‘Disturbing’ glimpse into how marketing dupes doctors —
We know that physicians meet a parade of drug company sales representatives
from their first days of medical school to retirement and that they see drug
ads every time they pick up a medical journal.
At least that is represented as the advertising it is.
But a study in this week's issue of the Annals of Internal Medicine
detail about how drug companies push their products in far more subtle ways.
Some drug makers pay key leaders in a field of medicine, such as chairs of
departments in medical schools, tens of thousands of dollars if they are saying
the right things about their product. They manipulate medical education sessions,
lectures, articles in medical journals, research studies, even personal conversations
between physicians to get their product message across.
"It is very disturbing," says lead author Dr. Michael Steinman of
the University of California, San Francisco and the San Francisco VA Hospital.
"It really does a disservice to patient care."
Reliable estimates put the drug industry’s expenditure on promotion to
doctors at $18.5 billion — that's about $30,000 a year for every physician
in the U.S. Companies conceal the specifics of those efforts with a jealousy
worthy of a state secret.
Now a huge collection of drug company internal documents — revealed as
part of a lawsuit —offers a wealth of detail.
In 1996, Dr. David Franklin, an employee of the drug company Parke-Davis, filed
the lawsuit under federal whistleblower statutes alleging that the company was
illegally promoting an epilepsy drug called Neurontin for so called “off-label”
uses. Under federal law, once the FDA approves a drug, a doctor can prescribe
it for anything. But the law specifically prohibits the drug company from promoting
the drug for any unapproved uses.
In 2004, the company, by then a division of Pfizer admitted guilt and agreed
to pay $430 million in criminal and civil liability related to promoting the
drug for off-label use.
Spokespeople for Pfizer say that any wrong doing occurred before Pfizer acquired
the company. But Pfizer fought hard to keep all the papers related to the suit
under seal. A judge denied the request and they are now part of the Drug
Industry Document Archive at the University of California, San Francisco.
Steinman and his team summarized some of the key findings from the extensive
collection in their paper. It is obvious why the company wanted to keep the
documents from public view.
What is most interesting is not the illegal actions they reveal, but the details
of activities that are perfectly legal. And according to people familiar with
the industry, the methods detailed in these company memos are routine.
One tactic identifies certain doctors as “thought leaders,” “key
influencers” and “movers and shakers” — those whose
opinions influence the prescribing pattern of other doctors. Those whose views
converge with the company goals are then showered with honoraria, research and
educational grants. In the Parke-Davis case 14 such big shots got between $10,250
and $158,250 between 1993 and 1997.
“Medical education drives this market,” wrote the author of one
Parke-Davis business plan in the files. Many state licensing boards require
physicians to attend sessions in what is called continuing medical education
(CME) to keep current in their field.
At one time, medical schools ran most CME courses. Now, an industry of medical
education and communications committees (MECCs) run most of the courses. These
companies with innocuous sounding names like Medical Education Systems set up
courses, sometimes in conjunction with medical meetings, at other times often
in fancy restaurants and resorts. The drug companies foot the bill, with the
program usually noting it was financed by an “unrestricted educational
grant” from the company.
Not innocent bystanders
The records in this case reveal in precise detail how the company attended planning
sessions for the meeting and were allowed to tailor the content to meet their
Using MECCs, Parke-Davis set up conference calls so that doctors could talk
to one another about the drugs. The moderators of the calls, often thought leaders
or their younger assistants, received $250 to $500 a call. Drug company reps
were on the line, instructed to stay in a “listen only” mode, but
monitoring to be sure the pitch met their expectations.
The papers also reveal a “publication strategy” where the drug
company would sponsor small trials of the drug and get the results published
only if they met the company’s expectations. If the “core marketing
team” found that results did not conform to the company’s goals,
"the results will not be published," the documents reveal.
Besides arranging for its own favorable studies, Parke-Davis also contracted
with MECCS to develop articles, review papers and letters to the editors of
medical journals putting its product in a favorable light.
The company paid the MECC $13,375 to $18,000 for each article, but the reader
would not know the drug company or the MECC authored the article. The MECC paid
$1,000 each to friendly doctors and pharmacists to sign their names to the articles
— creating ghostwriters to make the material appear independent.
Clearly, many of the physicians in these schemes are not innocent bystanders.
Whether it is ghost writing, making telephone calls to colleagues or leading
a CME session, many of the doctors got paid well. Others received a free meal
or transportation to a resort to listen to an “educational session.”
Physicians often claim they are not influenced by payments and perks from the
pharmaceutical industry. But with the methods so thoroughly detailed in these
papers, drug companies clearly believe they are getting their money's worth.
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