November 2, 2010

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

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.


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.


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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