Pharmaceutical companies play a vital role in improving the public health through drug discovery. These for-profit entities are in the business of selling their products to physicians and patients. If you’re a physician, the images of drug marketing are ubiquitous: the attractive, vivacious sales representative who always seems happy to see you; the sea of purple tote bags at the last national gastroenterology meeting (can you guess the drug advertised on them?); photos in medical journals of fit runners reaching their goal blood glucose.
You may not be as aware of the numbers behind the images. In 2004 US pharmaceutical sales totaled $235.4 billion, of which 24% was spent on marketing of existing drugs, over twice the expenditure on research and development of new compounds. Of the industry’s $57.5 billion marketing budget, 36% was spent on visits to physicians by industry representatives (“detailing”), 28% was spent on drug samples for doctors to give to patients, while only 7% was used for direct to consumer advertising. (Gagnon MA, Lexchin J. The Cost of Pushing Pills: A New Estimate of Pharmaceutical Promotion Expenditures in the United States. PLoS Med 2008). Physicians themselves become extensions of the drug advertising apparatus by accepting thousands of dollars to give lectures, with the implicit expectation that they promote the company’s drug (Carlat D Dr. Drug Rep. The New York Times Magazine Nov 25, 2007). Clinical researchers are offered something money can’t buy: authorship on manuscripts reporting drug trials which have been written by company employees (referred to as “ghostwriting”) (Ross JL et al. JAMA 2008;299:1800-1812).
Generations of physicians have become accustomed to lunches, pens, and dinners as a sign of gratitude for their hard work. Drug representatives, however, are paid to increase prescriptions. As one former drug representative wrote, “It’s my job to figure out what a physician’s price is. For some it’s dinner at the finest restaurants, for others it’s enough convincing data to let them prescribe confidently and for others it’s my attention and friendship…but at the most basic level, everything is for sale and everything is an exchange.” (Fugh-Berman A, Ahari S. Following the Script: How Drug Reps Make Friends and Influence Doctors. PLoS Medicine 2007)
So drug companies spend a lot of money marketing to physicians. What’s the big deal? The problem is that marketing works. Gifts of any value to physicians create a tacit expectation that they return the favor; these incentives may result in bias in clinical decision-making that affects patient health and increases health care costs. Many doctors agree that gifts influence other practitioners, but insist that they do not affect their own practices. The public, meanwhile, is as appalled with drug companies wooing doctors as they are with lobbyists “donating” money to politicians’ campaigns. In 2002 the pharmaceutical industry, fearing national legislation, voluntarily limited their marketing gifts to those of less than $100 in value, while explicitly allowing unfettered drug sample distribution, “ghostwriting,” and unlimited payments for physician speakers. The magnitude of these payments is staggering and continues to increase. In Minnesota, where most monetary gifts to physicians are publicly reported, at least 700 providers received more than $10,000 between 1997 and 2005, while the average internal medicine doctor received $1000, and the average cardiologist $2300 (Harris G, Roberts J. Doctors’ Ties to Drug Makers Are Put on Close View. The New York Times March 21st, 2007.
The public (and physician community) is increasingly aware of the conflicts of interest posed by gifts to physicians. The American Medical Student Association (AMSA; www.amsa.org) and No Free Lunch (www.nofreelunch.org) have for many years reached out to medical students and residents to avoid drug industry gifts. In 2006 Brennan et al. published an influential article urging academic medical centers to ban gifts of any value from the pharmaceutical industry, prohibit payments to physicians for speaking, allow free drug sample distribution only via a central repository, and allow unrestricted educational and research funds with limitations (Brennan TA. et al. Health Industry Practices That Create Conflicts of Interest. JAMA 2006;295:429-433. AMSA was the only professional medical society to endorse these recommendations until a task force of the American Association of Medical Colleges (AAMC), which included several chief executives of pharmaceutical companies, recently recommended that all medical schools ban pharmaceutical gifting to physicians (link: http://www.aamc.org/research/coi/industryfunding.pdf and http://www.nytimes.com/2008/04/28/us/28doctors.html).
A number of academic medical centers have independently done so to varying degrees (a partial list includes University of Pennsylvania, Stanford, Columbia, University of Pittsburgh, U Mass, the VA system, Boston Medical Center, University of Michigan, UC Davis, and Bellevue Hospital Center). We are working to implement similar regulations at our own institutions (NYU Medical Center and University of Connecticut), and anticipate that the remaining academic medical centers in the United States will soon do so as well. However, until professional groups such as the American Medical Association (AMA) adopt strong conflict-of-interest policies, the pharmaceutical industry will continue to spend billions of dollars on influencing the clinical decisions of our community physicians.
“To increase public awareness and hold academic medical centers accountable for their policies, AMSA recently developed a scorecard which grades academic hospitals’ policies on gifting from the pharmaceutical industry. The grading system has already grabbed the attention of hospital leaders (doctors aren’t accustomed to failing tests) and the New York Times.