ProPublica’s Dollars for Docs: Strengths and weaknesses

The non-profit media organization ProPublica last year announced a new website/database called Dollars for Docs. It lists cash payments made to 17,000 U.S. doctors by seven large drug companies.

I’ve been browsing through the database and I have some thoughts about its strengths and weaknesses—and how it might be useful for patients.

First, here’s what these journalists did. Rather than waiting for the provisions of the Physician’s Payments Sunshine Act to take effect in 2013 (this will be a public website listing all payments to doctors from all drug companies), they decided to take matters into their own hands. Seven companies currently post physician payment data, in most cases because they were forced to as part of legal settlements. The problems is that these websites vary in quality and usability, and of course the data is split up among seven different sites.

ProPublica assigned their journalists the daunting task of combining all the data into a single spreadsheet, which is titled “Dollars for Docs”. There are two ways you can use it: either by searching for a specific doctor, or by browsing the entire database.

For example, suppose you were interested in Dr. Lawrence Dubuske, the asthma expert who famously resigned from Harvard rather than having to abide by its new prohibition on promotional speaking. You would simply type in his name, click “search”, and you would find following entries. He received $25,500 from AstraZeneca in Q1-Q2 of 2010 for “speaker compensation;” $121,875 from GSK in Q2-Q4 2009 and another $72,400 in Q1-Q2 of 2010 for “speaking.”

Missing from the data, however, is any indication of what he was speaking about, who he was speaking to, or how many talks he had to give to make that kind of serious money. That’s not ProPublica’s fault, but rather the fault of the companies for not being specific enough. It would be crucial for me to know, for example, that my doctor made $100,000 for promoting the drug that I was just prescribed. The drug may be the best choice, or it may not be, but either way, I would feel deceived if I knew nothing about the doctor’s glaring conflict of interest. If I did know about this, and if I had enough chutzpah, I might then ask my doctor whether the money influenced his or her prescribing decision. (The inevitable answer: “Of course not, this money has absolutely no influence on my medical decisions.”)

There’s another way to use the Dollars for Docs database, although this is not spelled out on the website. If you want to browse for all the doctors in your city or state who are “on the take,” simply leave the “name” field blank, choose a state from the drop down menu, and click search. You’ll get a huge spreadsheet which is arranged alphabetically by last names of the doctors. By clicking on the various columns, you can sort the data by city, drug company, amount of money, or time period of the payments. This is a nice feature that is absent from most of the drug company databases.

I sorted all Massachusetts docs by “amount” and found that one doctor received only $17 from Eli Lilly in the first quarter of 2010. This payment was described as “Advising/Consulting and International Education Programs.” I’m not sure what that means, but I can’t imagine that Lilly got too much “advising” work out of this particular doctor.

Anyway, I scrolled down the chart looking for the more well-funded docs, and in doing so I quickly comprehended what is probably the most striking aspect of this database—the sheer enormity of it. Sure, I already knew from published surveys that well over 100,000 doctors receive cash from drug companies. But that number becomes much more tangible as you scroll through an endless list of doctors’ names, each associated with a specific dollar amount. The thought that runs through your mind is: “How have we allowed this to happen to our once proud profession?”

But occasionally I came across the name of a colleague who I knew was ethically scrupulous. In one case, for example, a friend was listed as having received $20,000 from a company for “consulting.” He is a former medical school classmate of mine, and I know he does serious epidemiological research, and that he is uninterested in working with drug companies. The point, again, is that without getting more specific information it’s hard to know what to make of these numbers.

Nonetheless, this database focuses on explicitly “promotional” activities, such as speaking and marketing consultation, and does not include payment for research studies. The vast majority of payments are for doctors who give “educational” talks to other doctors, presumably focusing on one of the drugs made by the funding company.

Is it ethically “bad” for your doctor to give these talks? That’s controversial. Clearly, there are some good apples who will express their honest opinions about which drugs are best without being influenced by the allure of money.

Nonetheless, doctors aren’t dumb, and they are acutely aware that they are serving two masters: the stockholders of the company and the doctors they are teaching. If they say bad things about the company’s drug, they’ll watch as the speaking invitations magically evaporate.

The true malfeasance here is in the aggregated effect. The companies are using these legions of doctors to artificially manipulate medical discourse. Any doctor who participates in the enterprise knows exactly how they are being used. You decide whether this is “immoral” or not.

Daniel Carlat is a psychiatrist who blogs at The Carlat Psychiatry Blog and is the author of Unhinged: The Trouble with Psychiatry – A Doctor’s Revelations about a Profession in Crisis.

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