Doctors are often preferred to market a drug to other physicians

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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  • Dr Robert Schertzer

    Well written article that really highlights the perceived conflict of interests when colleagues give these talks. Even if topic completely of the physician’s choosing there is still the potential of guilt by association.

  • Marya Zilberberg

    Great article! The only thing I would say is do not lump advisory boards together with promotional talks. Advisory boards, if legitimate, function as places to help formulate research questions and design studies. Also, consultancies can be of different flavors. Most consultancies should and do center around research. Finally, new CME rules are impacting how companies can influence MDs through their peers.

  • Pete

    The thing I miss the most about the “old days” is getting together with your peers. Let’s face, no docs every go to these drug rep dinners anymore, even with “national speakers”. They’ve become useless advertisements for drugs with no educational purpose. When you and your spouse could go to a suite at a baseball game, there would be 10 of your peers there with their spouses. You could catch up, market your practice, and more importantly – discuss cases. You could see how others would handle things and why. I think in this way our education and growth as physicians has been compromised.

  • solo dr

    The latest way to target community doctors is to have a drug company help a community doctor present a lecture at a hospital medial staff meeting or medical society meeting. The community doctor is paid $700-$1,000 for a 60-80 minute talk to his or her colleagues about the benefits of say insulin for diabetes, listing all the various insulins but really pushing Lantus. The drug reps are front row in the audience and handout the brochures on their drugs. Thankfully the AAFP does not allow CME from drug rep sponsored events.

  • Michael F. Mirochna, MD

    The AAFP allows the drug company CME to come up in every AAFP journal every two weeks. I feel like I should be prescribing so much savella, levemir, lantus and some big tire for insulin now after going through a bunch of the journals.

  • Kevin Aulini

    I have been reading blog posts here on KevinMd for years and never left a comment, but this article deserves one. Very well written indeed. Are doctors becoming the new drug reps? My answer is clearly yes. You actually wrote this article at an interesting time, the movie trailer for Love and Other Drugs was just released and should be in theaters in a few months, based on the life of Jamie Reidy, one of Pifzers first reps when Viagra was released. If you have read the book "The Evolution of a Viagra Salesman" you will get some insight on how reps market these meds. Back in the 1990′s reps where marketing them to the doctors. Now Doctors are marketing them for the reps to other doctors by giving these lectures. I write several news articles a week related to ED and can tell you from experience that Urologist marketing the big 3 ED meds are increasing every year.

  • A. Tsai

    @Pete: If you want to market your practice, pay for some advertising. If you want to catch up with your peers, invite them over for dinner. Why do you have any expectation that your patients (through higher drug prices due to the additional cost that drug companies have to pay to do this marketing) should pay for this?

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