaction of walking off the set, bless their hearts). Part of said flap was Fox News guy Brian Kilmeade defending O'Reilly's nonsense by asserting that "not all Muslims are terrorists, but all terrorists are Muslims," causing all teachers of Symbolic Logic to have one simultaneous nationwide seizure. Williams got into the act as something resembling the Dumb House Liberal, a role he apparently plays on Fox, by noting with an aw-shucks statement conceding that Bill-O was right: "I mean, look, Bill, I'm not a bigot. You know the kind of books I've written about the civil rights movement in this country. But when I get on the plane, I got to tell you, if I see people who are in Muslim garb and I think, you know, they are identifying themselves first and foremost as Muslims, I get worried. I get nervous." NPR, saying that the remarks were "inconsistent with our editorial standards and practices," fired him.

Whether or not NPR meted out an unjust punishment is, I suppose, up for debate. But what isn't really up for debate is that Juan Williams said something completely idiotic and, yes, of course, bigoted. The defense that Williams was just speaking his mind and should be praised for his honesty holds about as much water as Carl Paladino's insistence that forwarding ha-ha e-mails of a jungle-bunnyish Barack Obama doing a tribal dance wasn't racist, which is to say not at all. Let's try this one out:

You know, when I get on the plane, I got to tell you, if I see people who are black and wearing baggy pants and bandanas, and I think, you know, they are identifying themselves first and foremost as black people, I get worried. I get nervous.

How's that sound? Umm...bigoted, maybe? So Mr. Williams lost his job at NPR. This appears to have been a boon to both Fox and Williams, though, who seems to have gotten a raise in the wake of the whole matter. Boo Hoo Hoo.

Monday, October 11, 2010

The Dark Side of Medicine, in Corporate Form

Carl Elliot, a physician by training and currently a medical ethicist at the University of Minnesota, might have been pleased, in a twisted way, to hear the recent revelations about the US government's research project in Guatemala in the 1940's where physicians deliberately attempted to infect prison inmates, patients in mental institutions as well as soldiers with syphilis. After all, when you're writing a book about how the machinery of medicine can be used for unethical behavior, how much better can you do than by getting some free publicity from a news story about truly outrageous behavior by doctors employed by the feds?

There is one major difference between Elliot's thoroughly-researched book and the Guatemala Syphilis Experiment story, however: most of what Elliot documents is corporate-driven malfeasance, while the Syphilis study was done at the behest of government and, however wildly misguided its aims, with national security in mind. The bad behavior that goes on today in the medical research world is done in the name of the almighty dollar.
Elliot's title might seem a bit misleading--at first glance, I thought it was the memoir of a Chasidic Jew in the world of secular medicine--but White Coat, Black Hat more than makes up for it by painting a picture of just how the system of medical research, in particular pharmaceutical research, can be gamed by savvy corporations whose bottom line often doesn't overlap with patient needs. And a pretty picture it ain't. Elliot acknowledges in the introduction that he is not trying to paint a balanced picture of how the entire system works, and that he assumes there are many corporate-employed researchers as well as executives who really do want to succeed in business by making better drugs for patients ("There are still plenty of honest doctors out there. But honesty is getting harder all the time."). He does, however, aim to review the known abuses to give readers a sense of how patients and doctors alike can be conned, sometimes with lethal consequences.

The book dissects the system from the standpoint of the various players within it: he looks at "guinea pigs" (research study volunteers who have turned being a serial study subject into a most unusual professional career), "ghosts" (writers who author medical manuscripts), "detail men" (drug reps), "thought leaders" (MDs who have turned into shills for the companies), "flacks" (the corporate execs) and "ethicists." Throughout every step he recounts the half-truths and highly iffy behavior of pretty much everyone involved, and what happens to the careers of those whose ethical misgivings finally override their desire for wealth and admiration, leading them to speak out. The short version is that while it's not wise to mess with these entities, but it's decidedly highly unwise to mess with them after you've sucked at their teat for a few years.

For those who follow the New York Times regularly many of these stories won't come as much of a surprise, but when collected together the portrait does have a rather compelling effect, a bit like the difference between the distate one experiences when seeing one cockroach compared to watching the scene with Harrison Ford in Indiana Jones and the Temple of Doom when he discovers that the walls are enitrely covered with creepy-crawlies. Yes, the bugs probably aren't going to kill you, but the more you shine a light on them and discover how abundant they are, you can't escape the overwhelming sense of contamination.

PS--On the subject of Chasidic Jews and good timing--bravo to Carl Paladino! The Republican candidate for the Governorship of the State of New York couldn't have timed his ranting anti-gay speech better. In an address to members of the Sha'arei Chaim congregation (that's "Gates of Life" for non-Tribe members out there) that was greeted by applause, Paladino said, "I just think my children and your children would be much better off and much more successful getting married and raising a family, and I don’t want them brainwashed into thinking that homosexuality is an equally valid and successful option — it isn’t." Nicely done, Carl! Especially within days of the ugly revelations of the targeted assaults of gay men in the Bronx. Carl, you may be aware, is a fine example of the G-rated squeaky-clean right wing candidate who likes to decry the sexual lewdness of a permissive culture, until it turns out that he's not so squeaky-clean, as the revelations of e-mails containing bestiality and racism surfaced earlier this year. In Paladino's case, the revelations came months before the anti-gay speech. I'm not following the NY Gov's race close enough, but it smacks of someone trying to change the subject. Ladies and Gentlemen, the Tea Party!