As I sat to write a post this morning, I became more engaged in a story in the New York Times magazine by Dr Daniel Carlat entitled, “Dr. Drug Rep.” Joseph of Corpus Callosum recently commented here about being solicited to recommend fellow physicians in the local area and nationally who he perceived as “thought leaders” in his specialty.
Carlat was such a physician who was cultivated by Wyeth to discuss their antidepressant, Effexor XR, to fellow physicians at conferences and in doctors’ offices. His piece in the NYT magazine chronicles his development by Wyeth as a drug spokesperson and the increasingly unnerving ethical conundrums he faced in the process:
She handed me a folder containing the schedule of talks, an invitation to various dinners and receptions and two tickets to a Broadway musical. “Enjoy your stay, doctor.” I had no doubt that I would, though I felt a gnawing at the edge of my conscience. This seemed like a lot of money to lavish on me just so that I could provide some education to primary-care doctors in a small town north of Boston.
Like many of my physician colleagues who accept honoraria from drug companies to talk about the latest therapies, most go into the arrangement with the purest intentions of providing education for fellow docs. This is a very common practice and Carlat cites a study that estimated 25% of US docs receive drug money for lecturing to physicians or for helping to market drugs in other ways. Carlat:
If I gave talks to primary-care doctors about Effexor, I reasoned, I would be doing nothing unethical. It was a perfectly effective treatment option, with some data to suggest advantages over its competitors. The Wyeth rep was simply suggesting that I discuss some of the data with other doctors. Sure, Wyeth would benefit, but so would other doctors, who would become more educated about a good medication.
What Carlat found was that he was being cultivated as an expert drug representative:
“Dr. Carlat: Our main target, Dr. , is an internist. He spreads his usage among three antidepressants, Celexa, Zoloft and Paxil, at about 25-30 percent each. He is currently using about 6 percent Effexor XR. Our access is very challenging with lunches six months out.” This doctor’s schedule of lunches was filled with reps from other companies; it would be vital to make our sales visit count.
Carlat details how companies specializing in prescription data-mining sell data to drug companies for reps to know which doctors are heavy prescribers of the drug class but not that company’s drug. Most health care professionals know of such companies like IMS Health but Carlat reveals how the American Medical Association is also complicit in this practice by providing the missing link in matching prescription information to specific doctors:
Pharmacies typically will not release doctors’ names to the data-mining companies, but they will release their Drug Enforcement Agency numbers. The A.M.A. licenses its file of U.S. physicians, allowing the data-mining companies to match up D.E.A. numbers to specific physicians. The A.M.A. makes millions in information-leasing money.
(In 2006, the AMA began the Physician Data Restriction Program (PDRP) that permits member physicians to opt out of prescription tracking.).
However, Carlat became increasingly disturbed about the data and physician feedback that Effexor caused hypertension in a small but significant percentage of patients receiving the drug. With so many other antidepressants available that did not cause this side effect, he began to think more critically about the purported superior efficacy of Effexor relative to other antidepressants.
A year after starting my educational talks for drug companies (I had also given two talks for Forest Pharmaceuticals, pushing the antidepressant Lexapro), I quit. I had made about $30,000 in supplemental income from these talks, a significant addition to the $140,000 or so I made from my private practice.
Some people might think that doctors are making a killing out there and while $140,000 USD is a good living, it’s not that great considering how much training (and student loans) go into making a physician. So, as Calart says, there is definitely financial incentive for some docs to sign up with drug company education programs.
Carlat now fulfills his educational mission at Tufts School of Medicine and as publisher of a psychiatry newsletter, The Carlat Psychiatry Report. The newsletter is advertised prominently as being unbaised and, as such, he takes no drug company support for its publication or web hosting.
For more in-depth revelations on drug company marketing strategies, take some time to read the open-access PLoS Medicine publication, “Following the Script: How Drug Reps Make Friends and Influence Doctors.” Written by a former drug representative and a Georgetown physiology professor, the work was supported by a consumer education grant “as part of a 2004 settlement between Warner-Lambert, a division of Pfizer, and the Attorneys General of 50 States and the District of Columbia, to settle allegations that Warner-Lambert conducted an unlawful marketing campaign for the drug Neurontin (gabapentin) that violated state consumer protection laws.”