Physicians on the Take

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Physicians on the Take

Posted 03/20/2006 Jerome P. Kassirer, MD

In my view, relations between physicians and industry have become scandalous.[1] Many academics and community opinion leaders are paid large sums to market industry products by becoming members of speaker's bureaus, by developing marketing materials disguised as educational information, by signing articles written by ghostwriters, and by promoting the off-label use of products. These activities may benefit companies' shareholders, but they do not benefit patients, and because the products promoted are usually the newest and most expensive, they inflate the cost of care.

Though physicians who engage in these activities often believe that company largesse cannot influence their objectivity, all evidence from psychological studies suggests that this is a naive belief.[2] Aside from the harm of such biases to patient care, participation in marketing sets a poor example for younger physicians, who are being seduced by industry every day with lunches, dinners, and gifts. The public has become increasingly aware that doctors are making financial "deals" with pharmaceutical, biotech, and device companies. People are beginning to lose trust that their doctors' advice is for their benefit rather than for their doctors' benefit.

The profession's response to the increasing involvement with industry has been feeble.[3] Our professional organizations and academic medical centers must take a leadership role in reversing this troublesome trend by reducing or eliminating pharmaceutical largesse at their institutions.

That's my opinion. I'm Dr. Jerome Kassirer, Distinguished Professor of Medicine at Tufts University and former editor of The New England Journal of Medicine.

http://www.medscape.com/viewarticle/524994

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Disclosure: Allan J. Mira, MD, has disclosed no relevant financial relationships.Disclo

Letters

Readers' Responses to "Physicians on the Take"

Posted 05/12/2006 Allan J. Mira, MD; Isley, MD; Mark F. McDonnell, MD; Kim M. Huch, MD; M. Whittle, MBBS (Adel), DipRACOG, FRACGP; Terence J. Nugent; Dorothea Z. Lack, PhD

To the Editor,

I read/heard Dr. Kassirer's editorial, "Physicians on the Take,[1]" with deep concern and full agreement. Immediately, it grabbed my ear and stirred my emotions as I waited in anticipation of what he might say. As I read, I was anxious, hoping that before the end of his timely article he would touch upon the deep-rooted cause(s) of this truly scandalous and frightful phenomenon! With some disappointment, at the end, I was left yearning for an answer, or at least a good theory. I thought that there must be a cause for this rather recent, disturbing behavioral change. Otherwise, we may just hope that our inner conscience will someday soon prevail to throw off these temptations from industry, but raw human nature may prevail -- and it usually does. I say, "Please, Dr. Kassirer, go on; I know you have a theory or two, or maybe you just wanted to make those like me think and talk about it!"

I have the opinion that this great upheaval in medical care is the mandated devaluation of physicians' services by the government and insurance companies over the last 20 years or so. It seems that everyone is afraid to talk about this like it may be impossible or unthinkable. Increasingly, physicians are looking for alternate sources of income in the face of this and the tremendous inflation of expenses, and they are scrambling in competition to gain volume, royalties, and even meals! As we are less able or unable to afford (or have less time) to go to seminars, for instance, we are more easily seduced by a substantial subsidy to give or attend a biased seminar. This is the human nature theory.

There is no better way, especially for our patients' sake, to be paid for our services and advice than to be paid reasonably for the professional services alone, in a free market.

So why does a downtrodden, poor man steal or cheat? It seems unthinkable, but in some ways a physician may also!

We must get the free market back or we're all doomed.

Allan J. Mira, MDCarlisle, Pennsylvaniamiraorthopedics@...

Reference

Kassirer J. Physicians on the take. MedGenMed. 2006;8(1). Available at: http://www.medscape.com/viewarticle/524994 Accessed March 20, 2006.

To the Editor,

Dr. Jerome Kassirer[1] has said it exceedingly well.

Isley, MDRochester, Minnesotaisley.william@...

Reference

Kassirer J. Physicians on the take. MedGenMed. 2006;8(1). Available at: http://www.medscape.com/viewarticle/524994 Accessed March 20, 2006.

To the Editor,

I read with interest the opinion article, "Physicians on the Take,[1]" by Jerome P. Kassirer, MD. This ties in nicely with my favorite topic of bad-faith peer review. In Dr. Kassirer's opinion, certain doctors, at the behest and usually on the payroll of industry, are rendering opinions that profit themselves much more than their patients. In bad-faith peer review, certain doctors, also at the behest of and habitually on the payroll of industry, render opinions that profit themselves and damage the doctor-victim. In both instances, industry is exerting improper influence in medicine. Biased data are being passed off as scientific truth, and outrageous, biased medical opinions are being passed off as medical fact.

What we're seeing here is the politicization of medicine; these doctors are no longer practicing medicine but are practicing politics. They have a constituency that made them successful and to whom they owe everything. They are the greatest threat to American medicine today, for only an independent, ethical, and unbiased medical community can survive into the future.

Mark F. McDonnell, MDHouston, Texasmfmcdonnell@...

Reference

Kassirer J. Physicians on the take. MedGenMed. 2006;8(1). Available at: http://www.medscape.com/viewarticle/524994 Accessed March 20, 2006.

To the Editor,

I completely agree with the opinion of Dr. Kassirer[1] of the dangerous influence of pharmaceutical companies on academic medicine. However, one of the problems being faced by faculty in state-sponsored university programs is a severe shortfall in funding. Money for small projects for house officers and fellows, books, and other educational materials, and funding for attendance at meetings for trainees are all lacking. There is no where else that I am aware of that appeals for assistance other than the pharmaceutical companies. Faculty will often use speaker's fees to fund a communal "pot" to cover the expenses of the trainees. What other course of action would you recommend?

Kim M. Huch, MDMemphis, Tennesseekim.huch@...

Reference

Kassirer J. Physicians on the take. MedGenMed. 2006;8(1). Available at: http://www.medscape.com/viewarticle/524994 Accessed March 20, 2006.

To the Editor,

I am an Australian general practitioner and I agree with Dr. Kassirer's sentiments.[1] I am a member of an international medical organization that is committed to the reduction of harm from the misleading promotion of drugs -- healthy skepticism.

Your readers may be interested to visit the Web site, http://www.healthyskepticism.org/.

Yours sincerely,

M. Whittle, MBBS (Adel), DipRACOG, FRACGPAdelaide, South Australiahilsmw@...

Reference

Kassirer J. Physicians on the take. MedGenMed. 2006;8(1). Available at: http://www.medscape.com/viewarticle/524994 Accessed March 20, 2006.

To the Editor,

As a patient, I am moved by Dr. Kassirer's call for physician incorruptibility.[1] However, my enthusiasm is tempered by nearly 30 years of experience working for and with the medical profession in organized medicine and medical marketing.

Renunciation of pharmaceutical largesse would require revolutionary change of a profession that is chronically dependent on it, organizationally and individually. Its professional organizations and media, including the leading online and off-line journals, rely on pharmaceutical industry support. Rank-and-file physician backlash is evident against renunciation, which would result in higher professional dues, journal subscriptions, and CME costs. Physicians faced with reduced reimbursement and demands for ever greater expenditures on CME and recertification are reluctant to give up one of the few perquisites of their profession, the occasional subsidy from the pharmaceutical industry.

Many physicians resent the charge that they are corrupted by the industry. I submit that the pharmaceutical industry is far from the most powerful of the myriad forces brought to bear upon the physician's ethical compass. Virtually every decision about procedures, referrals, and reimbursement poses ethical dilemmas between financial gain and patient welfare. In many cases, prescribing a drug benefits the patient more than performing a procedure, but has the opposite financial consequences for the provider. In some cases, eg, leuprolide (Lupron) vs prostatectomy, such conflicts are existential financial threats that are far more powerful than the inducements of pharmaceutical sirens. Prudent patients must always supplement trust with a diversity of opinions to guard against ethically challenged professionals in matters across the ethical spectrum, and are perhaps the best protection against a moral pandemic.

As doctors of medicine, physicians depend on medicine to practice. The pharmaceutical industry also depends heavily on physicians. The long-standing symbiotic relationship between doctors of medicine and manufacturers of medicine has regrettably deteriorated to the point that respected physicians, such as Dr. Kassirer, are moved to seek the equivalent of a divorce.

As in many divorces, the dependents of the parties are at greatest risk. A viable, innovative industry, appropriately supportive of the profession, is perhaps the single best hope for patients struggling with unconquered diseases, such as cancer, and frightening new horsemen of the apocalypse, such as bird flu. The pharmaceutical industry is working to reform itself. I would encourage opinion leaders, such as Dr. Kassirer, to work with the industry to repair the relationship rather than renounce it.

Terence J. NugentWood Dale, Illinoist-nugent@...

Reference

Kassirer J. Physicians on the take. MedGenMed. 2006;8(1). Available at: http://www.medscape.com/viewarticle/524994 Accessed March 20, 2006.

To the Editor,

In my opinion this is a naive view.[1] I would prefer to see physicians being paid large sums to market and develop industry products than to lose them from clinical medicine due to shrinking fees, loss of income, and autonomy. For example, 10 years ago my aging uncle was operated on for a vascular problem by a brilliant surgeon in Boston, Massachusetts. This brilliant surgeon, who had a young family and brutal hours along with a modest salary, soon left medicine to become a venture capitalist.

I would prefer to see industry court physicians and surgeons assist in the development of excellent products, to pay them handsomely to join speaker's bureaus, and to send them to the corners of the Earth to ensure that the products are properly used. I think that we should thank industry for underwriting research and physician income in this way.

I believe that physicians are basically ethical, and as long as the products that they help develop and market are excellent, I have no problem with industry financing. I think that it is a good thing that they are motivated to use new top-of-the-line products, and I don't think that that significantly increases the cost of medicine. I think that the use of these excellent products increases the possibility of successful treatment, therefore decreasing costs in medicine. I also believe that physicians would only enter into this agreement if they knew that the products were excellent. This is one more insurance that patients are getting the best care. I also think that there is a built-in quality control if the competition remains high, and all companies are given equal access to this type of practice.

As reimbursement declines and pressure on physicians to produce at higher and higher levels continues, we should be grateful to industry for motivating these brilliant people to remain in medicine rather than to leave for other areas of employment that appreciate their brilliance and performance, and we should be grateful for whatever funds are absorbed into research for product development. Just compare the salary of the most brilliant surgeon to that of the dullest insurance executive and my point will be made.

Sincerely,

Dorothea Z. Lack, PhDSan Francisco, Californiadlack7@...

Reference

Kassirer J. Physicians on the take. MedGenMed. 2006;8(1). Available at: http://www.medscape.com/viewarticle/524994 Accessed March 20, 2006.

http://www.medscape.com/viewarticle/531612?src=mp