Doctors' Ties to Drug Makers Are Put on Close View

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Doctors' Ties to Drug Makers Are Put on Close View_

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(http://www.nytimes.com/2007/03/21/us/21drug.html)

By GARDINER HARRIS and JANET ROBERTS

Published: March 21, 2007

Dr. Allan may be the most influential kidney specialist in the

country. He is president of the National Kidney Foundation and director of a

government-financed research center on kidney disease.

Multimedia

Graphic

Drug Company Payments to Doctors

In 2004, the year he was chosen as president-elect of the kidney foundation,

the pharmaceutical company Amgen, which makes the most expensive drugs used

in the treatment of kidney disease, underwrote more than $1.9 million worth

of research and education programs led by Dr. , according to records

examined by The New York Times. In 2005, Amgen paid Dr. at least

$25,800, mostly in consulting and speaking fees, the records show.

The payments to Dr. and the research center appear in an unusual set

of records. They come from Minnesota, the first of a handful of states to

pass a law requiring drug makers to disclose payments to doctors. The Minnesota

records are a window on the widespread financial ties between pharmaceutical

companies and the doctors who prescribe and recommend their products.

Patient advocacy groups and many doctors themselves have long complained that

drug

companies exert undue influence on doctors, but the extent of such payments

has been hard to quantify.

The Minnesota records begin in 1997. From then through 2005, drug makers

paid more than 5,500 doctors, nurses and other health care workers in the state

at least $57 million. Another $40 million went to clinics, research centers

and other organizations. More than 20 percent of the state's licensed

physicians received money. The median payment per consultant was $1,000; more

than

100 people received more than $100,000.

Doctors receive money typically in return for delivering lectures about

drugs to other doctors. Some of the doctors receiving the most money sit on

committees that prepare guidelines instructing doctors nationwide about when to

use medicines. Dr. , who received more money than anyone else in the

state, is among a limited number whose payments financed research.

In dozens of interviews, most doctors said that these payments had no effect

on their care of patients.

Dr. said his sole focus was the health and well-being of patients.

" Just because I might do consulting work doesn't mean I don't press the agenda

of the public health, " he said.

Ken , senior vice president of Pharmaceutical Research and

Manufacturers of America, said interactions between drug companies and doctors

were

beneficial. " In the end, patients are well-served when technically trained

pharmaceutical research company representatives work with health care

professionals to make sure medicines are used properly, " he said.

There is nothing illegal about doctors' accepting money for marketing talks,

and professional organizations have largely ignored the issue.

But research shows that doctors who have close relationships with drug

makers tend to prescribe more, newer and pricier drugs - whether or not they

are

in the best interests of patients.

" When honest human beings have a vested stake in seeing the world in a

particular way, they're incapable of objectivity and independence, " When honest

human beings have a vested stake in seeing the world in a particular way,

they're incapable of objectivity and independence,<wbr> " said Max H. Bazerman,

a

professor at Harvard Business School. " A doctor who represents

In an e-mail message, Dr. said he personally received in 2004 less

than $10,000 from Amgen for educational presentations. " The contract amount of

$1.9 million from Amgen was paid to the Minneapolis Medical Research

Foundation (MMRF) for the research contract, on which I am the designated

senior

researcher, " Dr. wrote. He wrote that he did not work for or serve on

the board of directors of the foundation. Dr. discloses on his Web site

and research papers that he is a consultant to Amgen, among other companies.

Dan Whelan, an Amgen spokesman, said the company paid the Minneapolis

Medical Research Foundation " to conduct sophisticated research and data

analyses

that have enhanced the understanding of health care delivery " for kidney

patients.

But Dr. Coyne, a kidney specialist at Washington University, said he

was troubled by the payments.

" Amgen's funding for Dr. 's MMRF is another huge financial connection

to individuals at the National Kidney Foundation, " Dr. Coyne said. " The

foundation's recent pro-industry anemia guidelines - and the revisions due next

month - have to be viewed with great skepticism. "

Page 2 of 3)

Dr. Coyne recently wrote an editorial in an influential journal decrying

guidelines written last year by the kidney foundation that encourage doctors to

use more of Amgen's drugs to treat anemia in kidney patients despite studies

showing that increased use led to more deaths.

Drug Company Payments to Doctors

Ellie Schlam, a spokeswoman for the National Kidney Foundation, said the

foundation sought out the world's foremost experts. " These are the same people

that are wanted by government and industry, " she said. " We really work hard to

separate the financing from the content. "

Drug makers listed Dr. and the research group as the recipient of

payments totaling more than $2 million between 1997 and 2005. Most doctors on

the list are far less prominent than Dr. .

Ten doctors and one dentist in Minnesota received more than $500,000.

Because the records are incomplete, these sums likely underestimate the

providers'

earnings. Device makers and Wall Street firms tracking medical research were

not required to report, although consulting arrangements between such

companies and doctors are common.

More than 250 Minnesota psychiatrists together earned $6.7 million in drug

company money - more than any other specialty. Seven of the last eight

presidents of the Minnesota Psychiatric Society have served as consultants to

drug

makers, according to the Times examination.

After psychiatrists, doctors who specialized in internal medicine garnered

the most money, followed by cardiologists, endocrinologists and neurologists.

Unknown to Most Patients

Doctors in Minnesota said they generally did not tell their patients about

these arrangements. Indeed, few patients are aware of the financial

connections between those prescribing drugs and the companies making them.

A New York Times/CBS News poll last month found that 85 percent of

respondents thought it " not acceptable " for doctors to be paid by drug

companies to

comment on prescription drugs. Eighty-five percent also said such payments

would influence the decisions that doctors made about patient care.

In addition to Minnesota, legislators in Vermont, Maine, West Virginia,

California and the District of Columbia have passed laws requiring some level

of

disclosure of drug company marketing efforts. In Vermont, the state has

collected three years of data on payments to doctors, but drug makers are

allowed

to keep the records private by declaring them trade secrets.

In the 2005 fiscal year, the most recent year for which figures are

available, drug makers declared 73 percent of payments to doctors in Vermont as

trade

secrets. The Journal of the American Medical Association today is publishing

data summarizing physician payments from drug makers in Minnesota and

Vermont. The study concludes that many payments exceeding $100 were made but

that

the records were difficult to decipher and all but impossible for individuals

in either state to interpret.

Dr. Blumenthal, director of the Institute for Health Policy at

Massachusetts General Hospital, said, " We have given physicians a lot of

freedom

and self-governance because of their professional reputation and a sense that

they know how to help their patients. "

Doctors said their lectures about drugs to other doctors in return for the

payments were gentle marketing pitches that adhered strictly to messages

approved by drug makers and federal drug regulators.

Drug companies " want somebody who can manipulate in a very subtle way, " said

Dr. Frederick R. , a headache specialist in Minneapolis who earned

more than $710,000 between 1997 and 2005, much of that from GlaxoKline,

the

maker of the migraine drug Imitrex.

Dr. Realmuto, a psychiatrist from the University of Minnesota, said

most of the marketing associated with his lectures was packaged around his

talks.

" It's at a wonderful restaurant, the atmosphere is very conducive to a

positive attitude toward the drug, and everyone is having a good time, " said

Dr.

Realmuto, who compared the experience to that of buying a car in a glitzy

showroom. He earned at least $20,000 between 2002 and 2004 from drug makers.

Doctors said that lectures were highly educational, and that drug makers

hired them for their medical expertise and speaking skills. But former drug

company sales representatives said they hired doctors as speakers mostly in

hope

of influencing that doctor's prescribing habits.

" The vast majority of the time that we did any sort of paid relationship

with a physician, they increased the use of our drug, " said Kathleen

Slattery-Moschkau, a former sales representative for Bristol-Myers Squibb and

&

who left the industry in 2002. " I hate to say it out loud, but it all

comes down to ways to manipulate the doctors. "

(Page 3 of 3)

Reidy, a drug sales representative for Pfizer Inc. and Eli Lilly &

Company who was fired in 2005 after writing a humorous book about his

experiences, said drug makers seduced doctors with escalating financial

inducements

that often start with paid trips to learn about a drug.

" If a doctor says that he got flown to Maui, stayed at the Four Seasons - and

it didn't influence him a bit? Please, " Mr. Reidy said.

'A Silent Quid Pro Quo'

The lectures earn doctors more than cash.

" You're making him money in several ways, " said Gene Carbona, who left Merck

as a regional sales manager in 2001. " You're paying him for the talk. You're

increasing his referral base so he's getting more patients. And you're

helping to develop his name. The hope in all this is that a silent quid quo pro

is

created. I've done so much for you, the only thing I need from you is that

you write more of my products. "

For many doctors, marketing lectures are also a welcome diversion.

" It beats talking to little old ladies about their bowels, " said Dr.

Storvick of Mankato, Minn., who made more than $174,000 between 1998 and 2005

from drug makers.

The number of drug marketing presentations delivered by doctors across the

United States rose nearly threefold between 1998 and 2006, according to

Verispan, a company that tracks drug marketing efforts.

In some cases, consulting doctors are so well recognized that they offer

drug makers far more than the chance to influence their own prescriptions. For

drug makers, among the most prized consultants are those who write guidelines

instructing their peers about how to use drugs.

Drug Companies' Nature

This list of top doctors in Minnesota includes Dr. Grimm of the

Berman Center for Outcomes and Clinical Research in Minneapolis, who has twice

served on government-sponsore This list of top doctors in Minnesota includes

Dr. Grimm of the Berman Center for Outcomes and Clinical Research in

Minneapolis, who has twice served on government-sponsore<wbr>d hypertension

panels that create guidelines abo

Between 1997 and 2005, Dr. Grimm earned more than $798,000 from drug

companies, according to records. In 2003 alone, Pfizer paid Dr. Grimm more than

$231,000. Pfizer markets Lipitor, a cholesterol drug that last year had $12.9

billion in sales, more than any other drug in the world. It also markets

Norvasc, a hypertension drug that last year had $4.9 billion in sales.

Guidelines

that suggest greater use of these drugs would be a huge boon to Pfizer.

" Drug companies are like lions, " Dr. Grimm said of his sponsored talks. " For

lions, it's their nature to kill zebras and eat them. For drug companies,

it's their nature to make money. They're not really trying to improve anybody's

health except if it makes them money.

" On your side, you're making a bit of money, but you're also trying to

educate the doctors. And in my view, the doctors need a lot of educating. "

Dr. Grimm said that he contributed more than $50,000 between 1997 and 2005

to the Minneapolis Medical Research Foundation, and that his lectures were not

biased.

Dr. Hunninghake served on a government-sponsore Dr.

Hunninghake served on a government-sponsore<wbr>d advisory panel t Dr.

Hunninghake served on a government-sponsore<wbr>d advisory panel that wrote

guidelines

for when people should get cholesterol-<wbr>lowering pills. The panel's 2004

recommendations that far more people get the drugs became controver

In 1998 alone, Pfizer paid Dr. Hunninghake $147,000, and he earned at least

$420,800 from drug makers between 1997 and 2003. He left the University of

Minnesota in 2004 to become a full-time industry consultant. He is now retired.

" Most of my talks did not relate to drugs but the guidelines for treatment, "

Dr. Hunninghake said. He said his consulting practice included a variety of

activities, including lectures.

A 2002 survey found that more than 80 percent of the doctors on panels that

write clinical practice guidelines had financial ties to drug makers.

" It is critical that the experts who write clinical guidelines be prohibited

from having any conflicts of interest, " said Dr. Marcia Angell, a former

editor of The New England Journal of Medicine. " Since they have no data

themselves but are just making judgments based on their expertise, they

absolutely

must be impartial or it undermines the whole enterprise. "

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