How academic physicians turn into drug company shills

An excerpt from White Coat, Black Hat.

by Carl Elliott

These days many thought leaders find themselves on shaky ground. The past few years have not been good for business. Some of the most prominent thought leaders have been exposed and censured by Grassley. Others have seen public opinion turning against them and gone underground. As more states institute Sunshine laws, anyone considering an industry consultancy must weigh the money and status boost against the potential downside of public exposure.

Still, the thought-leader business has proved more resilient than many people predicted. Most of the thought leaders investigated by Grassley have managed to retain their academic positions, even in the face of withering criticism. A resistance movement has even formed. Led by Dr. Thomas Stossel of Harvard University, the Association of Clinical Researchers and Educators (ACRE) has defiantly opposed attempts to cut back industry payments to doctors.

Many former thought leaders simply confess disillusionment. “There is a feeling that you want to be where the action is, and even if it’s not real action, at least industry gives you the feeling that things are happening,” Healy says. “They give you the feeling that you’re up on the wave.” After a while, however, the thrill of consulting begins to wear thin. There are just too many airports, too many hotels, too many fancy dinners. Eventually they all look the same. Healy says, “You’ve got a choice between the boredoms of perpetually surfing—where the first two waves are fun, but eight hours later, Jesus Christ—or do you return to the tedium of the beach?”

Daniel Carlat, a Massachusetts psychiatrist, used to give talks on antidepressants for Wyeth but gave it up after deciding that he was being used as a marketing tool. Now Carlat is an outspoken industry critic. “The narcissistic satisfaction wears off, and then it is all about the money,” he says. “You come to the realization that you’re not being valued for anything important. You are valued for your commercial potential.” At that point, a doctor has to decide whether it is still worth doing. Simply being the center of attention is enough to keep some of them on the lecture circuit. “Some people love to talk so much they never seem to get tired of it,” Carlat says. “But it never gave me that much of a charge.”

My brother Hal says the event that drove him away from his work for GlaxoSmithKline came when he was giving a lunch lecture at a local primary-care clinic. To his irritation, none of the doctors in attendance paid any attention to the lecture. They were answering pages, talking loudly to one another, helping themselves to the lunch that Glaxo had brought in—anything, it seemed, to avoid listening to him talk. Eventually Hal got so frustrated that he cut the lecture short. As he was packing up his laptop to leave, however, the Glaxo rep asked him a favor. The director of the clinic had been unable to attend the lecture. Would Hal mind sticking around a few more minutes to say hello? He would really appreciate it. Reluctantly Hal agreed, and the rep took him to a small room adjoining the clinic, where he said they would wait until the director appeared.

“There was a line on the floor,” Hal says. He had never seen such a thing before. “The rep told me that we weren’t supposed to step past that line unless the doctor said it was okay.” They stood behind the line, waiting patiently. After a few minutes, the director walked down the hall toward them. “I sort of looked at him, hoping to make eye contact and speak, but he wouldn’t even look at us,” Hal says. “This rep just stood there with a big smile on his face, and the doctor stopped in front of the treatment room five feet away from us, and stood there for several minutes reading a chart. Then he walked away into the treatment room like we were not even there.”

Hal calls this his moment of understanding, after which he never gave another industry-funded talk. Up to that point, he had imagined himself as a high-powered academic physician bringing the latest university research to doctors out in the community. Standing next to the drug rep, however, Hal understood how the community doctors saw him. To them, Hal was a drug company shill. “I was literally standing in the drug rep spot begging for a minute of this doctor’s time, like a cocker spaniel begging for a leftover piece of meat from the table,” he says. It was no wonder the doctors saw little difference between Hal and the rep. “It was like I had become a psychiatric callboy,” he says. “I might as well have just said, ‘Hi, I’m Hal. The company sent me to make sure you all have a good time.’”

Carl Elliott is a writer for The New Yorker and The Atlantic Monthly and author of White Coat, Black Hat.

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