Your Doctor's Drug Problem

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November 18, 2003

Your Doctor's Drug Problem

By ARNOLD S. RELMAN

BOSTON — The rising costs of pre scription drugs are driving the current

debate about Medicare reform. Yet Republicans and Democrats alike may be unaware

of a primary reason for this inflation: doctors are taught about drugs by

agents of the pharmaceutical industry, which works hard to persuade them to

select

the newest and most expensive medications — even in the absence of scientific

evidence that they are any better than older, less costly ones.

Despite the increase in direct-to-consumer advertising, patients still rely

on their doctors to choose which prescription drugs, if any, they should take.

But what few of them know is that often their doctors' judgment is influenced

by the companies that sell the drugs. Most medical practitioners nowadays

learn which drugs to use, and how to use them, mainly from teachers and

educational programs paid for by the pharmaceutical industry.

To renew their licenses, doctors in almost all states are required to enroll

in continuing medical education programs, and these are now largely

subsidized, directly or indirectly, by the pharmaceutical industry. There are

official

guidelines for keeping these programs free of commercial bias, but they are

voluntary. Most of these educational programs are presented by industry-friendly

experts who are selected and paid by the companies selling the drugs being

discussed, and most of their talks emphasize the medical benefits of those

drugs.

Some of this information is useful, but much of it is simply marketing

disguised as education.

Of course, the companies sponsoring continuing medical education programs

deny that sales promotion is their intent. They say they merely want to help

" educate " doctors by giving financial and technical help to the institutions

offering the programs.

To its shame, the medical educational establishment tolerates this state of

affairs. Medical schools, professional associations and hospitals that offer

continuing education programs accept grants from the pharmaceutical industry and

frequently allow the industry to suggest topics and speakers and help with

preparation of the programs. They are reluctant to do anything that would

jeopardize the industry's support.

As for the doctors attending these industry-sponsored educational programs,

they like the slick presentations, which often use industry-supplied teaching

materials. They also like the low or nonexistent fees, the free food, and the

numerous small gifts given out at the commercial exhibits that often accompany

big education events. And naturally they are confident that their own

independence is wholly unaffected by all of this — although surveys reveal

that they

are less sanguine about other doctors' ability to resist industry's

blandishments.

But the companies providing the support wouldn't pour money into education

unless they were confident of a return on their investment. And there is

evidence that industry-sponsored programs increase the writing of prescriptions

for

the sponsor's products.

In this way, doctors are led to believe that new and expensive drugs are much

better than older and less costly generic drugs. Sometimes this is true, but

not nearly as often as the pharmaceutical industry wants doctors to think.

That's why it spends so much money on helping with the " education " of doctors.

So it is not merely that the pharmaceutical industry is using doctors to sell

its products. Medical schools and other educational institutions are not

teaching doctors how to use drugs wisely and conservatively. Until they insist

that the pharmaceutical industry stick to its own business (which can include

advertising but not education), we are unlikely to get the help we need from our

doctors in controlling runaway drug expenditures.

Arnold S. Relman, professor emeritus at Harvard Medical School, is former

editor of The New England Journal of Medicine.