An excerpt from White Coat, Black Hat.
by Carl Elliott
A few years ago a small group of first-year medical students at the University of Minnesota spoke to me about a lecture on erectile dysfunction that had just been given by a member of the urology department.
The doctor’s PowerPoint slides had a large, watermarked logo in the corner. At one point during the lecture a student raised his hand and, somewhat disingenuously, asked the urologist to explain the logo. The urologist, caught off guard, stumbled for a moment and then said that it was the logo for Cialis, a drug for erectile dysfunction that is manufactured by Eli Lilly. Another student asked if he had a special relationship with Eli Lilly. The urologist replied that yes, he was on the advisory board for the company, which had supplied the slides. But he quickly added that nobody needed to worry about the objectivity of his lecture, because he was also on the advisory boards of the makers of the competing drugs Viagra and Levitra. The second student told me, “A lot of people agreed that it was a pharm lecture and that we should have gotten a free breakfast.”
This episode is not as unusual as it might appear. Drug company–sponsored consultancies, advisory-board memberships, and speaking engagements have become so common, especially among medical-school faculty, that the urologist probably never imagined that he would be challenged for lecturing to medical students with materials produced by Eli Lilly. According to a recent study in the Journal of the American Medical Association, nine out of ten medical students have been asked or required by an attending physician to go to a lunch sponsored by a drug company.
Over the past several years pharmaceutical profits have started to level off, and a backlash against reps has been felt; some companies have reduced their sales forces. But the industry as a whole has been hiring more and more doctors as speakers. In 2004, it sponsored nearly twice as many educational events led by doctors as ones led by reps. Not long before, the numbers had been roughly equal. This raises a question: Are doctors becoming the new drug reps?
Doctors are often the best people to market a drug to other doctors. Merck discovered this when it was developing a campaign for Vioxx, before the drug was taken off the market because of its association with heart attacks and strokes. According to an internal study by Merck, reported in the Wall Street Journal, doctors who attended a lecture given by another doctor subsequently wrote nearly four times more prescriptions for Vioxx than doctors who attended an event led by a rep. The return on investment for doctor-led events was nearly twice that of rep-led events, even after subtracting the generous fees Merck paid to the doctors who spoke.
These speaking invitations work much like gifts. While reps hope, of course, that a doctor who is speaking on behalf of their company will give their drugs good PR, they also know that this doctor is more likely to write prescriptions for their drugs. “If he didn’t write, he wouldn’t speak,” a rep who has worked for four pharmaceutical companies told me. The semi-official industry term for these speakers and consultants is thought leaders, or key opinion leaders. Some thought leaders do not stay loyal to one company but generate a tidy supplemental income by speaking and consulting for a number of different companies. Reps refer to these doctors as “drug whores.”
The seduction, whether by one company or several, is often quite gradual. My brother Hal explained to me how he wound up on the speakers’ bureau of a major pharmaceutical company. It started when a company rep asked him if he’d be interested in giving a talk about clinical depression to a community group. The honorarium was a thousand dollars. Hal thought, Why not? It seemed almost a public service. The next time, the company asked him to talk not to the public but to practitioners at a community hospital. Soon company reps were making suggestions about content. “Why don’t you mention the side-effect profiles of the different antidepressants?” they asked. Uneasy, Hal tried to ignore these suggestions. Still, the more talks he gave, the more the reps became focused on antidepressants rather than depression. The company began giving him PowerPoint slides to use, which he also ignored. The reps started telling him, “You know, we have you on the local circuit giving these talks, but you’re medical-school faculty; we could get you on the national circuit. That’s where the real money is.” The mention of big money made him even more uneasy. Eventually the reps asked him to lecture about a new version of their antidepressant drug. Soon after that, Hal told them, “I can’t do this anymore.”
Looking back on this trajectory, Hal said, “It’s kind of like you’re a woman at a party, and your boss says to you, ‘Look, do me a favor: be nice to this guy over there.’ And you see the guy is not bad-looking, and you’re unattached, so you say, ‘Why not? I can be nice.’” The problem is that it never ends with that party. “Soon you find yourself on the way to a Bangkok brothel in the cargo hold of an unmarked plane. And you say, ‘Whoa, this is not what I agreed to.’ But then you have to ask yourself, ‘When did the prostitution actually start? Wasn’t it at that party?’”
Some believe that the marketing landscape changed dramatically for both reps and doctors in 2002, after the Office of Inspector General in the Department of Health and Human Services announced its intention to crack down on drug companies’ more notorious promotional practices. With the threat of prosecution in the air, the industry began to take the job of self-policing a lot more seriously, and PhRMA issued a set of voluntary marketing guidelines. Those guidelines specified, for example, that spouses of doctors should not be given free meals, and that gifts should be worth less than a hundred dollars and be for the benefit of patients. PhRMA updated the voluntary code again in 2009.
Although most reps agree that the PhRMA code has changed things, not all of them agree that it changed things for the better. Some say that as long as reps feel pressure to meet quota, they will find ways to get around the rules. As one former rep pointed out, not all drug companies belong to PhRMA, and those that don’t are, of course, not bound by PhRMA’s guidelines. Jordan Katz says that things actually got worse after 2002. “The companies that tried to follow the guidelines lost a ton of market share, and the ones who didn’t gained it,” he says. “The bottom line is that if you don’t pay off the doctors, you will not succeed in pharmaceuticals. Period.”
Carl Elliott is a writer for The New Yorker and The Atlantic Monthly and author of White Coat, Black Hat.
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