November 2, 2010

A Case Study On Why Policy Changes Fail: Pharma Paying Docs

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The authors report no conflicts of interest

The point here isn't to weigh in on the Pharma debate but to illustrate what's wrong with how Americans get things done.

Two reporters' investigations into docs who speak for Pharma have found:

  • Fewer than half are formal educators affiliated with academic medical centers or prominent leaders in their medical societies. The rest are a mix of physicians with limited credentials or about whom little could be gleaned.
  • Five of the top 43 are from Tennessee
  • Eleven of the 43 have board certification in the small field of endocrinology... Eight physicians, the next-largest subgroup, hold no advanced certification, despite speaking on specialized diseases and treatments.
  • Only three of the top earners are women--all endocrinologists
  • More than half worked for two or three companies. One Tennessee diabetes physician worked for five. Seven earned money solely from Glaxo.

A different article goes into more detail:

And in Georgia, a state appeals court in 2004 upheld a hospital's decision to kick Dr. Donald Ray Taylor off its staff. The anesthesiologist had admitted giving young female patients rectal and vaginal exams without documenting why. He'd also been accused of exposing women's breasts during medical procedures. When confronted by a hospital official, Taylor said, "Maybe I am a pervert, I honestly don't know," according to the appellate court ruling.

Last year, Taylor was Cephalon's third-highest-paid speaker out of more than 900. He received $142,050 in 2009 and another $52,400 through June.

The underlying principle is, "Docs should not accept money from Pharma."  If this is indeed what you believe, then you should look upon these reports and articles with dismay: they're helping Pharma.


II.


I have to wonder if as they uncovered all this stuff, there wasn't a sense of glee, rubbing the hands together like Perez Hilton does when he discovers Lindsay Lohan's gmail password.  (It's "velveteengirl")

But that's all besides the point.  While this information is interesting and salacious, it is masturbation: purposeless and for yourself only.  From a (Machiavellian) policy perspective, the thing to do would be to bury this info about bad doctors, not publicize it. 

Approaching this from the "bad/crazy/uncredentialed docs speak for Pharma" angle changes the focus from the noun (docs) to the adjective (bad/crazy).


diagram pharma.PNG

This happens all the time in political debates, which is why nothing gets done. 

Because the outcome you've guaranteed is that Pharma tightens their speaker's bureaus-- and only uses top tier academics.  So if you are worried your doc might give you Depakote because he gets paid by Abbott, imagine what will happen when your doc is told to use Depakote by the academics who write the journals and the reviews, who are paid by Abbott.   You don't have to imagine it, you just have to remember it, 1999-2006.  Were you on Depakote?  Yes.  Did your doc speak for Abbott?  No.  Enjoy your liberal democracy.

"Well, it shames the docs so they don't accept the money!"  Why would it shame them?  In fact, it gives them a defense.  "Since I'm not bad or crazy, since I do good clinical work, since I am not doing vaginal exams, therefore I can take Pharma money."

You can extend this to any social or political question.  There's an internal sense of "rightness" or "wrongness" to some issue, but lacking the information, logic, or simply the skills to defend the position, people resort to a core dump.  They hope that either something will stick or the volume of criticism will speak for itself.

But it doesn't, it allows the other side to counter with logical, precise, and legitimate fixes to your myriad of complaints-- all while keeping the main premise intact.  "Ok, we shouldn't pay docs to speak, we'll only pay them to write." 

If you think using oil is bad for the environment, don't say that it also leaves us beholden to terrorist nations.  I know you think that helps your case, but it doesn't, it gives the other side a straw man to ignite.  Argue from principle.

Arguments with your spouse go bad for the same reason.  Her chronic lateness is the problem, but you bring up her past infidelity, cooking skills, bitch friends, etc.  Result: you've just given her three new options for a counterattack.  If she can effectively defend any one of them, you lose the entire argument.  "My husband is an ass."  She's kind of right.

III.

The problem is that the principle is often a cover for more base instincts.  Put down your Diet Coke for one second and really consider what I am about to tell you.

While considerable investigative journalism went into finding out how much money speakers earned, their backgrounds, disciplinary actions, CVs, etc, not one single reporter has actually listened to one of their presentations.  Think about this.  Not one reporter thought it important enough to investigate what they said.

No one's even interviewed an attendee.  "Hey, what goes on in there?"

That should be your signal that they don't care what was said, what matters is the money.  Which makes this much less about Pharma influence on medicine, and much more about  class warfare: why should they get to have so much money?

While I completely understand the sentiments, this approach, let alone this sentiment, won't make patients feel better or healthcare run better. (Which is why the solution I offered-- simply making it illegal to accept any kind of Pharma money, at all-- is the most honest way of approaching it.  But, as I pointed out, it will have some consequences society may not be ready to accept.)

If it's class warfare you're going for, be honest about it.  Just say you don't like docs getting paid so much, period, or you don't like taxes so high, or so low, end of story.  You hate  welfare handouts.  You hate how investment income is taxed at half the rate of earned income, it seems unfair to you.  At least these are arguments that everyone can participate in because they're honest, they are your true sentiments undisguised by intellectualization. If you're ashamed to say these things, however, then perhaps you need to ponder why you believe them.

If you pretend-- even to yourself-- that it's really about Pharma causing doctors to do something they wouldn't/shouldn't do, then you have to explain how this happens.  I'm not saying this is a hard thing to do, either, but it must be done, it's not enough just to say it. 

But, and this is the point, if you have not really be honest about your principle, once you explain your reasons the other side will quickly dispatch a series of remedies which legitimately address each of your complaints, all while leaving the underlying principle untouched.  And yes, now I'm talking about today's elections.


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You might also like:

Ten Things Wrong With Medical Journals

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Comments

I really enjoy your posts, ... (Below threshold)

November 2, 2010 12:27 PM | Posted by MH: | Reply

I really enjoy your posts, Alone. Thank you for writing them.

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Alone, you're quite right t... (Below threshold)

November 2, 2010 1:25 PM | Posted by Ben Zod: | Reply

Alone, you're quite right that the big story is not the perviness (et cetera) of certain docs who take pharma money--graphically described, of course, in all its wanky detail. Creeps and badasses walk among us. We all know this, and fixating on it just dilutes and destroys the argument. Agreed.

But... the suggestion that the reporters don't much care about undue pharma influence, and that their real agenda is to attack the rich? Come on.... The distortion of objectivity, or even a facade of objectivity, by pharma dollars is old news. It's been documented and proven fifteen ways to hell. In 2010, we can take it as read: docs who receive money from pharma are pissing acid on the truth. Maybe it's just a dribble, but the fact remains.

At this stage in the game, the reporters are not seriously obliged to attend professional education dinners and take notes. They do not "have to explain how this [warping] happens". We already know how it happens! We know it in painful, academic, nit-picking detail. There is no need to go over it again, and failing to do so does not indicate that one is (subconsciously?) a class warrior masquerading as a medical journalist.

So you're quite right that the reporters "don't care what was said, what matters is the money." Damn straight. Because the reporters know with certainty that the money distorts professional conduct. Everyone who cares knows this by now; the studies have been done and they're solid. Omitting the details of "how this happens" does not warrant your conclusion that the reporters are in truth envious little crybabies looking to eat the rich. Sure, we don't need the all the prurient details. But we do need to know about the money. And that doesn't mean we're jealous. (I mean, seriously.... $142K? In 2009? That's supposed to turn us green?) No, the money definitely matters. But it's not the quantity that's significant--it's the provenance.

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Abbott is one of the larges... (Below threshold)

November 2, 2010 3:51 PM | Posted by Anonymous: | Reply

Abbott is one of the largest manufacturers of Baby Formula...

The two largest countries with the worst maternity leave policies are Switzerland and the United States... where Abbott and Nestle manufacture their formula.

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I don't think it's the jour... (Below threshold)

November 2, 2010 5:37 PM | Posted by acute_mania: | Reply

I don't think it's the journalists who are envious. They just know their target market. 6 figures is a big deal for most Americans, which is why repealing the tax cuts only for families making $200,000 or more was such an easy sell.

I remember an article from 2007 in the NYT about a greedy psychiatrist who took $200,000 over the course of 5 years from j&j. When asked why, he replied "my university position doesn't pay me enough". It was followed by in the story with "Dr Soandso's salary was $116,000 in 2006." They're were obviously trying to make him look greedy, but it really didn't seem like a whole lot of money to me, especially for a doctor. But the class warfare side really makes sense now.

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I find it incredible a "phy... (Below threshold)

November 3, 2010 12:57 AM | Posted by Anonymous: | Reply

I find it incredible a "physician" can get away with sexually assaulting patients (which is pretty much what a diagnostically irrelevant vaginal & rectal exam is - it is assault, sexual assault, no different than someone on the street raping you)... and not only does this "physician" never face any sort of criminal charges, but it takes THIS LONG for the piece of shit to lose his practicing privileges in his hospital? Holy fucking shit. Puking in my mouth R.N.

Why didn't any of those women report him to the authorities? If I go to a doctor for an ear infection and he insists on doing a vaginal exam, you better believe once I got my shit together (as I imagine they would be shocked at least a few days wondering what happened in there) I would report it to police and I wouldn't stop until some kind of investigation occurred.

Having a hard time focusing on the rest of the post at the moment, still shocked about this rapist physician, raping patients, and all that happened was his hospital declined to use his services. Still practicing. Still sucking pharma's tit.

This motherfucker needs to be shot in the head, stat.

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Re 3:51...Then Abb... (Below threshold)

November 3, 2010 1:16 AM | Posted, in reply to Anonymous's comment, by Anonymous: | Reply

Re 3:51...

Then Abbott can sell the kid depakote when he turns 16 and has his first manic episode, due to not having enough breast milk as an infant, resulting in any genetic susceptibility to mental illness becoming manifest.

ALL, THE PIECES, THEY FIT.

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Alone is crying IRL because... (Below threshold)

November 3, 2010 1:31 AM | Posted, in reply to acute_mania's comment, by Anonymous: | Reply

Alone is crying IRL because of the response I wrote (in the previous entry) where in which I said doctors do not deserve more money and are not entitled to it.

I suppose this idea shocked him so much he had to make a whole blog entry describing how people are jellin' on the $$$ doctors make.

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LOL, "families" making 200,... (Below threshold)

November 3, 2010 1:31 AM | Posted, in reply to acute_mania's comment, by Anonymous: | Reply

LOL, "families" making 200,000? Like your wording, AM. You did a bang-up job painting a picture of the evil government stealing milk from your infant son's mouth. No "family" requires that much money to live. Any "family" can live with far, far less than >200,000 and still live extremely well and go to good schools and stuff.

I make between 50-60k before taxes, and I live in new jersey. I consider my income to be roughly middle class. If I were making 3-4xs my salary, I would definitely be upper class. Don't sell me a load of bullshit that 200,000 is not a lot of money, 200k is definitely UPPER class, even in new jersey/new york area. Maybe it isn't if your cost of living is way out in space, in which case I would suggest you stop renting summer homes and stop owning multiple new cars and get a cheaper cable package and not to purchase a giant house you can't afford. Retard.

Maybe Dr Soandso only made 116k because of the path he chooses for himself? maybe if he did private practice and made rounds at hospitals and actually WORKED HARD he could bring in way more than 116 k? Maybe Dr Soandso is a lazy bastard who only works at a university, yet unrealistically expects to make as much as a top cardiac surgeon who is a type A personality? Everyone knows teaching pays less than practice.

Or, maybe the NYT article only showed half the story... maybe Dr Soandso made 116k doing university work, but they neglected to mention the income he brings in by working at hospitals and having a private practice. Most doctors have their hands in multiple ventures. If you had unlimited potential to earn money (limited ONLY by how often YOU CHOOSE to work)... wouldn't you also?

Either way, it isn't about class because most americans do not think 116k is an outrageous sum for a physician. Most americans would read that and think "116k is a lot of money but not considering the person is a doctor".

The NYT didn't have to make him look greedy. The fucker IS greedy. When anyone says "116k isn't enough money", that person isi greedy. TLP wants us to be honest, but that goes both ways (for whining professional physicians, the honest statement would be "116k isn't enough money FOR ME"). The honest statement is "I can live comfortably on 116k but I want to make tons and tons of money, can you blame me?"

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Alone I appreciate your vei... (Below threshold)

November 3, 2010 2:22 AM | Posted by Anon: | Reply

Alone I appreciate your veiled political innuendo, but help me out here.
Maybe explain to me exactly how this relates to todays election? Who is the doctor? the Journalist?

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Alone I appreciate your vei... (Below threshold)

November 3, 2010 2:23 AM | Posted by Anon: | Reply

Alone I appreciate your veiled political innuendo, but help me out here.
Maybe explain to me exactly how this relates to todays election? Who is the doctor? the Journalist?

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When anyone says "116k i... (Below threshold)

November 3, 2010 11:05 AM | Posted, in reply to Anonymous's comment, by Reader: | Reply

When anyone says "116k isn't enough money", that person isi [sic] greedy.

Or that person is strapped with a mortgage worth of student loans so they could "get a good job." (Doctors graduate with an average of $100,000 of student loans, or $1200 per month of payments.)

Or that person needs to buy a mortgage's worth of pharmaceuticals every month (which cost so much so Pharma can keep paying docs to hock the latest medi-gadget).

Or that person gets their income from a small business. (Illinois: 116,000 - 15,600 [SS 13.5%] - 1,740 [State #1 1.5%] - 3,480 (State #2 3%] - 17,400 [Fed ~15%] = 77,780 per year)

Everything is relative. Of course, you could argue that the person-in-question made the choices that made a low six-figure income "not enough," but that doesn't change anything. If the money coming in

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A doc makes a lot of money ... (Below threshold)

November 3, 2010 11:53 PM | Posted by Jack Coupal: | Reply

A doc makes a lot of money making sppeches to other docs about some med. Does the doc have to be a credible speaker about the medicine? Does the speaker answer audience questions about the med to the audience's satisfaction?

If the doctor makes a fool of herself in front of the medical group, will she continue to be a high paid speaker for Pharma? I didn't think so.

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I know this is reall... (Below threshold)

November 4, 2010 9:31 PM | Posted by air max 90 premium: | Reply


I know this is really boring and you are skipping to the next comment, but I just wanted to throw you a big thanks - you cleared up some things for me!

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Donald Ray Taylor is quite ... (Below threshold)

November 5, 2010 1:23 PM | Posted by acute_mania: | Reply

Donald Ray Taylor is quite a character. He managed to convince the hospital board to agree to rehire him provided he was seeing a psychiatrist who specializes in "Medical Sexual Abuse Disorders" and showing compliance with the treatment plan. In the meantime, he got to keep his admitting privileges at the hospital, even though he wasn't employed there and was a liability. After unsuccessfully appealing the the board's decision 3 times, he sued them. His own psychiatrist testified against him and the court ruled in the board's favor.

http://www.propublica.org/documents/item/11132-donald-taylor-georgia-appeals-court-ruling

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Well that sounds like a NPD... (Below threshold)

November 5, 2010 4:08 PM | Posted, in reply to acute_mania's comment, by Anonymous: | Reply

Well that sounds like a NPD in action!

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who gives a shit about how ... (Below threshold)

November 6, 2010 8:59 PM | Posted by America: | Reply

who gives a shit about how much these people earn.

#1 rule in journalism- follow the money.

not because you want to foment class warfare. BUT BECAUSE YOU WANT TO FIND OUT WHY THE SYSTEM IS SO FCKED. and when you get to the end of the rainbow and find the elusive leprechaun with his mysteriously huge pot of gold, you can count how much fckn gold it takes to corrupt people, to influence decision, to get highly educated brilliant people to promote and sell FCKED- FDA studied and approved (for off-label use and not)- product (see: vioxx, depakote, celebrex, zyprexa, help me out here theres more).

AND THEN YOU PUBLISH THIS INFORMATION TO LET THE PEOPLE KNOW....not because you want to project your so-called jealousy and class-based resentment (because everyone knows that journalists working for non-profit d.c. based Pro Publica grew up in shithole city, mississippi and therefore not only wanted to kill themselves but were dirt fckn poor and taught to blame overeducated northeast liberal elitist professionals for their socioeconomic predicament ) ...BUT TO LET THE PEOPLE KNOW HOW IT WAS THAT THEIR DOCTOR WAS LED TO PRESCRIBE THEM FCKED, FRAUDULENTLY OVERPRICED (and in too many cases, LETHAL) MEDICINE.

You then hope that your tireless undervalued investigative efforts result in your readers taking action to reform what has become a corrupt and untenable system. ultimately, your tracking and publication of this information has helped to save the nation from its increasingly speedy downward path to burning hell. complete with a disturbingly high population of homeless people, also known as bums (seriously, has anyone been to San Francisco lately? or Boston?).

FCK, ALONE. WHERE DID YOU GO WRONG ? YOU ARE SMART AND CHARMING AND ACCOMPLISHED AND PROBABLY VERY GOOD-LOOKING AND THEREFORE WORTHY OF BRINGING HOME TO MOM, BUT YOU HAVE LET ME DOWN WITH THIS POST. PLEASE REFUTE EVERYTHING I JUST WROTE SO THAT I CAN GO ON WITH MY BELIEF THAT YOU WILL HELP SAVE THE WORLD FROM TOTAL AND COMPLETE BROKENNESS AND THAT SOMEDAY WE WILL SERENDIPITOUSLY MEET WHILE CATCHING THE SAME PLANE EN ROUTE TO NEW YORK- I TO ATTEND A CONSTITUTIONAL LAW CONFERENCE AT COLUMBIA LAW SCHOOL, YOU TO MEET WITH YOUR SNOBBISH LITERARY AGENT- THE TRUTH OF LOVE AT FIRST SIGHT WILL BE PROVED, YOUR AWFUL CYNICISM WILL CONSEQUENTLY VANISH, WE SHALL EVENTUALLY MARRY, HAVE A BIG EXCESSIVELY OVER THE TOP WEDDING CHELSEA CLINTON STYLE (SANS THE CLINTONS), AND LIVE HAPPILY EVER AFTER.

I SHALL BE WAITING EARNESTLY 4 UR NEXT POST. I must now return to my studies.

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Wow! Docs that are writing ... (Below threshold)

December 4, 2010 3:14 PM | Posted by KILL DR. PILL: | Reply

Wow! Docs that are writing and speaking highly of drugs are supposed to kill you, only that you don't know they have ALSO a cut under the table-- excuse me, lawfully earned income?

Docs that engage on violating their patients privacy only cause they've got a cop friend that suspect one is too worried about his/hers personal information-- so the only thing they can do is spy on patients when they visit the docs office?

YOU MUSTA BE GOD DAMN KIDDING ME!

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