August 27, 2008

What Happens If Pharmaceutical Marketing Disappears? Part 1

Everyone (including me) thinks Pharma is too heavily involved with the practice of medicine.  So we try to think of ways to stop this.  Restrict gifts and consultant fees to doctors; decrease, or at least separate, industry funding from research; and, of course, no more reps in doctors' offices.

These all sound like great ideas, how could you even come up with an argument against any of them?

Here goes.

As a bonus, I even offer a practical long term solution.

The core issue is that Pharma exposure represents a conflict of interest.  Does anyone understand what that term actually means?  Ok, let me ask you a question.  What is the plural of "conflict of interest?"

a. conflicts of interest
b. conflict of interests
c. conflicts of interests

Not so easy to answer, because any of them could be correct.  You can't create a workable policy against something so vague it can't be pluralized . You have to target the individual conflict and weigh it against the individual interest.  It may be a conflict of interest to take money from Merck while doing AIDS research; it might also be a conflict not to.

Ask The Question Differently:

Instead of asking what should be done to curb COIs (clever, huh?) ask: what would happen if we succeeded?

1. No more reps.

I don't know what goes on in other branches of medicine, but if you get rid of reps-- and detailing, and "lunch and learns" and all that goes with them-- psychiatry will instantly grind to a halt, and people will die.

It is an indisputable point that reps know more about the medicines than the doctors do.  Worse, doctors don't know much more than a patient on the Google.  We can argue whether Lilly hid the diabetes risk of Zyprexa, but it took Pfizer's (launching Geodon) to tell us about it.  Don't tell me that we would have learned about it from the extensive journal articles written in 2000 (three.)  Doctors only recently discovered Vioxx had a cardiac risk, though Yahoo! News had an article about it in 1999.  Abbott et al may have rammed Depakote down our throats through 2008, but it took Astra Zeneca to kill it.

2. No more Pharma education money.

A frequent complaint is that there's $1B of Pharma money in CME.  Is that just extra money?  What's going to happen if you take it away?  Then there's no more education.  All of post graduate medical education is done by Pharma.  The residency didn't buy the textbooks for the residents, Pharma did. Pharma sponsors the short "throwaways" and supplements that at least get some readers, unlike the regular journals which get no readers.  Pharma also pays for the CME. 

Who's going to pay the CME lecturers?  Who is going to pick the topics?   The government?

Here's an anecdote: I'm talking to a psychiatrist, and finding it difficult to keep all the receptor pharmacology straight he says, "these new drugs are no better than the old ones, we should go back to them."  Is that a fact, commtard?  You want to go back to Trilafon and Pamelor?  If perphenazine is so great now, how come it wasn't when they called it Trilafon?

If your reason for prescribing a generic is that it is a generic-- I don't mean sertraline vs. Zoloft, I mean imipramine vs. Zoloft-- you are worse than the guy who prescribes Abilify because Pharma paid him.

(More on separating Pharma from CME.)

3.  No more Pharma research money.

Do you know how many clinical trials are done by Pharma?  Lots.  You know how many are done by NIH? Not lots.  If there exists one person on the planet who can tell me what society got from the $68M tapayer dollars spent on CATIE, I'm listening.

Clinical research is performed for two reasons.  Secondarily, it is to promote the science.  Primarily, however, it is deficit spending.  It gives jobs to people.  Few clinical researchers end up studying their passion; they study what's being funded.  If Depakote's paying, we're studying Depakote.  You want a job at Harvard in 2004?  Make sure you can spell Depakote.  You want one in 2009?  It's S-E-R-O-Q-U-E-L. 

If Pharma stops paying, then there will be much less research, even if it is biased. People are missing the hidden benefit of the "biased" Pharma trials: they are still information.  I know Depakote isn't a maintenance agent because of the failed trial that Depakote paid for.  I know Zyprexa causes diabetes and weight gain because of Lilly's own data (and the data from comparator trials done by other Pharma companies.)  I recognize Pharma spins the data, but you can't tell me the data is non-existent.  (Though that is preposterously what was argued about Vioxx.)

If Pharma did not pay for these trials-- if we had to wait for the NIH to investigate Zyprexa's diabetes-- we'd wait a long time.  And, per #1, without Pharma  to inform us a study was even done, we simply wouldn't know.

4. No more Pharma building money.

You know that new wing of your university hospital?  Who do you think paid for it?  The New England Journal of Medicine?  My favorite of all Pharma ironies is that a university will take $25M to build something that it will then ban reps from entering. 

5. No handouts to doctors.

Why do doctors get entangled with Pharma at all?  Is it really just greed?  Then why not just move to California and prescribe marijuana out of a shack?

I'm going to write something that so extraordinarily impolitic that no doctor will even admit to hearing this argument, let alone agreeing with it:

Doctors don't view this as extra money, they view this as money they are entitled to. 

$120k may seem like a lot of money, but no academic doctor thinks that university salary is what he deserves.  So he does extra things for Pharma, or gets some unrestricted grants from Pharma to free up time (so that he can do "other" things).  His assumption is he is worth, say, $200k, the University only pays $120k, and he's going to make the rest up.

BTW, that's why the University gets away with paying you $120k.

The same is true for non-academic docs.  They didn't imagine they'd be getting paid so little to do not exactly the job they thought they had signed up for.  So they make up the difference.

I'm not justifying it, I am explaining it.  If you completely ban all Pharma money going into doctors' pockets, they will demand it from somewhere else.  They are not going to be satisfied with $120k.  Or 15 minute med checks at $30 a pop.   And you'll have a brain drain-- many docs will actually go work for Pharma.  I can't tell you how many times I've been offered jobs at Pharma-- easy jobs, at 2-3x what I make now.   Good students will think twice about medicine.  Maybe they try biotech.  Or law.

Do not email me "what ever happened to working for the common good?"  The only people who say that are not working for anyone, let alone the common good.  Doctors do have a nobler sense of purpose, but not at half price.  Sorry.  It's America.

Before you take that money away, makes sure you have a plan B.


In order to solve the problem, you have to adequately explain the problem. Right off: patients are not the customers of Pharma.  Doctors are.  Pharma isn't making medicines that people want/need, they are making medicines that doctors want/need, i.e. that they will prescribe.  So the way Pharma operates is to either identify what doctors will use, and market it, or they wil find a way to take an existing chemical and market it so that doctors will use it.  Viagra, a drug "for" pulmonary hypertension, was decided to be marketed as a penis pump.

Like everything else in life, the solution is the demand side.

(Part II here.)