My medical school class (UC San Francisco class of ’78) was full of idealistic young people. A number of us had volunteered at the Berkeley Free Clinic before applying to medical school. We wanted to save the world—one patient at a time. And we believed, at that time, that we would have worked for free—or at least for a pittance—so great was our desire to become doctors.
But, no question, even then, there were companies that wanted to woo us with free “trinkets and trash”—coffee mugs, pens, EKG calipers, pizza lunches, and so forth. Of course, we thought we were above such temptations. My class self-righteously voted to turn down the free stethoscopes that Eli Lilly offered us, even though some of us could have used the handout.
Our professors taught us that we should look to “The Medical Letter” for information about new drugs. The Medical Letter for Drugs and Therapeutics, a non-for-profit organization, provides unbiased reviews, including head-to-head comparisons of various prescription medications. Our class was never going to rely on drug detailers to teach us about the latest and greatest.
As a result of my training, I subscribed to The Medical Letter for most of the years that I was in clinical practice. In addition, Kaiser Permanente San Francisco, the medical center where I worked, prided itself on keeping pharmaceutical representatives away from their clinicians. I was lucky to work in an environment where my medical decisions were based on my interpretation and the interpretation of respected peers of published medical literature.
Buying doctors’ hearts and minds
Fast forward to the present, although it is not new, the magnitude of the efforts to buy doctors’ hearts and minds, and most importantly, prescribing and ordering practices is downright shocking. Two recent news stories tell this sad tale.
One is a story in the NY Times about the rebate practices of drug makers who make expensive anemia drugs, erythropoietin stimulating agents. Amgen and Johnson & Johnson, according to the story, are paying doctors hundreds of millions of dollars in rebates to “reward” them for prescribing their drugs. The more they prescribe, the more money they get. This wouldn’t be so bad if more drug meant better outcomes, but studies have shown that high doses of these drugs are associated with an increase in the incidence of heart attacks and strokes.
The other story, from the Newark Star-Ledger, is titled “Feds Accuse Medical Device Makers of ‘Buying’ Doctors.” It describes practices of device makers’ such as Johnson & Johnson subsidiary DePuy Orthopaedics, Zimmer Holdings, Biomet, Stryker, and Smith & Nephew. These companies are said to have “illegally paid off surgeons with vacations, gifts, and no-show consulting jobs in an effort to win their business.”
According to attorneys involved in the case, “The evidence includes statements from prominent doctors around the country who allegedly accepted lavish vacations, gifts, and ‘consulting fees’ as high as $200,000 a year from the implant makers for little or no work.”
Medical societies and other physician organizations will protest that they have ethics guidelines that prohibit doctors from participating in these nefarious practices. And, indeed, they do. But that hasn’t stopped some doctors from yielding to the temptation to earn the big bucks from drug and device companies hoping to increase their market share.
Some of my physician colleagues may argue they have to do these things to make up for income lost by years of cutbacks in reimbursement. Well, perhaps. But how do you explain orthopedic surgeons, some of the highest paid of all medical specialists, indulging in such practices? Other doctors will insist that these financial rewards do not change their prescribing and ordering practices, but the evidence suggests otherwise. Drug and device companies do these things because they work. If they didn’t, they would devote their time and resources elsewhere.
Respect for the profession
In America, we admire the free market. Well, these are free market tactics. But they are tactics that pit a doctor’s self-interest against his/her duty to put the patient’s interest first. They simply should not be allowed to continue.
Physicians bemoan the loss of respect for the profession. They complain bitterly that health plans have come between them and their patients and disrupted the oft-vaunted “physician-patient relationship”. But I bet, in the minds of patients, stories like the ones above have more to do with how patients feel about us as professionals than any HMO rules and regulations.
Medicine is a wonderful profession that each and every one of us who has earned the right to call themselves a physician or surgeon should honor and protect. We don’t have to work for free as my classmates and I originally thought we would be willing to do. But neither do we have to make wads of money off of every single thing that we do.
Come on, guys. It’s time to speak out—and act out—and refuse to indulge in or tolerate these types of marketing practices. If we don’t, someone else surely will do it for us…and that would be a shame—a shame on us.