Originally published in MedPage Today
by John Fauber, Milwaukee Journal Sentinel/MedPage Today Reporter
When looking for a doctor to travel the country to promote its prescription fish oil product, a leading pharmaceutical company looked to a small-town community doctor rather than an academic heavyweight.
Its choice was a Delafield, Wis., primary care physician and clinical lipidologist who entered private practice in 2001.
For speaking engagements over just three months of last year, Tara Dall, MD, earned $45,000, making her one of the most highly paid of the more than 3,600 doctors who spoke for this company, which was one of four drug companies that made public their payments to physicians for promotional talks.
George Ho, MD, a urologist in private practice in Columbus, Ohio, was paid about twice as much as Dall to give dinner talks about a drug used to treat prostatic hyperplasia.
Rod Halvorsen, MD, a private practice obstetrician/gynecologist in Manitowoc, Wis., was paid $61,000 during the first nine months of 2009 for talking about osteoporosis drugs for a different drug company.
Not bad for part-time work, but does work of this type improve the quality of medical care?
The practice of doing promotional speaking for drug companies is not new, but it has come under fire in recent years.
In this special report by MedPage Today and the Milwaukee Journal Sentinel we examine the forces behind the recent increase in the use of non-academic physicians on the “dinner speaker” tour and the arguments used to support it and criticize the practice.
What’s Wrong with Dinner Speeches?
The arguments on this issue — and there are many — tend to break down into two distinct camps.
Critics of dinner meetings say the talks are biased and may contribute to spiraling healthcare costs by promoting the use of more expensive brand name drugs over generics. They charge that such talks have led to off-label prescribing.
Proponents counter that the talks provide a direct conduit to the practicing clinician and, in fact, deliver the latest clinical findings to a busy audience.
For years, drug companies sought out influential academic physicians with impressive research credentials as their dinner speakers, hoping that the doctors listening would be convinced — not only by the message, but also by the messenger — to write prescriptions for the drug being promoted in the talk.
Lynne Peterson, editor-in-chief of the newsletter Trends in Medicine, who frequently attends dinner talks, says a lot of doctors get useful product information from the events.
She said many doctors no longer see sales reps, and academics increasingly are barred from giving paid talks. “If community doctors are also restricted, then where will doctors hear about new drugs and devices?” she asked.
Critics say the doctors who don’t attend promotional dinners have numerous ways to keep up with the latest research through professional journals, conferences and courses, and consultations with other physicians.
In the past, drug companies claimed they would have little choice but to rely on private-practice physicians for promotional speaking if medical schools banned their staff from participating, said Susan Chimonas, co-director of the Research Center on Medicine as a Profession at Columbia University — a medical school that has, itself, come under fire for its relationships with makers of percutaneous coronary intervention devices.
Chimonas described what she called a frequent pattern with doctors who speak: When doctors learn more about the drugs they are discussing, the talks become less positive, and when that happens “they [the paid speakers] get dropped.”
She said the speakers — be they academics or community physicians — do the work for different reasons. For some, she said, “I think it is ego. Some of them think they are doing a good thing.”
Chimonas said she believes the doctors “are clearly being used.”
Drug companies, meanwhile, have been forced to recruit new speakers as leading medical schools — including Harvard, Stanford, the Mayo Clinic, and the University of Wisconsin School of Medicine and Public Health — have developed conflict of interest policies that ban their physicians from doing such talks.
“There has been a clear trend to ban or restrict the practice at leading academic centers,” said Ann Bonham, chief scientific officer at the Association of American Medical Colleges.
Within five years, she predicted, most medical schools will take such action.
In 2008, the Association issued a report strongly discouraging academic physicians from doing drug company speaking.
At the same time, it’s difficult for physicians — especially those whose academic rank is assistant or instructor — to pass up the extra income. Payment lists released by four drug companies, Cephalon, GlaxoSmithKline, Lilly, and Merck, confirm that last year alone tens of millions of dollars were paid to doctors for promotional speaking.
Perhaps no case illustrates this dilemma better than that of Lawrence DuBuske, MD.
In January, DuBuske, resigned his position at a Harvard teaching hospital rather than give up his drug company speaking. He was the top-earner on a list of payments made public by GlaxoSmithKline.
It was front-page news in the Boston Globe when he said that was resigning because his hospital, Brigham and Women’s, and Harvard had adopted a policy on Jan. 1 banning doctors from doing such speaking.
DuBuske, an allergy and asthma specialist, was paid at least $99,000 by GSK during the second quarter of last year alone, more than any other doctor in the country.
The Law of Unintended Consequences
While medical schools can restrict speaking and require doctors to fully inform patients of ties to drug companies, there are no such restrictions on physicians in private practice.
About 45 doctors from Wisconsin got payments from one company of at least $1,000 during the quarter for which GSK publicly released payment information. All but 10 of them were in private practice.
Nationally, only eight doctors among the top 25 earners on one company’s speakers’ list had full-time university positions.
Critics suggest that community physicians are free agents, not subject to institutional controls and with little incentive for self-censorship.
Delafield’s Dall serves as an example of some of the issues that can arise. She hedged when asked if she fully disclosed her financial relationship with drug companies to the patients.
“Whether I tell every single patient, I’m not sure. It is absolutely disclosed to patients that I am a speaker and that I speak for pharmaceutical companies and it is listed on my Web site,” she said.
Dall’s resume indicates she was a paid speaker for six drug and medical companies. She also is active as a speaker at community events, as she notes on her Web site, http://taradall.com.
It should, however, be noted that while the issue of disclosure to patients raises ethical questions, a review of GSK-produced slides used by Dall found no evidence of factual errors.
Last year, the Journal Sentinel series “Side Effects” found that there was little disclosure to patients of drug company ties among dozens of doctors at the University of Wisconsin.
That led to a ban on promotional speaking. And signs are now posted at the UW Hospital and clinics informing patients that their doctor may have a financial relationship with a drug or medical device company and telling them they can find out the details.
Manitowoc’s Ob/Gyn Halvorsen earned his $61,000 during the first nine months of 2009, according to information publicly released by Eli Lilly & Co.
Halvorsen said he gives talks involving osteoporosis drugs, as well as about osteoporosis in general.
He said he has a passion for the topic because his mother died as the result of osteoporosis.
Halvorsen said he does not tell all his patients that he is a paid speaker and consultant.
Will Public Disclosure Help?
It is impossible to say exactly how much physicians — be they academics or community physicians — are being paid on an annual basis for promotional speaking. There is no federal requirement that either the doctor or the drug company publicly report such income.
U.S. Sens. Herb Kohl (D-Wis.) and Chuck Grassley (R-Iowa) would like to change that. They’ve introduced legislation requiring pharmaceutical companies to make public their payments to doctors in order to highlight conflicts of interest for the public.
But Cephalon, GlaxoSmithKline, Lilly, and Merck are not waiting for the new law. Late last year, all four companies began publicly listing payments to doctors.
Two of those lists, from Lilly and Cephalon, were part of legal settlements.
Lilly’s disclosure of doctor payments was part of its 2009 settlement of a U.S. Department of Justice investigation of its marketing of the antipsychotic drug, olanzapine (Zyprexa), which was being promoted for elderly dementia patients when it was approved only for schizophrenia and bipolar disorder.
“Obviously we are required to do it, but Lilly believes it is important to be transparent,” said company spokesperson Carole Puls.
Transparency is clearly the new watchword as several other big drug companies are promising to make public their payments to doctors this year.
The lists from Cephalon, GlaxoSmithKline, Lilly, and Merck, which look at part of 2009, provide the first glimpse at the cost of drug marketing as well as financial ties between individual doctors and drug companies.
For just those four companies, more than 10,000 doctors and other healthcare professionals from around the country did promotional or other consulting work at some point in 2009, according to an analysis by the Journal Sentinel and MedPage Today.
GlaxoSmithKline said it does not seek doctors in private practice over other healthcare professionals. But the company acknowledges its speaker program has been affected by new conflict-of-interest restrictions put in place by universities.
The company looks for respected, qualified experts who are good presenters, said Mary Anne Rhyne, GlaxoSmithKline’s U.S. director of media relations, in an e-mail response to questions.
GSK chooses the speaker, the topic, and program content, as well as provides slides, Rhyne said.
“Sharing information on complex disease states is important to advancing patient care, and healthcare professionals often learn best from their peers and colleagues,” she said.
When it comes to published studies in peer-reviewed medical journals, however, there was little to be found for Dall.
Nonetheless, Rhyne described Dall as highly respected with significant experience in clinical lipidology.
She said Dall brings a unique perspective as the medical director of one of the few lipid clinics in the country.
Many private practice doctors also have strong research credentials.
Ho, the Columbus, Ohio, urologist who earned $87,000 for just three months of talking about a drug to treat enlarged prostate, said that he has done basic research on the drug and that he was mentored by the Nobel scientist whose work led to development of the drug.
Last year, Ho was frequently contacted to do speaking, in part, he says, because new data were coming out on the drug, and a lot of doctors had questions, including whether lower-than-approved doses can be used.
With pressure to cut doctors’ fees and possible cuts in Medicare reimbursement looming, the speaking money has been a way to supplement his income, he said.