Two Maine physicians, Drs. Ben Schaefer and Bethanie Picker, threw in their hats Monday for LD4 in the op-ed pages of the Bangor Daily News.  LD4 is a law passed in Maine earlier this year that gives doctors a choice to keep their prescribing data from being sold to the pharmaceutical sales force via a nifty process called “data mining” (more on that here and here).  The law is being challenged by industry and the middle men running the sale, who claim medical data is the ticket to better health care. 

Schaefer and Picker say yes, data matters, but so do the hands it is in, and they think prescribing data in the hands of sales people with a Lipitor quota to hit is hardly a guarantee of better medicine or patient care.

If Dr. Schaefer’s name looks familiar, you might have seen his letter to the editor in the Wall Street Journal on Saturday.

“Frankly,” he wrote, “I am tired of hearing Big Pharma complain. There may be a crisis looming, but it is largely a self-made crisis and not even close to the one faced by patients who haven’t been able to afford their medicines in recent years.”  If you are a subscriber, go here.  And he and Picker have been in the op-ed pages before in support of stopping the sale of prescriber data for marketing purposes.

What to make of Dr. Schaefer’s rising word count? Well, the conversation around conflict of interest is certainly not a new one, but one could argue (and we will) that the debate is heating up. PostScript takes it as a good sign that doctors are joining in as vigorously as Picker and Schaefer have. 

After all, medicine is not just practice but an idea, an ethic, and a critical, if broken, social contract.   Healing patients is good, yes, but healing them and also thinking about how it’s done and how it could be done better – in this case, without the over-the-shoulder help of the pharma’s sales team – is even better. 

Schaefer and Picker are both members of the National Physicians Alliance, a great group of docs and ally of the Project.   Other NPA docs in print (and online) are Daniel Carlat,  Howard Brody, and NPA blogger Chris McCoy.  But the common thread here is not the newsprint, but their self-made roles as citizen MDs.

Let’s be clear; we’re not talking about the long-standing tradition of the doctor-writer, the William Carlos Williams way of putting down the art and science of medicine in poems, or of Atul Gawande, who writes with a definite audience in mind (readers of The New Yorker, for one). 

Instead, Schaefer, Picker, and other physician-advocates like Carlat, Brody, Joshua Sharfstein and Roy Poses, to name just a few, are writing because they believe there are things that need to be said, opposed, and fought for.  As those practicing medicine, they have the twin right and responsibility to do it. And, let’s face it, the letters behind their name to get heard.

Ta-da!

The Prescription Project Weekly Reader,  a weekly email of pharma/conflict-of-interest news in review, is moving to PostScript, where it will appear every Friday,  rain or shine.

If you have been receiving the Weekly Reader by email, we invite you to subscribe to PostScript in the right-hand column, and every friday, the Reader will arrive in your inbox, just like the old days.

And if you are just passing by, we hope you’ll subscribe, too, or stop back on Fridays to catch up.

No shortage of news, though, so let’s start in.

Putting off-label studies on the table

Yesterday we posted here about the FDA’s draft guidance on permitting drug marketers to use off-label studies, but coverage abounds in the Washington Post, WSJ Healthblog, and Kaiser Health Policy Daily Report, to name a few.

and speaking of detailing…

This AP report says that physicians are spending less time with drug reps and more time with online detailers.  According to the report, a research firm recently found that just one-quarter of sales visits actually involved an in-person encounter with the good doc.

“Patients are watching, medical students are watching and it’s just become harder and harder to justify these interactions,” online pharma marketing executive David Kramer told the AP.

Weighing the pros and conflicts

Doctors don’t always adhere to the high ethical standards they hold their profession to, according to a new study in the Annals of Internal Medicine this week.  Though 90 percent said that incompetent colleagues should be turned in, 45 percent said they hadn’t always done so, according to this AP report.

Moreover, a quarter of respondents said they’d refer a patient to an imaging center in which they had financial stake without revealing the conflict of interest.  Our favorite part: The AP reported that 21 doctors cashed the $20 survey incentive check without sending back the  survey.

Here’s coverage at the Boston Globe, Washington Post, Health Care Renewal and Pharmalot, too.

What sort of asssistance is Montel offering, anyway?

Montel Williams pitched critics of PhRMA’s marketing machine (and matching tour bus) a softball this week when he threatened a high school intern who asked whether pharmaceutical companies would conduct as much research if profits were restricted.  In the age of YouTube, this story is even juicier.  Read all about it at Prescription Access Litigation blog, Pharmalot, or WSJ Healthblog.

Osh Kosh, My Gosh

The Oshkosh Northwestern points a finger at Oshkosh orthopedist Dr. Jeffrey McLaughlin, who received $600,000 last year in payments from medical device makers, 45 percent of Wisconsin’s take and the most among state docs and healthplans.

The balance sheets are part of an anti-kickback settlement with the federal goverment earlier this year in which five medical device-makers were required to post payments to doctors and providers in online public databases.

The Kennebec Journal – Morning Sentinel looks again at the prescription data-mining issue. Hearings from a challenge to the law restricting the sale of doctors’ prescribing data through an ‘opt-out’ provision have begun, and the health information organizations that aggregate the data and pair it with pharmacy records are looking for an injunction to the law.

Old and off-label

In a follow-up to last week’s summary of an earlier St. Petersburg Times story, the Wall Street Journal looks at the growing use of atypical antipsyotics in nursing homes and connects it with the 1987 law President Reagan signed that restricted restraint tactics that could be used in eldercare facilities. Sen. Chuck Grassley (R-IA) has begun an investigation.

FDA isn’t tilting at windmills for this one

At least, that’s the word from a new report by the Center for Science in the Public Interest that said finding conflict-free experts isn’t as hard as the FDA said it was last month, when it released the results of its own report on the feasibility of assembling conflict-free expert panels.

In an open letter to FDA commish Andy von Eschenbach, CSPI joined with the National Physicians Alliance, Consumers Union and the Union of Concerned Scientists to call on the FDA to create conflict- free panels as opposed to the patchwork of COI waivers that currently compose the committees. Healthcare Renewal, The Scientist, and Pharmalot all weighed in.

Too different to disclose? drugs vs. devices in MN

In a follow-up to last week’s question about why Minnesota’s drugmaker gift disclosure laws don’t cover device makers, Howard Brody over at Hooked has a few ideas.

“I don’t need a drug rep on site to show me how the patient is supposed to swallow a capsule,” Brody writes.  “Virtually all the information that I need to know about how to prescribe a drug could be provided to me in writing. For many devices this is not true.”

A banner year for safety breaches, and a bad one for pharma

Hats off to Pharmalot for pointing out this “Top Ten Drug Warnings and Recalls of 2007″ from FiercePharma.

And it this makes you nostalgic, here’s a new WSJ report on an old refrain: Big Pharma’s prospects are drooping as economic, management and regulatory models shift. Bonus gloom and doom: you may need a subscription to read this one.

This week, the FDA issued a draft guidance that could, if adopted, change the contents of the drug rep’s briefcase.  It will free up the industry to distribute studies of drugs for off-label indications.  That’s a concern.

Of course, many off-label uses are medically appropriate. Once a drug is on the market, there is nothing to stop a clinician for prescribing it for any indication he or she sees fit. Providing there is good evidence to support those prescriptions, we support that. But do we really want pharmaceutical marketing mavens pumping up the volume?

Right now, drug reps are prevented from promoting drugs for off-label uses. So whatever the quality of the information they provide, we at least know that the FDA has established that this particular use of the drug has some merit.

The argument for changing the system, presumably, is that companies can play a role in “educating” doctors about peer reviewed studies. But peer review is no guarantee of quality.

As a general rule (very, very general), the most important, best-designed studies show up in first- and second-tier journals. But a slew of minor peer-reviewed rags exist to snap up the remaining vast quantity of unbelievable rubbish. We’re talking about studies that are badly designed, lacking appropriate endpoints, outcomes, comparators, randomization, blinding, follow-up, analyses and conclusions – sometimes all at once. The good news is that nobody reads most of this junk. It gets published in minor journals and serves mostly to pad out CVs and grant applications.

But what if America’s 100-thousand-or-so drug reps were to load up the trunks of their cars with these studies and start driving around, handing them out to doctors? That would be bad — especially if they were using these studies to promote off-label uses of their drugs (that is, indications that the FDA has not reviewed or approved). And yet, that is precisely what the FDA’s new draft guidance is proposing to allow.

What on earth would prompt the guardians of the nation’s drug safety system to invite industry to reach into the Pandora’s box of crap studies for unapproved uses and, well, start selling?

That’s the question that Representative Henry Waxman is asking. We await the answer.

Right now, Dr. Daniel Carlat’s article, “Dr. Drug Rep,” is sitting atop the vaunted Most E-mailed list on nytimes.com.  Featured in Sunday’s New York Times Magazine, Dr. Carlat’s narrative recounts his year as a paid speaker for Wyeth Pharmaceuticals and its depression drug, Effexor.  Carlat, a psychiatrist with a practice in Newburyport, MA and author of a great blog, spins an intriguing tale complete with dialogue, disillusionment, and Broadway glitz in four parts.  If you haven’t already read it, chances are someone has sent it to your inbox.

No doubt: We are a list-crazed culture. From the fatalistic travel book series 1000 Places to See Before You Die to the Seven Habits of Highly Effective People to Casey Kasem’s American Top 40, we are a people in love with the list.  And “Most E-mailed” at nytimes is no exception, showing a real-time ranking of the stories being sent (and to extrapolate, being read) most frequently from the New York Times website.  “Most E-mailed” has been elbowed as an echo-chamber metric, perhaps most charmingly by The Onion, which reported in April that the coveted top-ten was tearing the New York Times newsroom apart.

But despite this and other “real news” criticisms, nytimes.com “Most E-mailed” has become the sidebar to watch for what people are talking about around the web-based water-cooler.

And what they are talking about today is Carlat’s “Dr. Drug Rep.”  Over every other Times news story.  We read this as a really good sign that pharmaceutical influence on doctors—the economics of it, the tactics, the pervasiveness (Carlat cites a report that estimates about 25 percent of U.S. physicians receive money for speaking about or helping to market drugs)—is at the top of readers’ minds.  And though we’re biased, we think that’s where it should be.

The blogosphere is also a-flutter with Carlat’s confessional (the story is currently at #8 on the Times Most-Blogged tab), and is yielding some interesting side stories, including a comment on Pharmalot from an ex drug rep who says that some pharmaceutical reps just go through the motions of setting up speaking engagements and ‘ghost-dinners’ under pressure to spend their speaking budgets. More blogs here, here, and here.

All of this buzz comes along as more and more legislation is being introduced at the city, state, and federal level to alter the way drug companies court and co-opt doctors.  Recent headliners include the Physician Payments Sunshine Act, similar legislation slated to be introduced in the House, Maine’s data-mining restriction bill, and the Safe Rx Act being considered by the D.C City Council.  It’s a natural feedback loop, and the volume is growing. 

Does all this add up to our nation taking stock, just as Carlat did, about the ethics and consequences of our relationship with medicine and the pharmaceutical industry, and the relationship we permit between the two?  Perhaps.  Or perhaps it’s too a big leap to see the patchwork of moves by individual, corporate, academic, and public healthcare stakeholders as the actions of a united, albeit clumsy, moral agent.  Either way, it seems we can read the growing policy and media attention—measured in bills and newspaper inches and airtime—like a loudening macro version of the silent internal dialogue Carlat describes having with his conscience after each Wyeth talk he gave. 

It will be interesting to follow this story and see whether this interplay among policymakers, press and the public concludes, as Carlat’s tale did, in a collective, incremental “No Thanks.”

Then Shakespeare might have enjoyed these 5-minute videos from PharmedOut.  Dubbed “Pharma Insider Parts I and II,” former insider Doug Melnick, MD MPH talks with Pharmed Out’s Adriane Fugh-Berman, MD about off-label prescribing and competitive intelligence. 

And the bard meets YouTube.

Exeunt.

Howard Brody is a professor of family medicine and director of the Institute for the Medical Humanities at University of Texas Medical Branch in Galveston, Texas.  Prior to joining the faculty at UTMB, Dr. Brody was a professor of medicine at Michigan State University and director of the Center for Ethics and Humanities in the Life Sciences.  He holds an M.D. and Ph.D. in Philosophy from Michigan State University and has written five books, including most recently Hooked: Ethics, the Medical Profession, and the Pharmaceutical Industry.  Brody, a member of the National Physicians Alliance, also keeps the Hooked blog, a terrific companion to the book which tracks medical conflicts of interest in the news.  

PS: You do a good deal of touring and giving talks about the ethical conflicts between medicine and pharmaceutical dollars. Do you get the sense that the medical students you encounter are the right amount of worried about pharma influence?

HB: Well, among general audiences, there’s always the question of preaching to the choir.  But it seems from the talks I give that those who didn’t see this as an issue before are more concerned and engaged now. I sense an amount of general commitment increasing, and actions being taken to do something. 

For instance, when I did Grand Rounds at the dept. of medicine at UC Irvine a few weeks ago, they told me they had already ended all drug lunches a couple of years ago. I talked to some med students who were having trouble convincing the administration, but on the other hand they were already engaged in doing something.

PS: You mentioned general audiences: is public outrage and involvement key to this movement?

HB: Well, a superficial look might indicate it’s not the public’s business. From that standpoint, this is an issue of medical professionalism, an internal matter for physicians to decide. But at the next level we say: okay, this absolutely has to do with public trust. Physicians should be making decisions based on science and their patients’ well-being, not which rep just took them to dinner last. The public ought to be able to trust that your physician can trust what he reads in the med journals, and that the content there hasn’t been influenced by who buys the ads.

So there needs to be a dialogue with the public eventually. We have to turn to them and say, “If we do these things, will you trust us?” 

Reform has to be a two-pronged thing. First, a professional level of reform: individual physicians growing a certain underdeveloped piece of anatomy….we need our professional spines to be strengthened. And the second piece is regulatory reform: We need to take back medical research from the pharmaceutical industry. There’s got to be some accounting for the bennies that these contract research organizations and investigators get from the drug companies. 

The public simply cannot demand further tax cuts unless they confront the fact that they are selling medical integrity to the hands of private industry.  I think that means we are going to have to pay so that science remains a public good, and not property of the commercial outfits.

PS: Do you consider yourself a doctor or ethicist first? Did you have a wakeup call that linked the issues for you, or is your interest in bioethics just the transfer of a worldview into academic pursuit?

HB: Fast backward: I’m in med school, it’s the early 1970s and students are uppity, they’ve been throwing their weight around.  When stuff comes in from the drug companies, there was a vocal group that said we don’t want this stuff, maybe it came from a general distrust of traditional authority. In a drawer at home I still have my Eli Lilly stethoscope that I was given my first day of medical school—so I’m not saying I was totally pure about that stuff back then. But somehow, as a med student I got the idea it was not a good use of my time to see drug reps. 

During my residency in family medicine at Virginia, each resident rotated for two months as head resident at the clinic, which meant you saw every drug rep that came in.  At that time, we gave out a lot of stuff from the sample cupboard. I told my chief I wasn’t really into seeing the reps.  And he said tough, it’s your job.  So okay, I said, for two months I’ll have to see all the drug reps, and this is my chance to see what I’ve been missing.  I had already finished my Ph.D. in bioethics but it wasn’t about this–these issues just weren’t on my ethic radar screen yet. There was one rep out of all of them that might have taught me something, but that’s it. One. It seemed it’d be a much better use of my time to spend that same time reading The Medical Letter.

Over the years, I served on a residency committee on industry relations and became known as anti-drug rep for trying to push policy in that direction. At no time was I thinking this is an ethical issue; this is just me in my medical existence.

But then in 1997, I read Drummond Rennie’s editorial, “Thyroid Storm,” which described the saga over publication of an article on generic vs. brand-name levothyroxine that showed that the generic was equivalent to the brand name. The article was blocked for four years by the brand name manufacturer, Boots-Knoll. At one point JAMA tried to resolve the impasse by seeking independent reviewers to referee the paper, and in this editorial, Rennie noted that it was extremely hard to find any thyroid experts in the U.S. who were not paid consultants of Boots-Knoll.

I had no idea that the waterhole of science was so polluted by industry funding. I thought: “Where is this in the bioethics literature?  I’ve got to get involved here.” And that lead to [writing] Hooked. 

But it took me awhile for the ethics piece to come on board with the doctor piece of my thinking.

PS: Has this issue begun to get attention in bioethics?

HB; Yes, I think so. There was a panel on these topics last year at the American Society for Bioethics in the Humanities. So that barometer would suggest that some people are working on this.
 
PS: Why only now?

HB: For too long, it appeared all we were talking about small scale stuff: pens, lunches, that sort of thing.  But then the article, “All Gifts Large and Small” (Katz, Mertz, Caplan. “All Gifts Large and Small,” American Journal of Bioethics 3(3):39-46)  came out, and that paper was a pivotal moment because it demonstrated that we are not just talking about pens and coffee mugs, we are also talking about principles. 

In writing Hooked, one of the things I thought was important to do is get at: how did this all happen? And I found the degree by which the pharma rep and the investigator rose up as dual presences in American medicine was very gradual—a case of the proverbial fish not noticing the water. Physicians and ethicists both were lulled because it was such a gradual intrusion.

Renee Rulin, Medical Director at Commonwealth Care Alliance and a clinical professor of family medicine at Brown University, talked to PostScript about the way pharmaceutical companies affected her days in private practice, and the work CCA is doing now.  She says that just showing up is often the biggest weapon in a drug reps arsenal.

PS: As medical director of Commonwealth Care Alliance, how does pharmaceutical marketing influence the work you do?

RR: Well, as vendors for Medicare and Medicaid, we have a pretty standard formulary, and we negotiate with the drug companies through our Pharmacy Benefit Manager.  So the pharmaceutical companies interact with our PBM, who then selects drugs for the CCA formulary based on our requests.  But a lot of times the way drugs are “bundled” by pharmaceutical companies creates a formulary based more on cost than clinical relevance. 

Despite this, our formulary is broad and follows our philosophy of giving all the authority and decision making back to the doctor, who does the best job of patient care.  We want to get the doctors free to do what they do best.  We really try to get out of the way.

PS: So do doctors make their own decisions about drug reps, or does CCA have a policy?

RR: CCA does not have such a policy.  Our docs make their own decisions.

PS: As a physician and a professor now at Brown, have you seen any shift in how the pharmaceutical companies operate throughout your training and teaching?

RR: Over time, AMCs have really tried to keep Pharma out.  Faculty have begun to see the magnitude of influence they exert in teaching hospitals and in the wards, and are making efforts to replace drug rep visits and CME with real teaching, evidence-based teaching.

But when I was in private practice, every pen was from a drug company, every post-it note.  And that’s true in every private practice, you always end up in a negotiated relationship with the drug reps.

PS: In every practice?  What do you mean by a negotiated relationship?

RR: They would just show up constantly–constantly.  They just sail in, sweet talk the receptionist.  “Can I see the doctor?”  You try to restrict them as much as possible, but they bring lunch for your staff, chocolate chip cookies, and the samples, of course.  I mean, it’s like a gift to have some one show up and  tell you something you want to and need to  know, on your schedule. 

They are generally attractive, well-dressed, and articulate and mostly they are there, willing to talk to you whenever you have a minute.  And all of that is very attractive.  So you sort of delude yourself, saying you’ll pull out those nuggets of information you can use and ignore the marketing.  And it is, it’s a delusion.

Frankly, the docs tend to like that conversation; they like to hear from drug reps.  I think that if academics could counter-detail in the very same way–to really meet docs where they are–they’d do very well.

PS: So when it comes to Academic Medical Centers, you mentioned you see somewhat of a turning tide.

RR: Yes.  They are much more conscientious about keeping out the drug representatives—all the time. 

For instance, the Family Care Center at Memorial Hospital (Brown Family Medicine Residency training program) does not allow pharmaceutical reps into the clinic.

PS: Did you have any particular interactions with drug reps that stand out?

RR: I was no longer a resident, I was a clinical precept, but the reps brought in a lasagna for the whole teaching hospital and gave half of all family medicine residents salmonella.  Half the staff couldn’t work for two months.

Then there are docs that say, “I read the Medical Letter, and I let the drug reps in.”  And I think there are probably people who do that—who get their information independently, take their food and free samples, maybe argue with them.  But I think they are the exception, not the rule. 

PS: So beyond the Medical Letter, are there other good alternatives to detailing out there?

RR: Yes, I think that information is out there: online, in organized courses, in publications such as the Medical Letter.  The thing about drug reps is they just show up, and they have goodies.  And it’s tough to push back against that, it just is.

Elissa Ladd’s career as a nurse practitioner has run parallel to the nursing field’s entry into the prescribing world.  Ladd, who holds nursing degrees from the University of Pennsylvania and Rush University and a doctorate in health policy and nursing from the University of Massachusetts, is now an assistant clinical professor of nursing at the Massachusetts General Hospital Institute of Health Professions.  She recently received a $400,000 grant from the Attorney General Consumer and Prescriber Grant Program to create an education program to teach advanced practice nurses about pharmaceutical companies’ influence on prescribing.  

Ladd talked with PostScript about her time in the classroom and the exam room, and how she’s seen pharma pay increasing attention to nurse prescribers in both. 

PS: How does the pharmaceutical industry interact with the nursing profession? Does it differ from industry interaction with physicians?

EL: Throughout my career, I’ve watched the evolution of prescribing influence on nursing grow.  When I first started practicing as a nurse practitioners, most NPs across the country didn’t have the statutory authority to prescribe yet—we would be practicing, and we’d get scripts from physicians.  About 20 years ago, NPs began to gain prescriptive authority on a state by state basis.

PS: So how wide does nurse prescribing power extend?

EL: Nurse practitioners can now prescribe in all 50 states, as can a group of advanced practice nurses (APNs), which includes psychiatric nurse specialists/clinicians, nurse anesthetists and nurse-midwives.  And that whole group of APNs who prescribe – 150,000—is comparable to the number of family practice physicians practicing in the U.S. today. So we are a sizable force, and Pharma has begun to recognize that.

For the last decade, it’s been interesting to watch the drug company influence grow.  Drug detailers are heavily, heavily targeting NPs now.  It’s the same thing as physicians — annual meetings, continuing education.  And even though there’s been a lot written in the press, I think it’s going to be a developmental process for our profession, because we haven’t had prescribing authority as long as doctors have. Advance practice nurses are now getting  a lot of attention from pharma, and they are enjoying the recognition in a sense, but it’s, you know, perverse. 

PS: In the course of your training and career, when did you become aware of the relationship between the drug industry and the medical profession?  Was industry present in nursing school? 

EL: Well, there wasn’t any pharmaceutical influence during my training at nursing school.  We took pharmacology, but that’s about it.  We didn’t have prescriptive authority, and though it was understood to be just a matter of time and regulation, industry influence was never an issue.  The same is true today: they really haven’t injected themselves into NP training and nursing school, and Im not sure the reason for this – it could be now that pharma influence in medical schools is being scrutinized more closely.

PS: In your view, what is the most worrisome part of the pharmaceutical industry’s relationship with prescribers?

EL: Continuing Education. Absolutely.

PS: Why?

EL: CE is required in order to maintain your nursing license and nurse practitioner certification, just as CME is for physicians, and many times the ones that are free are offered by pharma—and that means pharma provides the speakers.  There’s clearly a conflict of interest operating in this system, and people are really naïve about that.  They can get CE credits and go to these sponsored luncheons.  The problem is that most people think it’s educational, but the programs are really biased.  It’s a veiled process of marketing that people don’t acknowledge or understand, but it’s clearly marketing, nonetheless.  I just think a lot of people aren’t even at the point of acknowledging it.  But both nurses and physicians are very influenced by industry-funded continuing education programs.

PS: Are there alternatives?

EL: Yes, you can find industry-free CE programs, but you have to go looking.  The thing that concerns me is that a lot of the industry-free content  is for CME, not CE, which is what nurses need to get recertified.  I know there are some NIH ones.  But I’d say overall it’s probably less available for nurses than physicians. 

PS: You’ve written that there is a dearth of literature about pharmaceutical influence on your profession—have we missed an opportunity by not paying enough attention to industry relations with nurses?

EL: As I said, nurses are still a bit naïve about this whole thing, since prescribing is a relatively new aspect of the profession.  Physicians are naïve, too, but also in denial.  Oh, it doesn’t influence me, you hear them say.  But of course, pharmaceutical companies aren’t stupid, and they wouldn’t be spending billions unless it influenced practices.  So they know, but they don’t want to know. 

PS: From your vantage as a professor and clinician, do you see this relationship between industry and medicine changing?

EL: I do think there is a tremendous momentum around this.  I think that there’s not only an individual awareness, but policy-wide awareness is growing, too.  Academic Medical Centers are leaders in terms of practice issues, and I think changes there will really trickle down into smaller practices and hospitals, and filter into the NP community as well.  Whether people like it or not, I think the culture is changing. 

PS: A recent survey by the Center for Congressional and Presidential Studies at American University reported that 82 percent of Americans trust the FDA to oversee medication approval, 67 percent trust drugmakers, and 53 percent trust Congress.

In your opinion, how much unrealized public outrage is out there to be harnessed?  And is public outrage—grassroots anger—necessary to move this issue?  Whom must we convince?

EL: There have been some interesting studies that have asked patients: “Do you know your doc takes gifts from pharmaceutical reps?”  It’s funny because most of the patients didn’t know that, and they are angry once they find out.  I see a shift happening at the physician and medical center level.  But once consumers become more aware, I think there will be even a larger shift.

The Attorney General Consumer and Prescriber Grant Program [of which Ladd is a recipient] will be awarding a grant to a consumer education project on these issues in the coming months, which I think will help patients  become more involved in this issue, too, the way they did with antibiotics.

PS: A shift in antibiotics?

EL: Once the public learned that about bacterial resistance – from their doctors and the CDC guidelines issued in 2001 about antibiotic overuse – we saw a lot of awareness, a big decrease in prescribing, especially among pediatricians.  It was a significant shift.  That’s an example where the docs, especially pediatricians, have done a very good job of changing their own culture. 

PS: What has been your most memorable experience with pharmaceutical reps or marketing? How did it change the way you practice or prescribe?

EL: It was a couple of years ago and I was working at a family practice, with two docs.  I had never seen so much drug paraphernalia—it was plastered all over the place, down to the paper on the exam table.  It was like the Nexium ad or something.  He couldn’t even buy his own exam paper?  I mean, that’s pretty in-your-face.  I’ve actually seen it on toilet paper, too.

And this practice was getting free lunches every day.  Every day!  And you listen to a talk while you eat.  You don’t really think about it initially.  But one day, I did start thinking: Wait a second, they’re doing this every day, and I just didn’t feel right about it. So I decided I wasn’t going to go to the next lunch.  One of the docs passed me on his way there. 

“Don’t you want to get some lunch?”  I said no, I was just going to stay and work on my charts.  Then there was this silence, probably ten seconds.  “It doesn’t affect what I prescribe,” he said.  “I just go in there and eat their food.”

But ultimately, it’s the patients that pay for those meals, in the form of higher cost drugs.  It was a cascading clarity that I got about this issue.  It’s all unconscious, that name recognition.  It works for drugs, for cars, for washing machines.  It works for refrigerators.  It just works.

The amazing thing to me is that we know this happens.  We know.  They wouldn’t be spending what they spend if they weren’t getting some return.