Lunch money Pharma spends on physicians

Actually I’ll take a Ford Shelby GT500 Convertible, thank you very much …

Today’s stream of socially conscious thinking comes to you after having feasted on a tasty lunch paid for by a drug company (and no, it wasn’t Pfizer).

It has spurred me to contemplate the ever increasing scrutiny paid to the relationship between the pharmaceutical industry (a.k.a. Big Pharma) and physicians (a.k.a. Big Doc) by an increasingly suspicious public (henceforth referred to as Big Patient).

One of our friendly neighborhood (by neighborhood, I mean covering most of the state of Michigan) drug reps bought lunch for our office today, as another did last week, and possibly a different one may be doing in the coming days. They haven’t been doing this quite as often as they used to, there are fewer of them in the business due to cuts by the companies and consolidation in the industry as a whole. Today we were brought burgers from a local restaurant that is a favorite among our staff.

For years this symbiotic relationship was the norm. For the price of lunch at a local burger joint, Big Pharma got access to Big Doc and a chance to peddle their wares, citing various reasons why their drug is better than their competitors. Big Doc got some happily fed office staff, in addition to various bits of information that varied from highly informative to mildly useful to lightly febreezed bull droppings. In return for footing this bill, Big Patient got a Big Doc who was then better informed about the Big Pharmas that Big Doc was telling Big Patient to put into their bodies. And thus, was the manner of our glorious capitalist system of health care that was the envy of Canadians and kumbaya singing commies the world over. Or something like that.

For years, Big Patient thought that this was just the cost of doing business, and that the benefits to them outweighed the price paid in terms of any possible higher drug costs. But as the costs of peddling to Big Doc approaches the astronomical, and as patients see their own costs increasing, that sentiment, for better or worse, has changed.

In 2004, self reporting from Big Pharma put their expenditures for R&D at $29.6 billion, while it estimated it spent $27.7 billion on marketing. However, independent estimates put marketing expenditures by Big Pharma in 2004 from $47.9 billion to as high as $57.5 billion, far outpacing R&D spending that year. The number works out to a staggering $61,000 spent on marketing per physician in one year. Right now all of us as physicians are troubled with that figure and are wondering the same thing. Was the $50,000 spent on turndown service at the Heart Rhythm Society meeting deducted from my 61 grand, or was it somebody else’s?

This leads me to the point which I am trying to make here. Which is this, “hey guys, could I just get that $61,000 up front, please?” C’mon, lord knows with all the inhaler scripts I’ve written over the years, I must have moved your stock prices by at least a cent or two, right? So, I reiterate, let’s stop this silly dance, and cut out the middleman. I’ll take my Shelby GT500 Convertible in blue with white racing stripes. At an MSRP of $56 thousand, it will even save you a few grand, and you can pass those savings on to Big Patient, how’s that for value?

Deep Ramachandran is a pulmonary and critical care physician who blogs at CaduceusBlog.

 

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  • http://drsamgirgis.com Dr Sam Girgis

    When I was a resident, our program director forbid the drug reps from attending our morning reports and noon conferences. We were not even allowed to use a drug company pen for that matter. The way he viewed it was this: Big Pharma is playing a deceptive game of trickery. They are buying your attention to promote their product with lunches, dinners, books, trips, pens, etc. As residents, he didn’t want our educational process to be improperly effected by Big Pharma’s promotional machine. Let me ask you this then… why is it okay to allow their propaganda to influence us as attendings?

    Dr Sam Girgis
    http://drsamgirgis.com

    • stitch

      Whatever in the world gives you the idea that nurses and PAs are immune to drug reps? Have you never seen nurses using drug company swag?

  • soloFP

    It may seem like $56,000 going to the doc, but often it costs the doc more to deal with drug reps, lunch or not. I stopped lunches over 10 years ago, when I figured out I would lose at least an hour a day with the reps at lunch alone. I also stopped 98% of the samples. I usually eat lunch in around 10 minutes. I then use the leftover time to go over incoming US mail, email, front desk and MA questions, refill requests, and billing questions. For the last five years I added 2-3 additional lunch time visits and cut my late hours in the week. I actually have a job where I am done by 5 pm daily instead of staying until 6-7 PM catching up. I also do not start the afternoon 15 minutes or more behind, as drug reps take up your time and also your staff’s time. You are paying your staff do deal with patients and not reps.
    The reps would want to do a 30-45 minute presentation at the lunch and push the latest drug, which either was a Tier 3 copay or nonformulary. This would cost me additional time filling out prior auth forms and telling my MA what to say on the prior auth line for drugs that usually were not any better than the proven generics and for drugs that cost my patients more money. They also like to chit chat with your main MAs to try to get in good with doc to rx the latest meds. Those bagels and donuts are costing you salary time and inefficiency.

    Look at drug rep food like this: would you be willing to ask your patient to take you out to lunch and pay for it? Would you ask your patients to bring you snacks like kindergartner? Most health plans prohibit charging anything outside of the copay or deductible, yet drug rep lunches are an under the table way to save a few bucks. I figured I can fix my own lunch for less than $5 a day and make another $200 at lunch each day adding on patient visits.
    Finally, drug rep expenditures to doctors, including lunches, are going to published online by name in the next 1-2 years as part of the health care reform. I do keep the reps cards on file for patient who lose insurance and for the rare case when a generic alternative does not exist. 90% of the samples can be substituted with a $4 drug at the national discount stores that works as well. I figured this out when I was filling out home delivery for a cardiac combination med that cost $200 a month but could be had with 3 generics of the same drug components for $30 a month without me doing more free paperwork. I have noticed that many sample requests are now online, and drug reps are being replaced by UPS and Fed Ex. Paying someone $80,000 a year plus a free car and travel expenses is proving not worthwhile to the drug companies. I think the lunches will completely end in the next 3-5 years.

    To play devil’s advocate, it is okay when politicians, accountants, lawyers, DJs, hospitals administrators, and other people get wined and dined by the latest equipment manufacturers or software systems. The difference is docs are held to a higher moral standard.

    • http://Www.twitter.com/alicearobertson Alice

      I do not think it is alright for politicians or doctors to profit in a deceptive manner. Dr. Z devoted a show last to this problem. Almost every clinical trial is paid for by Big Pharma, then the outcomes are played with, the drug reps are trained how to answer the dctor’s objections….they are selling a disease. Dr. John Abramsom from Harvard wrote a book about this, so he debated with a rep for Big Pharm…then Gwen Olsen an ex rep for Big Pharma, an insider who is shining a light on these bad practices that are affecting a nation of patients spoke. Most shocking was the research that showed statins do not work for women. And rarely for men. The answer could wipe out a lot of bogus jobs…..over 80% of people can help themselves with good old hard work and discipline…..exercise and diet. Dr. Oz is pulling patients off drugs because the repercussions from side effects are much higher than we realize.

      I am consistent…I am not a fan of lobbyists…..or doctors and politicians who rely on sales people to romance them into ruining lives for their own gain.

  • http://davidbeharmdejd.blogspot.com David Behar, MD, EJD

    The left wants those lunches to be reported as income. My accountant’s analysis agrees, and is here:

    http://davidbeharmdejd.blogspot.com/2011/03/eat-sandwich-from-drug-rep-get-reported.html

    That means, I come to your home. I give your wife a box of chocolates out of good manners. I say, “Thank you for your gracious hospitality. Here is a box of chocolates, you might enjoy. Could I have your social security number, so I can 1099 you.” They might not even be Godivas.

  • http://davidbeharmdejd.blogspot.com David Behar, MD, EJD

    Dr. R: Did you watch the Super Bowl? That was an expensive show made free by advertising. You should forbid yourself from watching any free expensive show.

    I love Bud Light commercials. Bud Light gives me horrible headaches. Will any amount of money or commercials induce me to drink it?

    No.

    • http://Www.twitter.com/alicearobertson Alice

      I get your point about truth in advertising, but a doctor has a type of sacred position with a patient….a type of contractual trust we do not have with TV. We are naive enough to esteem doctors research methods that are being exposed to be no research methods….they are self gain methods with faulty stats. We have an avalanche of stats and a shortage of wisdom. We know what TV advertisers are pumping, but we do not know why the doctor is prescribing or who paid for lunch…unless doctors want to post something telling us the drug company paid for lunch so he needs to give you some false data to keep the burgers flipping! Hope they were veggie burgers and baked fries….at least the patients would see something of consistency in the message. Imagine being told to eat more healthy then seeing the staff munching on burgers….I know where I would be going for lunch….knowing there are no true free lunches…someone pays.

    • gzuckier

      Yeah, the whole advertising industry is just kidding themselves. I choose what beer to buy by a rigorous cost/benefit analysis, like any good citizen.

  • pcp

    My requirement for meeting with drug reps:

    75% of the samples you leave have to be generics.

    I haven’t met with a drug rep in more than 10 years.

    • stitch

      Drug reps don’t like me because they know I will prescribe generics as much as I possibly can. I refuse to meet with ones who push unsubstantiated claims about superiority. Others, I like to mess with.

  • http://ethicalnag.org/2010/05/28/fewer-physicians-see-reps/ Carolyn Thomas

    Pity the poor Big Pharma drug rep, facing not only corporate layoffs and industry uncertainty as their blockbusters fall off the patent cliff, but – according to an Access Monitor report last spring – the number of busy health care professionals now willing to see visiting drug reps is down by 20%. This is problematic for Big Pharma marketing, because drug rep visits really work. For example:
    – Favourable change seen in a doctor’s prescribing habits after spending less than one minute with a drug sales rep: ↑16%
    – Prescribing change seen after three minutes with a drug rep: ↑52% (source: ‘Drug Marketing By The Numbers’)

    So if you’re one of the growing number of physicians who no longer sees drug reps, you can download this “No Drug Reps” certificate for your waiting room from PharmedOut – http://www.pharmedout.org/tools.htm

  • Big Thinker

    I hope you intended to leave out further facts. Why didn’t you consider those actual costs?

    Rep- $$$$
    This includes transportation for the rep to visit all 250 doctors assigned to them, fuel to power, and insurance as required.

    Paper goods- $$$$
    All of those leave behinds you throw away? Yep, they cost money.

    Samples- $$$$$$$
    Pretty self explanatory. You use them. Next to the rep it’s the most expensive portion of marketing.

    Meetings- $$$
    Not as much as you’d assume.

    Dealing with the FDA- $$$$$$$$$
    You’re AMA lobbyist could buy your U.S congressman that GT 500 before your rep could bring you a pen.

    • ninguem

      Exactly.

      More efficient to use that money to buy off the politicians and the hospital executives, insurance executives, and various other suits.

      Colcrys comes to mind. Take generic colchicine, play the FDA rules to get all competitors off the market, then force everyone to pay a hundred times more for a drug that’s been around since ancient times. Yes, a hundredfold, that’s not really an exaggeration.

    • http://Www.twitter.com/alicearobertson Alice

      Let’s add $$$ to the patient in expenditure, side effects….lose of trust….and then when they do the research the doctor should have did, and was paid for their expertise, they are often met with disdain….$$$ patient doesn’t get better, or moves on.

      Big Pharma has it’s place…but lying/laying with doctors defense isn’t one of them. I think doctors should be very concerned about the false bill of goods they are providing under the guise of being dubbed themselves.

  • Marc Gorayeb, MD

    Unspoken among all this sarcasm is the fact that developing new drugs costs money that only an investor can afford or is willing to provide, and some of these drugs actually occasionally save or change the lives of some of our patients. Marketing increases the chances that this will happen, and it’s our responsibility to pick and choose which of our patients are likely to benefit from these admittedly expensive advancements in medical technology. I am happy to learn about these advancements and to take on that responsibility.

    • http://kevinmd.com Mary

      Dr. Gorayeb
      Your comments regarding pharma are the only one with a lick of sense. I practiced for 25 years as an NP and was thankful the reps kept me abreast of the latest research. It was up to me to decide if the research was good and if the product made sense.
      I did notice that the providers who refused to see reps, did not know the latest developments in disease state management. ie a pediatrician used albuterol syrup for asthma instead of the steroid inhalers for the appropriate patient and stage of the asthma. When the child vomited and continued to wheeze, I would see them and treat their asthma according to the presentation as well as the guidelins

      • http://Www.twitter.com/alicearobertson Alice

        I do not think this is true anymore. Dealing with cancer one of the pieces of advice you receive is to get to a hospital that is affiliated with a university doing medical research.

        Cleveland Clinic now makes doctors disclose what their speaking fees are, who they speak for and the research grants they obtain. Yet, 85% of clinical trials are financed by Big Pharma. Any doctor who would willingly rely solely on this information from clinical trials is getting paid by trusting patients who are being mislead by a doctor who isn’t doing his homework. Why let Big Pharma do your homework? Irresponsible!

        Patients are not against research….that would foolish to even contemplate a thought like that. Patients are paying doctors to be informed…and not by self serving reps who care more about commissions than the patient. A doctor has a responsibility to do research. Do not misunderstand our message….we are telling you if we wanted to be part of a clinical trial we know where to sign up for free….do not involve us if you have not did research beyond the easy information from a Pharma rep who is playing you for a puppet.

        • imdoc

          Alice:
          “Yet, 85% of clinical trials are financed by Big Pharma… Patients are paying doctors to be informed. A doctor has a responsibility to do research…we are telling you if we wanted to be part of a clinical trial we know where to sign up for free…”

          So, you want the clinical trial for free, but you don’t want the pharmaceutical industry to pay for it? I guess that leaves taxpayers

          • http://Www.twitter.com/alicearobertson Alice

            I want honest data and for them to stop playing with stats. Ultimately, we do pay via prescriptions, etc. ,

    • gzuckier

      Not sure how marketing increases the chances that a drug will save the lives of patients, rather than spending the same sum on more/better clinical trials. Does this hold for all products, or just pharmaceuticals? Are all those Axe bodywash commercials increasing the chances that it will get somebody a girl?

  • http://caduceusblog.com Deep Ramachandran, M.D.

    Very interesting discussion, here. As the author of this article, allow me to make a few points.
    –The original post (at caduceusblog.com) was titled “Oh (drug company) won’t you buy me a mercedes benz” this was edited. Therefore the punchline about the Shelby did not make much sense, and may have been lost on some people.
    –I’m a pulmonologist. I prescribe generics whenever possible. There are no “4 dollar” generic inhalers, they are all expensive.
    –I trained in an environment that severely curtailed access to drug reps. However, I have found that amongst the stinky seaweed of information provided, there are (please physician God forgive me for this blasphemy) occasional pearls of useful information from drug and medical supply reps, particularly in regards to issues of cost, access, and advanced therapies.
    –Physician marketing contributes to drug costs. However, I remain skeptical that elimination of physician marketing will reduce drug cost. I suspect the money will go elsewhere and both physicians and patients will lose yet another resource.

    • Charles R

      What would your society meeting look like without the funds garnered from industry? Would you support a ban from Pharma providing financial support and the elimination of the “exhibit hall”? Assuming the scientific agenda was not scaled-down, how much would you and other society members have to pay to attend? I think Pharma should make a clean break from attempting to “influence” doctors. But doctors will have to be willing to forgo a lot of conveniences.

  • http://www.heyman.Yourmd.com Joe Heyman

    Actually the lead article is misleading because it implies that the $61000 is spent on marketing to physicians. Actually a huge portion is spent marketing to others including patients. So it may be that figure per physcian, but a more realistic figure would be how much per patient!

    I enjoy a free lunch and I do learn something on occasion. On the other hand, I admit that I often spend more time challenging the representative than I do learning.

    • http://Www.twitter.com/alicearobertson Alice

      But the rep is better than you…they learn how to answer your objections with more spin. Visit some industry insider story sites….it is very discouraging. Doctors are often willing to be wooed!

  • Charles R

    What would the flow of information about new therapies look like if Pharma discontinued all funding for physician interaction and to medical societies? It would change the landscape in a heartbeat. For better? I don’t think so. Perhaps there is a balance to be found.

    • http://Www.twitter.com/alicearobertson Alice

      Innovation is vital….but so is disclosure, research financed beyond commissions, and both patient and doctor responsibility to makes drugs the last choice…not the first.
      If we cannot trust our doctor our relationship suffers.

    • Charles R

      The internet plays an important and growing role in medical communication. However, there are advantages at times to face to face education. Also, the internet is not free of bias. In fact it is sometimes more difficult to detect the bias and determine the true source of the information. My point is that private sector R&D funds account for over 90% of all new therapies. The same folks that developed the drugs are often the most qualified to communicate information about the drugs. If we eliminate all communication/education that takes place with direct and indirect funding from drug companies, we will be doing a disservice to ourselves and our patients. This issue is complex and too many of the posts I read call for a poorly thought out solution.

    • gzuckier

      well, pharma would undoubtely continue their current level of support, only anonymously, to demonstrate that the system works to improve medical care, not to grease the palms of starving physicians who in turn metaphorically kick it back to the brandnames they see covering their bar tab.

  • Molly Ciliberti, RN

    Great post! I have often wondered about all the money Big Pharma spends on marketing at shows like AMA, ACEP, AHA, ACA, etc. when they have huge booths manned by armies of little power suited sales persons and give aways from the trinkets to the iPad lotteries, and then has the audacity to charge sick people hundreds of dollars a month for prescriptions that they cannot live without. This isn’t R&D money folks; it is marketing and it is out of control.

    • Charles R

      The medical societies would not be able to hold annual meetings in the manner they do now. Doctors would have to pay thousands of dollars to attend instead of a few hundred. The landscape would change 360* as the very same that criticize pharma, depend on funding from pharma. Those exhibits someone mentioned are what funds the overall scientific program of the society meeting. This reality check wold be good for all stakeholders to experience.

      • Charles R

        Have you ever been to a medical society meeting? ASCO is in Chicago next month. Pretty important gathering of experts, a lot of new data will be released, with access to the principal investigators and lead authors. Oncology experts from allover the world will be in Chicago. So, there must be some value to this. Not sure it could take place without funding from industry and an “exhibit hall”. But I would like to see pharma discontinue funding, even if only temporarily, just to see what would happen to the entire landscape.

        • gzuckier

          Yeah, sounds like my industry, if you don’t attend conferences you fall behind. Of course, even despite some sponsorship, it still costs us a bundle to attend. But we’re not as needy as the medical profession apparently is.

      • http://Www.twitter.com/alicearobertson Alice

        I recently went to Chicago for a cancer symposium. Committed people and doctors gave their time for free and I picked up quite a tab for travel. It was worth every penny. The doctors were professors and they were communicative, great at opening ideas that are “controversial”…very astute.

        Why is it different for doctors who would get a tax deduction? I went to learn….it was worth the sacrifice monetarily and personally.

      • stitch

        Not all meetings take place at fancy resorts; in fact, I’ve only been to one such meeting and to the best of my memory, there were no reps (but it’s been 10 years.) The meeting costs were expensive, I was in class 12 hours a day, and there were no “prime rib dinners.” There is value in actually sitting with other people and having active discussions about topics.
        I do much of my CME by book or by computer these days. I am fortunate to live in a town with two excellent medical schools who regularly sponsor conferences, and it’s no seaside resort. Even so, the fees for a week of CME can top $1200 or more.

      • gzuckier

        they might not be able to go to hawaii, might end up in nashville!

  • http://kevinmd Mary

    Don’t know if you all. Know this but pharma does not give out “trinkets” anymore. Who is going to pay billions to research drugs that may no come to market? Can you apply for a loan and tell the creditor you might not have anything to show for it? Europe waits for the US to do the research because with universal healthcare, there is no funding for research

    • http://Www.twitter.com/alicearobertson Alice

      Big Pharma isn’t going anywhere…no fear there. They will make their money….give insider tips to the powerful in exchange for their blindness. And buy some burgers so doctors will do the same.

    • gzuckier

      You realize that the majority of basic medial research is academic, pharma only seizes on the most promising and R&D’s it? Even that pipeline is drying up now. Of course, medicare used to offer higher reimbursements to academic medical institutions to cover the basic research, but they stopped that a few years back.

  • Mary Kemen, MD

    There is no question that marketing by pharmaceutical companies is directed solely at increasing market share. I agree that occasionally useful information is gleaned from a rep but it is always suspect coming from an individual who benefits from the sale of the drug discussed. Why do we continue to wallow in corporate medicine in this country? Why do physicians not communicate directly with one another about which drugs or therapies work best for their patients? As was suggested above, a blog, website or webinar for physicians would be an efficient way to compare notes and spread ideas. Why do companies still provide vacations, dinners, t-shirts, coffee mugs, etc, etc when the real need is for development of meaningful therapies? To say no research happens in Europe because they do not have our system ignores the abundance of fraudulent research that has been unearthed in our system of late. There has been massive dishonesty and complicity on the part of physicians and companies hoping to reap financial rewards. I hope European doctors are carefully scrutinizing any research results which will change their treatment regimens. Our health care “system” is tainted by profit, blindness to the suffering of nonpayers and elitism.

  • http://kevinmd.com Mary

    Do all you providers work for free? Do you not benefit from your patient’s ills?

  • Mary Kemen, MD

    I favor a single-payer system which would eliminate the profit motive for physicians as well. Basic health care should be a right in the wealthiest nation in the world. Physicians should no more profit from the ills of patients than medical supply companies. We should make a living but not expect to join the ranks of the financially elite via the medical miseries of patients.

    • Charles R

      Who pays the cost of medical school and training in your system? Does your system also include major tort reform? Does your system still attract the very brightest young students in the world choosing a career as a doctor? There are clear merits to a system as you have described, but there are a lot of moving parts to consider. I am not offering a better solution, just a perspective after 30 years in health care that acknowledges how complex of a topic this is.

      • http://Www.twitter.com/alicearobertson Alice

        The answer is Uncle Sam…yech! Where they can choose your specialty. I do not want the government to own my doctor….nor Big Pharma.

        • http://Www.twitter.com/alicearobertson Alice

          Nope…not joking! Lived in the UK…can get free care there….no thank you to government care.

          Recent Regulation has forced insurers to spend a huge proportion on the patient. The government refused my friend’s Medicare claim. It is cheaper to cut off his leg. They have exhausted the appeals, and their specialist. The infection traveled to his heart.

          We were denied a claim, but it was not life threatening…more cosmetic ( daughter has a rare keloid problem associated with American Indian DNA). The government would have denied more though…like thyrogen, etc.

          Insurance companies own doctors? Hmmm….doctors hate them.

      • stitch

        Fine, as long as those ratings measure something truly valuable and not just the easy, low-hanging fruit. Right now hospital ratings include parking. No kidding. But hey, if that’s how you want your health care measured, have at it.

      • gzuckier

        well, the news flash is that ANY profession/job/career right now is risky. i think the average new MD is in better shape, risk wise, than the average new engineer or architect. i don’t know about lawyers, though. they always make out.

    • stitch

      The problem is, tony, that there is a paucity of research on many conditions. Heart disease, diabetes, asthma, okay, lots of people suffer from those conditions and there are guidelines. But many people have more than one of those problems, and most guidelines don’t take into account those interactions or the contradictions that can occur among guidelines for different conditions. Not to mention that individual patients don’t “read the book.”
      The problem with too much reliance on guidelines is that it does not allow for individual variances.
      What we really need to get away from, however, is the ridiculous premium put on procedures and pay providers for thinking. Otherwise we will continue to have, as Abraham Verghese said, a system in which we get paid more for doing to the patient than for doing for the patient.

    • imdoc

      Reality check: Like it or not, if you make your living as a doctor, you are in some fashion profiting from the ills of patients.
      Second, the US is not the wealthiest nation in the world. We are the greatest debtor nation. Stay tuned as we enter severe inflation and a debt crisis. This is happening because of the delusional thinking that society can provide all things to all people, resulting in unsustainable social programs.
      Lastly, I have yet to hear a working definition of “Basic health care”

  • Mary Kemen, MD

    I do realize that pharmaceutical and supply companies have a role in most medical conferences. I do not find that quite as troublesome because there is so much open discussion amongst reps and physicians in those settings. I have a huge issue with companies supplying lunch to offices, hospital staff, physicians. I also think the vacation or elite destination junkets should be eliminated.

  • Mary Kemen, MD

    I would insist upon tort reform, though recent analysis shows malpractice is actually a very minor component in the burgeoning cost of medical care. I believe malpractice would be improved by having screening boards of ACTIVELY PRACTICING physicians to vet cases.
    Medical training should be a cooperative expenditure between tax payers and students, as is currently the case with all collegiate and professional education.
    As for attracting the “brightest young students in the world” to be physicians, I fear we are doing only that, with no consideration for the compassionate, patient-directed individuals medicine so desperately needs. Medical schools are engaged in an arms race to attract those with the highest scores, even though no one has shown that these candidates make the most effective physicians. The financial and emotional abuse of med school and residency leaves individuals who are too often looking for high pay, fewer hours, no call. A survey of medical students in the AMA newsletter in ?2008 showed the decline in students’ empathy with each successive year of medical school. You should look it up in the archives. It was a very disappointing trend, to say the least.
    The equation is indeed complex but I see a dramatic increase in the arrogance and demanding behavior of physicians which seems to parallel the corporate turn of medicine in my community and nationwide. I recognize the expertise and hard work of physicians but feel the encroachment of corporate care has significantly impacted the cost of care across the board.

  • Mary Kemen, MD

    I totally agree! I think the biggest myth in our current system is that we do not have rationing. We have extreme rationing, based on ability to pay, city of residence or neighborhood. If one is lucky enough to survive to age 65, the entire gamut of care is available – total joints, ICDs, ICU care – but the expense of required medications may be prohibitive. If one is insured and under 65, much of care may be available, unless there is a pre-existing condition or one’s employment status suddenly changes (fewer hours or termination). Medicaid allows excessive visits to ERs but is not accepted by too many primary care offices. And the bottom of the heap is the poor individual who may work 60 hours a week but have no benefits.
    We need to stop providing care based upon ability to pay! It has NEVER provided the best care in the most humane fashion for the best price. I agree that we need standards of best practice which determine who gets an ICD, dialysis, ICU care, total joints, etc, etc.

  • Mary Kemen, MD

    Some of the care Medicare denies is appropriate. We cannot afford to provide many forms of care we now do, whether through Medicare or private insurance. For instance, Medicare just approved use of the new prostate cancer wonder drug, which prolongs life by a matter of weeks at a cost of $90,000. Is this cost/benefit ratio sustainable for those who are 80, 90 or older? What about the dramatic increase in patients requiring dialysis, many of whom develop kidney failure because they received inadequate care for hypertension or diabetes? As Tony says, how do we justify letting people die of preventable diseases because they lack the funds to see a doctor or purchase medications?

    • imdoc

      “Medicare just approved use of the new prostate cancer wonder drug, which prolongs life by a matter of weeks at a cost of $90,000. Is this cost/benefit ratio sustainable for those who are 80, 90 or older?”

      NO, and it is likely only a few would choose to pay this with their own funds, but you insist we cannot distribute care based on ability to pay. Which way is it?

    • gzuckier

      Actually, the previously approved chemotherapy for prostate cancer of that same stage costs about the same, the only saving is that it is so brutal that only a small fraction of the patients stay on it; they either quit, or die from side effects. Whereas this new therapy is mild enough that patients can continue for the whole 2 years or so median extended life. So, call it $50k to extend life an average of each year… ?? I don’t know how to evaluate it, except that if we approved the previous drug, it would seem we ought to approve an improvement over it unless we are so cynical we want to profit from the previous drug’s death rate.

  • Mary Kemen, MD

    I disagree with Charles that the person most qualified to discuss a drug is the pharma rep. That is not the individual who developed the drug or is familiar with the clinical points of judgment. Many (most?) pharma reps do not have a scientific or clinical background. They have never used the drug. They are trained by the company promoting the drug and gather information incidentally from physicians. Their information is not assimilated in a systematic, unbiased fashion. When Midazolam was first introduced in Europe, there were many deaths because the company marketed it as a Diazepam equivalent. Its dosing and profile are quite different.
    I would rather learn about medications from physicians who have studied the drugs clinically and have experience in their usage.

    • gzuckier

      i don’t know how many are familiar with how tightly the FDA oversees the Chinese Wall between marketing and scientific representatives of pharma organizations; a lot of training of reps goes into ” if the conversation turns in this direction, tell them you can’t discuss it and steer them to this guy, who can”. For instance, at a scientific meeting, market reps are not allowed on the exhibit floor, but they are allowed to hang around outside the hall, and inquring docs get steered there by the scientific reps should they come up with questions that veer off pure scientific info.

  • http://kevinmd.com Mary

    I am always amazed when I see professionals with the attitude of throwing the baby out with the bath water. Why is there a need to use all inclusive statements such as pharma is bad. When I was in practice I saw many unethical practices from health care professionals who were suppose to have the patient’s interest at the forefront. In all segments of society there will be the ethical and unethical people, whether it is in medicine, nursing, clergy, banking etc. But to use statements as all pharma is bad, is really narrow minded thinking.
    If it wasn’t for pharma, we wouldn’t have the decreased mortality from childhood diseases; cures for many forms of cancer that once were fatal. We would be prescribing castor oil and arsenic. Mortality for heart disease, stroke have decreased due to the research and development of new therapies. Of course there have been unethical practices among all segments of society, but most of the people I know working in pharma are working hard to support their families just like you and I. In addition, they are ethical in their work.
    I am not sure why in society today, there is a need to generalize all people in a particular group. I am always amazed when I hear these blanket statements used by people with advanced education.
    We never hear about the high cost of hospitalizations and the ten dollar tylenol given to patients while in the hospital. Or the high cost of higher education; Is it because we are like sheep and articulate what is told to us by the media?
    What group can we vilify next?

    • http://Www.twitter.com/alicearobertson Alice

      Mary..it is not the innovation and research that are bothering us….it is integrity. And doctors are researchers (a study on research methods is quite eye opening too). Doctors deserve a lot of credit for discovering methods that may he keeping more people alive than the pharmaceutical companies. I believe hand washing, indoor plumbing, sewers, sanitation, exercise and eating well are more helpful to mankind.

      Years ago they would put secret cameras in our cars and appliances and tape the repair men replace brand new parts that were completely unnecessary. The public screamed…the repairmen were on commissions. Patients often feel like that when they hear their doctor is taking a type of commission at their risk, expense, or ignorance. It is worthy of conversation.

      Another practice that needs to end is doctors investing in innovation and using that product for self gain. The Clinic was sued for this, and changed the practice. Items concerning heart surgery, stents, etc., where the surgeon would choose to use the brand they were invested in on the patient. As we now know stents can be worthless and unnecessary. But as long as an element of self gain persists at the patient’s peril….well…let the public conversation amd exposes continue. There is nothing wrong with wondering if the person you are paying to treat you has ulterior motives. The honest doctor should have the answers to these questions…as crisis counselors love to say, “Keep ‘em accountable”. Or the Reagan advisor Luce…”Trust….then verify.”. Do this beforehand because after the fact cause tons of emotional distress….really…it can be preventative medicine to look before you leap.

    • gzuckier

      we talk about how the current medical “system”, industry, really, is set up with some inherent structures that make it difficult to optimize best care/lowest cost. In the same sense, the pharmaceutical biz is structured as a high risk high gain industry, where the company essentially stakes everything on each drug development. Similar to the computer chip biz, if any of you have any experience there. A couple of serious failures in a row in late phases of clinical trials, after a ton of money has already been invested, and you’re in serious trouble. Nobody’s going to invest in that casino unless the win is big. If we want to reduce their profit margin, we need to reduce their risk. I.e., completely restructure their industry, the same as we are trying to do with our medical delivery system.

  • Laura

    Thank you for this inside look at the thought process for and against the use of drug reps that you all struggle obviously struggle with. I am not a medical professional, but a patient with MS. Yes, MS is a disease that is treated with very costly drugs, most of which are still under patent protection. Treatment of this disease for me and the other 400,000 of us in the US alone, would not be there if it weren’t for BigPharma. Our choice is to face a future of extreme disability – probably at the very least being in a wheelchair in less than 20 -or trust what is being offered to us from the pharmaceutical companies and our neurology specialists.

    This is also a disease that a growing number of people who live with MS believe that it is a conspiracy of BigPharma to keep us ill, they are not working to find a cure and blocking possible treatments, just to satisfy their share holders. Go to facebook and search the CCSVI communities if you want to hear their perspective. For the record, I am not one of those people and their singlemindeness frightens me.

    Several of you insightfully point out, as the consumer we are tremendously confused and conflicted. The recent out-of-court settlement by a very large player in the MS drug picture over their alleged influence of doctors to prescribe their drug over the other disease modifying drugs for Multiple Sclerosis patients, leaves us wondering about a number of issues, including the question if we received the best medical advice when being offered this drug.

    I know I speak for many of us when I say that I hate that our attention is diverted from being compliant patients and following our doctors orders in our battle against MS. As a group, we are conflicted by all the changes facing the medical industry as a whole. It has to be equally difficult if not more so for you doctors.

    Thank you all for being the best doctors you can be – we need more of you in the trenches for us. My apologies if I inappropriately jumped into your blog with my observations.

    As for me, I would be happy to trade in the annual cost of my MS for that Shelby, but make mine red; my husband wants the black one with the remaining balance of money spent for my care each year.

    Be well.

  • imdoc

    Some history may help: FDR put wage and price controls in place in WWII. Employers responded by adding medical benefits to attract workers. The whole system of benefits then got institutionalized after the war, giving us the present employer-based system. LBJ set up Medicare/Medicaid which promotes price controls, cost shifting, and has led to current lack of price transparency. Pharma is operating in this delivery scheme, so except for the $4 generics, there aren’t a whole lot of market forces in play.
    Now, we all “need” health insurance or a public plan so we can have a ticket to the game.

    • gzuckier

      I don’t want the government choosing my health care for me! I want my employer to do so, as God intended!

  • http://kevinmd.com Mary

    Dr Mary
    In order to be hired by pharma the minimum requirement is usually a bachelor in science with often biology and chemistry as the degree. Today many pharma companies are hiring NPs, PAs and MDs as well as PhD in sciences. The person without those degrees do not have a good chance of being hired for the job. In addition, the training is several weeks with tests on the study design(ie is it a good or poor study), what are the endpoints, subjects etc. In order to continue with the position, the candidate must know the disease as well as all treatment modalities as well as know all or most of the studies on the product. Because of the rules of the FDA, only approved statements by the FDA are allowed to be discussed. So it may appear that the person may not know as much, but often they have extensive knowledge but cannot share unless approved by the FDA
    I have worked for two pharma companies and the expectations for knowing the disease and the therapeutic modalities is extremely high. Also if a person is found to go off label, immediate firing is usually the case. Hope that clears up that perception

    • gzuckier

      The fact that drug reps tend to be not just well educated, but also young, attractive, and mostly female doesn’t help the stench much….

  • doctor1991

    Late to this discussion. Interesting if predictable viewpoints. A few observations, along the lines that people in glass houses should not throw stones:
    1. Drug reps always overestimate their influence, because it justifies their position.
    2. One’s susceptibility to marketing is usually inversely related to their income; as doctors’ incomes decline, they will become more susceptible. From our office, it is not the attendings, but the medical assistants and front desk workers who attend the drug dinners. (and the PA, who writes more brand name than anyone else) In socialized Europe, I am told it is common for the drug companies to get cars and condos for docs- it is illegal, of course, but apparently goes on.
    3. It is advertising from Big Pharma that allows all of the “know it alls” in their ivory towers to publish in journals to get tenure and then speak at conferences and collect their honoraria.
    4. Most educational information about new drugs IS now done through webcasts and teleconferences.
    5. We should also examine how much money is spent on marketing by hospitals and universities to pat themselves on the back. The saintly Cleveland Clinic sends me multiple glossy propaganda packets even though I live far away on the east coast. How much is spent on advertising on the radio and television? I am sure the cost of 30 seconds in prime time (as well as all the dinners and travel that go along with selling that) is astronomical compared with bringing sandwiches or coffee. But I have to stop typing because it is time to go to my bank (or local political party headquarters) to pick up my free pen to write my prescriptions.

  • http://Www.twitter.com/alicearobertson Alice

    But I have to stop typing because it is time to go to my bank (or local political party headquarters) to pick up my free pen to write my prescriptions. [end quote]

    Ha! You mean you didn’t tap into the taxpayer bonus for EMR’s? A purist!

  • Deep Ramachandran

    Wow, never expected this kind of response after writing about eating a burger! I have been contacted by CNN, requesting an interview. My response and an update to this post have been posted at caduceusblog.com.

    • Laura

      This is such a hot topic on so many levels – I hope you will continue this discussion. I read your blog response and I find it interesting that CNN gets some of its news headlines from blogs. Congrats on opening up a significant dialogue. best, Laura

    • http://ethicalnag.org/2010/10/31/is-your-doctor-a-thought-leader/ Carolyn Thomas

      Hi Dr D – I think you should have said YES to the CNN interview. Otherwise, their reporters are just going to go talk to one of those “thought leaders”, as Big Pharma likes to call their hired ‘white-coated MD sales reps’ – where they’ll be told that there is simply no problem at all whatsoever with Big Pharma spending $7+ billion marketing directly to doctors last year.

      You might also be interested in attending the upcoming Georgetown University CME conference, June 16/17 in Washington called “Pharma Knows Best? Managing Medical Knowledge” co-sponsored by PharmedOut and the Kennedy Institute of Ethics – http://www.pharmedout.org/2011Conference.htm

      • Laura

        Carolyn,
        Do you still live in Canada? I’m wondering how this all plays out in your system of medicine up north.

        • http://ethicalnag.org/2009/12/12/pfizer-exec-cihr/ Carolyn Thomas

          Yes, a proud Canadian here in the commie pinko land of socialized medicine, where Big Pharma wields a similar power to yours in its rush to “marketing-based medicine”. In a brilliant tale of foxes guarding the hen house, for example, we had a wee bit of a scandal here a couple years ago when Bernard Prigent, vice-president and medical director of Pfizer Canada (and coincidentally a registered Pfizer lobbyist) was appointed to the governing council of the Canadian Institutes for Health Research, which funds the work of thousands of medical researchers across Canada. This government appointment was all the more remarkable because just a month earlier, Pfizer had been fined $2.3 billion – the largest criminal fine ever assessed in the U.S. – for fraudulently marketing its arthritis drug Bextra to physicians.

          Prigent’s appointment (and subsequent near-universal condemnation from medical ethicists here because Pfizer stands to profit directly from the decisions made at CIHR) resulted in an extraordinary review by the Canadian Parliamentary Standing Committee on Health, but his appointment was not reversed.

          “Quelle surprise….”

    • http://Www.twitter.com/alicearobertson Alice

      So does this mean the burger lunches are but a distant (and bad) memory? Doctor prescribing a cleanse? :)

    • gzuckier

      you’ve tapped into a larger topic, explicit or implicit: marketing is destroying everything. I’m not exaggerating. We marketed the war in Iraq to the citizens, for God’s sake. And why not; terrorism is marketed these days to susceptible youth. We elect our politicians on the basis of their marketing. We’re trying to decide whether to do anything about global warming or not, based on the marketing of either side. If you don’t have an example from your life of how somebody got a job for which they were unqualified because they were a good salesperson, then you’re that unqualified salesperson…….

  • http://Www.twitter.com/alicearobertson Alice

    Laura there are staff at hospitals, big businesses, and news stations that do nothing but search google, and search engines. We were sitting with our doctor and he ran out to get me a copy from the network printer and one of the staff shared something with him. He came back beaming and explained that the conversation we witnessed was about two great reviews for him on Facebook. The hospital was scanning everywhere for reviews on each doctor who works for them.

    Also, many people gripe online about stores or products. The squeaky wheel gets the grease.

    • Laura

      Alice, I work at a university and social media drives the market for us in more ways than one. Many of our profs will deny it publicly but they all know what ratemyprofessor.com says about their classroom demeanor. We encourage members of our MS community to do the same for neurologists who do and don’t meet our needs. It’s the way we all do business these day.

      • http://Www.twitter.com/alicearobertson Alice

        Laura…so the professors do not like being rated?  Hmmm….sorta reminds me of another occupation….gosh…isn’t the Internet just so intriguingly and fascinatingly changing the landscape of privacy, office visits, classrooms….and exposing of arrogance?  Problem is amidst our onslaught of images, and the sea of words, we must use our newfound power with great restraint and discernment.

        Looks like the captives have been set free:)

      • gzuckier

        but of course, 90% of the folks writing on the internet are cranks. or maybe i should say that 90% of the writing is crank writing; it’s not so many cranks just that the amount of writing is proportional to the degree of crank.

        I actually looked on the internet for reviews of the surgeon who i had picked to do my surgery, described elsewhere…. found only one review, not good at all. But, in fact, it was such a bad review it raised my crank flag so I ignored it. And the surgery went unbelievably well in all aspects. I suppose I should write a good review now….

  • Laura

    Alice, Funny, but the poorly rated professors claim they don’t know what this site says, but we all know differently. The well rated profs just knowingly smile when it is mentioned.

    The students certainly gage their class choices from their peers’ reviews and comments. I do the same with my doctors – I have rated my neurologist on several sites, but they have all been positive reviews. When I have a complaint/criticism/suggestion, I take it directly to the doctor and staff rather than anonymously bashing them online. As consumers we are going to continue to use these internet tools and hopefully they will be well informed decisions.

    This ability to hide yet be vocal on the internet leads to all sorts of problems – unsubstantiated claims/criticisms and plagarism are at the top of the list of abuses I see all the time.

  • gzuckier

    easy: let me give you an example. I had ulnar nerve surgery last year. hospital billed amount: $8,000+. (including anesthesiologist, not including surgeon). insurance discounted amount: $2,000. I paid $200 of that as copay, and of course the rest of the $2000 (and all the other charges of all the members) are averaged out over all the members’ monthly payments, but even with 25% overhead (including 3% profit), that means my actual marginal cost for this operation was in the neighborhood of $2500. Thus, the value the insurance companies brought to this particular consumer was $8000 – 2500 = $5500, just for this one operation.

    Let me put it another way; if it weren’t for the insurance, I couldn’t afford to have my arm fixed, even though I know over time (prior and post) I’m going to pay the insurance back what they spent plus overhead and profit. It’s not just the “insurance” function, as many have observed that’s a misnomer given the current system; it’s the volume bargaining power, along with what appears to be extreme elasticity in the fees charged by all providers in the medical system, to the detriment of the uninsured.

  • http://Www.twitter.com/alicearobertson Alice

    American Scholar has an interesting article on this; Flacking for Big Pharma

    http://www.theamericanscholar.org/flacking-for-big-pharma/