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There are two topics about which I am a crank. The first, as you might have guessed, is alternative medicine. The other is pharmaceutical reps. Drug companies are somewhat schizophrenic. They have amazing scientists who invent drugs that treat an astounding array of diseases. Then, they take these drugs and turn them over to marketing, to be sold with all the enthusiasm and truthiness of a late night infomercial.

In the spirit of openness, I will say that I have not talked to a drug rep in 20 years. As far as industry supported gifts and food, I have not taken a pen or eaten pizza from industry in almost 30 years, since I was a fourth year medical student. I have accepted one gift over the years. Years ago, when the Pfizer rep left, he sent me Fleets enema with a Unasyn sticker on it. I still have it in my office, unused. But you never know when it might come in handy.

Being an absolutist about industry gifts does have downsides. It is distracting to sit in an auditorium filled with the smell of pizza and not eat any; somehow the PB&J I bring with me doesn’t smell as sweet. Administration has received one letter complaining about me that was ostensibly from an employee, but curiously was printed from a windows folder that had the same name as the levofloxacin rep. Just a coincidence, I am sure.



As an Infectious Diseases fellow I was the on call physician for the hospitals antibiotic stewardship program where expensive or problematic drugs had to be approved before they could be released from pharmacy. It was curious how there would be spikes in approval requests, often for drugs that the surgical resident couldn’t pronounce correctly. Ain’t no drug called ciprofloxacillin, although there should be. Investigation revealed that these spikes often occurred shortly after a service was treated to a good dinner by the drug rep. Hmm. Funny thing, that. Probably just another coincidence. I remember once as an intern late at night trying to decide what antibiotic to give a patient and I decided to prescribe what was embossed on my pen. Turned out Bic was not on the formulary.

Over the years it has been rare to find a physician as extremist as I am. It is curious, since the literature supports the concept that interaction with pharmaceutical reps is detrimental to patient care: docs who interact with reps are more likely to prescribe expensive and/or inappropriate drugs after being detailed. When pointed out, every doctor tells me the same thing: That may be true of others, but I am not swayed by information provided by drug reps. It is the one area of science-based medicine to which most physicians are immune, and understandably so: who wants to jeopardize free pizza? Most of the literature on the topic is collected at nofreelunch.org, which appears to be under construction. It all may be publication bias, but I know of no reference that demonstrates improved patient care as a result of physicians interacting with drug companies.

So imagine my surprise when someone came out in favor of physicians learning from drug companies. Over at Slate.com is “Appetite for Instruction. Why Big Pharma should buy your doctor lunch sometimes,” by Jessica Wapner.

It starts out sedately enough “The war against industry-sponsored medical education is in full tilt.” War? It is an interesting choice of words. I might have started by writing “physicians are finally reclaiming their integrity after whoring for 50 years,” but I have a dog in the fight.

But with the mounting concern about ties between doctors and the pharmaceutical industry, commercially supported medical education is being axed from hospitals and university medical centers around the country. Not only is this change unfortunate for anyone with a doctor, but it also doesn’t make any sense.

It does make sense if you bother to read the extensive literature. The preponderance of data strongly suggests that medical practice and research is altered, and not for the better, by interaction with pharma. She quotes only one reference in her article in support of drug company sponsored education.

There is no substitute for a small group of people listening to a doctor talk about how to treat a disease. And there is no substitute for the commercial support required to run such programs. In a recent study, academic researchers were paid a modest honorarium to travel around the country teaching more than 14,000 doctors about new treatment guidelines for high blood pressure. Each researcher met with small groups of doctors to educate them about the latest advances. In counties where the most sessions took place, adherence to the guidelines rose by more than 8 percent. In counties with the fewest such sessions, adherence decreased by 2 percent. The approach that the pharmaceutical industry has been taking for years is actually an effective way to educate doctors.

The “recent study” refers to “Impact of the ALLHAT/JNC7 Dissemination Project on thiazide-type diuretic use.”

I pulled the article, and it does not say what the author thinks it says. What a surprise. The academic researchers were educating physicians about generic medications, it was “was supported by contract N01-HC-35130 from the National Heart, Lung, and Blood Institute (NHLBI), as well as an NHLBI mentoring award (RSS, K24HL086703),” not pharmaceutical money, and if they were paid an honorarium it is not mentioned in the reference.

Academic detailing, or counter-detailing, is what is done to try and give evidenced based, minimally unbiased information about treatments in an attempt to give practitioners information free from pharmaceutical company spin and bias.

Academic detailing incorporates many of the approaches used in pharmaceutical marketing. By using persuasive, individualized small group or one-on-one communication of key points, detailing can summarize findings, suggest concrete changes in practice patterns, and explore potential barriers to change. In addition, by targeting specific physicians recognized as opinion leaders, resources can be concentrated on locally influential prescribers. Several systematic reviews have examined the effectiveness of academic detailing in changing clinical practice and found this type of intervention to be effective. The effectiveness of academic detailing is described as ranging from small to strong with results that are consistently favorable. The effectiveness of academic detailing in affecting prescribing practices is particularly prominent. In this situation, even small changes in prescribing may be important when the population affected is large or where large cost differences exist between alternative medications.

Academic detailing is the Spock without the goatee.

The effects of the intervention was modest:

The ALLHAT/JNC7 Dissemination Project was associated with a small effect on thiazide-type diuretic use consistent with its small dose and the potential of external factors to diminish its impact.

What external factors may have impacted the results?

…There was substantial questioning of the ALLHAT findings by recognized hypertension authorities, as well as by the pharmaceutical industry, that likely reduced the potential impact of the results on clinical practice.

So the authors suggest that using inexpensive, effective generic drugs for hypertension are being undermined by drug companies.

The take home message is that academic detailing, using the methods of drug reps but not their funding, is an effective alternative to pharma-financed education. It so irritates me when I read the original reference and discover it was almost completely misrepresented or misunderstood. I suppose she will be writing for Medical Voices next.

When Consumer Reports discusses cars, it is education. When Chrysler discusses cars, it’s an advertisement, even if they are having Dale Earnhardt Jr. as the discussant.

She also says the lack of pharmaceutical-sponsored education has lead to an increase in the misuse of drugs. No reference. So I went looking. Pubmed? Nothing. Google? The only reference is her article.

Stephen Hanauer, one of the clinical investigators who developed Remicade and who has been paid to speak to doctors about it, explains that as Remicade teaching sessions have been nixed, misuse of the drug has risen and Hanauer thinks that the two phenomena are connected.

The basis of the increased misuse is the experience of Dr. Hanauer. Well. Good enough for me. Lets get him back on the paid speaker trail, ASAP. Patient care depends on it. Even if the literature suggests that it is interaction with drug companies that more commonly leads to more medication mis-prescribing. Who are you going to believe, the published literature or the anecdotes of Dr. Hanauer?

He has been paid to speak. I wonder how much, because the money can be substantial.

However, the largest median payments were for research ($6593; range, $109-$922,239), speakers ($1430; range, $118-$154,188), consulting ($1000; range, $121-$334,180), and unspecified purposes ($1000; range, $100-$331,947).

I have always thought as part of mentioning conflicts of interest at the start of a talk, speakers should be required to give a dollar amount of direct and indirect (food, hotels, airfare etc) payments they have received. Does anyone think $154,188 isn’t going to buy something? I know if I were making that kind of cash as a speaker in this economy, I would want to keep the cash cow alive. But I really shouldn’t suggest others are subject to base motivations for their actions — I sound too much like Mike Adams.

Of course, if the drug company doesn’t provide food, no one will come to the talks.

But surely there must be other options. Can’t doctors meet with the experts in the absence of fancy cheese? Not necessarily. Teaching sessions often take place during the lunch hour. As Hanauer, who practices at the University of Chicago School of Medicine, describes, the elimination of paid lunches sent hungry doctors to the cafeteria instead of the lecture hall. “But the lines were so long that they missed the conference,” he says. “So attendance at our grand rounds conferences went to miniscule.” Now the doctor has a sandwich but isn’t up to date on how to treat a serious disease. That may sound silly, but it’s often the mundane reality. “There are sometimes times when residents have to choose between lunch and a conference,” Richard Goldberg, an oncologist at the University of North Carolina, wrote in an e-mail.

I just had to laugh. At my hospital system, administration takes education seriously and there is lunch provided at Grand Rounds. We get a sandwich and a lecture. University of Chicago is evidently not all that serious about the ‘school’ part of their title. Or, I don’t know, try planning ahead: it is Wednesday and we’ve had Grand Rounds every Wednesday at noon for the last 100 years, maybe I will pack a sandwich. Pu-lease. If my doc doesn’t have enough on the ball to plan for eating at conference, I don’t want them prescribing my Remacaid.

Of course, I don’t know how I manage to keep up in my field with no pharmaceutical support. I can’t read journals, can’t use websites like Medscape (I am a paid blogger for Medscape, so of course I suggest them), can’t go to conferences, can’t listen to podcasts, can’t attend meetings, can’t do the MKSAP. There is such a wealth of educational opportunities in medicine to keep up you have to be either lazy or stupid not to find them. It does takes discipline and time to keep up. I spend a minimum of 24 hours a month on CME. If you want job that requires no continuing medical education, perhaps you should be a naturopath or homeopath. Part of being an MD is the endless education it takes to stay current.

The problem is that drugs have more and different uses than the FDA approved indications and the only way that information can be disseminated is pharma sponsored education.

Only way? Sure worked for Neurontin.

…ParkeDavis executive reportedly told Franklin, I want you out there every day selling Neurontin. . . . We all know Neurontin’s not growing for adjunctive therapy, besides that’s not where the money is. Pain management, now that’s money. Monotherapy [for epilepsy], that’s money. . . . We can’t wait for [physicians] to ask, we need [to] get out there and tell them up front. Dinner programs, CME programs, consultantships all work great but don’t forget the one-on-one. That’s where we need to be, holding their hand and whispering in their ear, Neurontin for pain, Neurontin for monotherapy, Neurontin for bipolar, Neurontin for everything. I don’t want to see a single patient coming off Neurontin before they’ve been up to at least 4800 mg/day. I don’t want to hear that safety crap either, have you tried Neurontin, every one of you should take one just to see there is nothing, it’s a great drug… The Neurontin marketing plan consisted of both general strategies such as the promotion of Neurontin use among high-prescribing physicians and cultivation of thought leaders and tactical programs. Local physicians were recruited, trained, and paid to serve as speakers in “peer-to-peer selling” programs, which the company saw as “one of the most effective ways to communicate our message.” Academic leaders were solicited with educational grants, research grants, and speaking opportunities; some received up to $158,250 over a 4-year period. Advisory boards and “consultants” were convened so that the firm could cultivate relationships with them and deliver “a hard-hitting message about Neurontin. Marketing “tactics” included education, publications, and research whose promotional intent was disguised, in addition to more transparent activities, such as advertising and sales visits. “Educational programs” reflected the belief that “medical education drives this market!” Teleconferences involving practicing physicians were moderated by physicians who were paid as much as $176,100 over 4 years. ParkeDavis formed speakers bureaus and sought “strong Neurontin advocates and users to speak locally for Neurontin.” “Unrestricted educational grants” were made to for-profit medical-education companies that produced programs to discuss unapproved uses of Neurontin and to grant credit approved by the Accreditation Council for Continuing Medical Education.

Yep. That’s what I want for continuing medical information, programs that resulted in payments “of more than $430 million to resolve criminal charges and civil liabilities.” Of course, industry has learned their lesson. I can trust industry, and my patients life and health, with information about off-label indications provided by an industry that stands to profit from giving me the information. “There’s an old saying in Tennessee — I know it’s in Texas, probably in Tennessee — that says, fool me once, shame on, shame on you. Fool me, you can’t get fooled again.”

She concludes:

But the entanglement caused by for-profit drug development can’t be undone by eliminating the free lunch. As one physician suggested, perhaps pharmaceutical companies should be required to pay for medical education. After all, if companies are going to unleash new drugs into the world, shouldn’t they be responsible for teaching people how to use it? Ousting commercial support is creating a huge chasm in medical education, leaving doctors not only hungry but also starved for knowledge.

No, but it is a start. Physicians can take responsibility for their own education. And lunch isn’t free. In the end, our patients pay for it. The price of drugs, in part, takes into account the cost of advertisement. Maybe you feel it is fine for the underinsured to pay $1500 out of pocket for a 10-day course of linezolid, but I can’t justify my patients indirectly subsidizing my pizza and education.

While we are at it, let’s have MacDonalds be responsible for teaching nutrition, Nintendo teach us about fitness, lobbyists determine congressional voting, tobacco companies provide research cancer and oil companies tell us the cause of global warming. “The only way that information can be disseminated is ‘fill in the industry’ sponsored education” indeed.

Perhaps as professionals, doctors should be responsible for their own education, especially when the lives and health of their patients may depend on it.

The conclusion of the only other journal article referenced sums it up:

… attending sponsored CME events and accepting funding for travel or lodging for educational symposia were associated with increased prescription rates of the sponsor’s medication. Attending presentations given by pharmaceutical representative speakers was also associated with non rational prescribing.

That’s the chasm being created by banning pharma-sponsored education: more rational prescribing, more physician integrity and patient trust, better education and information. I can live with that, and so can my patients.