The doctors' bashing continues...

[W19]

http://finance.yahoo.com/news/doctors-net-billions-drug-firms-232900866.html

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[DrOwnage]

Yahoo finance knows best... Especially when the information is gathered from someone who's wearing an Xbox gaming headset and looks like he just finished a WoW raid in his mom's basement.

 

[DermViser]

Comments hilarious as always. Hope they enjoy not getting any medication samples bc they're fearful that a doc gets a pharma lunch (as if we give a ****). Notice PAs and NPs are not covered by this law. I wonder why.

 

[W19]

Comments hilarious as always. Hope they enjoy not getting any medication samples bc they're fearful that a doc gets a pharma lunch (as if we give a ****). Notice PAs and NPs are not covered by this law. I wonder why.

Because people still perceive wrongly that physicians are the 'captain of the ship' so to speak regarding healthcare delivery when NP/PA are a major component of the system and are doing quite better than physicians... Do you think ANA have a hand on that?

 

[DermViser]

Because people still perceive wrongly that physicians are the 'captain of the ship' so to speak regarding healthcare delivery when NP/PA are a major component of the system and are doing quite better than physicians... Do you think ANA have a hand on that?

Except the American people didn't write the law - Congress did. So now Pharma will just sell thru them. It wouldn't surprise me.

http://ethicalnag.org/2013/08/07/nurse-practitioners-physician-assistants/
As one former drug rep explained on an online industry forum:

“Many doctors are getting harder and harder to see, if at all anymore. But most Nurse Practitioners will see drug reps. They are usually younger and eager to learn about new and existing drugs.

“Some of my highest (prescription) writers were NPs, and I showered them with goodies and attention. With no disrespect, I found them to be low hanging fruit when I carried a bag.”

Suzanne Gordon teaches at the University of Maryland School of Nursing and is the author of When Chicken Soup Isn’t Enough: Stories of Nurses Standing Up for Themselves, Their Patients and Their Profession. As she wrote in the Boston Review:

“Nurses, understandably tired of being overshadowed and under-valued by their physician colleagues, take whatever attention they can get.

“Big Pharma is ready and waiting to give it.

“Some nurses are fighting valiantly to help their colleagues break this growing dependence on Big Pharma. But others are jumping onboard. What they refuse to acknowledge are the consequences of the bargain they are making.”


http://blogs.wsj.com/health/2011/02/17/nurse-practitioners-get-free-meals-from-pharma-too/

The researchers surveyed 263 members of the American Academy of Nurse Practitioners (9% of their initial randomly selected sample of 3,000 members ended up participating) on their prescribing practices and interactions with industry, perceived reliability of information from the pharma industry and ethics of accepting gifts and meals.

A full 96% said they have regular contact with pharma-industry reps, and 83% said the information they received was reliable. Almost everyone (96%) said they’d attended CME courses sponsored by industry, with 91% saying the information they received there was at least somewhat reliable.

Most (66%) reported giving out drug samples, said they were at least somewhat helpful in learning about new meds (73%) and acknowledged that samples encourage the prescription of new branded (and heavily marketed) drugs (62%).

As for the free meals, 49% reported attending lunch events in the past 6 months, and 64% said the same about dinner events. And 48% said they were then more likely to prescribe one of the drugs featured at these events. Almost all (90%) said it was acceptable to attend these sponsored meals and 75% said it was fine for a speaker appearing there to be paid by a pharma company. Most (61%) said it was fine for practices to accept small gifties and free meals from pharma companies.

NPs were asked if the free gifts distributed by sales reps had any effect on their likelihood of prescribing a certain drug; 93% said no.

 

[Dral]

Because people still perceive wrongly that physicians are the 'captain of the ship' so to speak regarding healthcare delivery when NP/PA are a major component of the system and are doing quite better than physicians... Do you think ANA have a hand on that?

Please qualify your post. I don't think they're doing quite better at treating stage IV Glioblastomas, fixing gastroschisis, diagnosing Melanoma under the scope, fixing cleft palates...I'll stop there.

 

[DermViser]

Please qualify your post. I don't think they're doing quite better at treating stage IV Glioblastomas, fixing gastroschisis, diagnosing Melanoma under the scope, fixing cleft palates...I'll stop there.

I believe he's taking about the ROI personally, not on actual diagnosis, knowledge, etc. Of course, the NPs and PAs I meet tend to not be the medical knowledge hungry type anyways.

 

[BamaNicole]

Comments hilarious as always. Hope they enjoy not getting any medication samples bc they're fearful that a doc gets a pharma lunch (as if we give a ****). Notice PAs and NPs are not covered by this law. I wonder why.

I loved the pharma lunches when I worked in a clinic. We just wanted the free food and Starbucks they gave us for putting their product in our sample closet.

 

[DermViser]

I loved the pharma lunches when I worked in a clinic. We just wanted the free food and Starbucks they gave us for putting their product in our sample closer.

Yup. If anything it brings up the morale of the group. It's not like we're actually listening while they go on about their drug. It's not like you're going to prescribe the HTN drug for someone with asthma.

 

[BamaNicole]

Yup. If anything it brings up the morale of the group. It's not like we're actually listening while they go on about their drug. It's not like you're going to prescribe the HTN drug for someone with asthma.

Totally. I think I'm the only one that listened bc I was curious but I wasn't a doctor so it didn't matter.

Our doc would purposely wait until they were gone to go eat.

 

[DermViser]

Totally. I think I'm the only one that listened bc I was curious but I wasn't a doctor so it didn't matter.

Our doc would purposely wait until they were gone to go eat.

Yup. Pretty much the only person who actually listens in the room is the med student - bc you're in school so you're much closer to your education and they usually review the disease process, the mechanism of action of the drug, etc. By taking these things away - won't make the drug any cheaper and in fact will hurt patients bc no more samples - as has already happened. Which sucks when you want the patient to try the drug for a bit, see if they get improvement, before having them shell out money for it. Very helpful esp. in Derm to see that the topical works, before they get the 35 g tube.

 

[BamaNicole]

Yup. Pretty much the only person who actually listens in the room is the med student - bc you're in school so you're much closer to your education and they usually review the disease process, the mechanism of action of the drug, etc. By taking these things away - won't make the drug any cheaper and in fact will hurt patients bc no more samples - as has already happened. Which sucks when you want the patient to try the drug for a bit, see if they get improvement, before having them shell out money for it. Very helpful esp. in Derm to see that the topical works, before they get the 35 g tube.

This was before I was a student but I did have my interest in medicine.

I totally agree with what you said here. There were drugs that the patients tried samples of and they would see great improvement. I helped me justify to their insurance company as to way they should pay for it over their formulary.

This is only gonna hurt the patients in the long run.

 

[qtpai]

I think the idea behind this is that your anecdotal tales that drug reps don't influence your decision-making is irrelevant--as anecdotes have always been irrelevant to science. The research consistently shows that drug rep gifts (and time with drug reps, more generally) affect physician decision-making in favor of drug rep prescription recommendations.

Common sense would suggest this: if you are positively disposed to a drug rep because of the gift that you receive (as you will tend to be), you will also be positively biased toward his or her claims. Common sense, from another direction, points to this conclusion as well: pharmaceutical companies are not stupid, and wouldn't invest the hundreds of millions of dollars in physician gifts, if their research didn't show efficacy.

Don't believe me. Read the research. It is an very extensive. Here is a sampling.

1. On interactions (in particular gift-exchange) influencing physician behavior.

CONCLUSION:
The present extent of physician-industry interactions appears to affect prescribing and professional behavior and should be further addressed at the level of policy and education.

Link: http://www.ncbi.nlm.nih.gov/pubmed/10647801?dopt=Abstract

2. On some of the well-researched techniques used by pharmaceutical companies to influence physician prescribing practices.

To this end, some companies combine data sources. For example, Medical Marketing Service “enhances the AMA Masterfile with non-AMA data from a variety of sources to not only include demographic selections, but also behavioral and psychographic selections that help you to better target your perfect prospects” [8].

The goal of this demographic slicing and dicing is to identify physicians who are most susceptible to marketing efforts. One industry article suggests categorizing physicians as “hidden gems”: “Initially considered ‘low value’ because they are low prescribers, these physicians can change their prescribing habits after targeted, effective marketing.” “Growers” are “Physicians who are early adopters of a brand. Pharmaceutical companies employ retention strategies to continue to reinforce their growth behavior.” Physicians are considered “low value” “due to low category share and prescribing level”

Link: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1876413/

Moreover, since there is a widespread notion among informed people that drug representatives, and drug companies more generally, have a conflict of interest in promoting their products--i.e. their interests prioritize their bottom lines, rather than the patient interest--there is therefore a widespread notion that when drug reps influence physicians, they influence them in ways that are potentially adverse to patient care. Evidence for this is also very consistent. See, for example:

3. On the relationship between evidence-based prescribing and time spent with pharmaceutical representatives.

Conclusions and RelevanceAmong physician trainees, our survey showed an association between positive attitudes toward industry-physician interactions and less knowledge about evidence-based prescribing and greater inclination to recommend brand-name drugs. Policies intended to insulate trainees from pharmaceutical marketing may promote better educational outcomes.

Link: http://archinte.jamanetwork.com/article.aspx?articleid=1878469

One should also not forget the distortion of the research record on the part of the pharmaceutical industry, nor its scandals in promoting drugs (e.g. Vioxx) when it had conclusive internal evidence that these drugs were dangerous. Here is an (accurate) re-telling of the Vioxx story.

4. On the Vioxx scandal.

Madigan’s own data strongly suggests that Merck was well aware of the fatalities resulting from Vioxx, a blockbuster drug that earned them $2.4b in 2003, the year before it “voluntarily” pulled it from the market in September 2004. What you will read below shows that the company set up standard data protection and analysis plans which they later either revoked or didn’t follow through with, they gave the FDA misleading statistics to trick them into thinking the drug was safe, and set up a biased filter on an Alzheimer’s patient study to make the results look better. They hoodwinked the FDA and the New England Journal of Medicine and took advantage of the public trust which ultimately caused the deaths of thousands of people.

Link: http://mathbabe.org/2012/02/15/how-big-pharma-cooks-data-the-case-of-vioxx-and-heart-disease/

And this is not the only time the pharmaceutical industry has lied--or been sued--about drug safety.

The pharmaceutical industry also engages, as I have said, in a systematic distortion of the research literature.

5. On the systematically negative impact that the pharmaceutical industry has had on the integrity of biomedical research.

Link to TED Talk: https://www.ted.com/talks/ben_goldacre_what_doctors_don_t_know_about_the_drugs_they_prescribe

(You can find a lengthy, in-depth discussion of this in Goldacre's extremely well-written books.)

In conclusion. First, to believe that gift-giving doesn't influence behavior (of all kinds) is naive and is not supported by the data in the context of medicine (or in much else). Second, to believe that drug company educational materials are benign suggests an inability or unwillingness to be read up on the most basic literature about the pharmaceutical industry. For these reasons, many medical schools and hospitals have rightly set up strict restrictions on the interactions between physicians and pharmaceutical reps, including but not limited to restrictions on pharm reps visiting physicians, gift-giving, disclosures of conflict of interest, etc. Most recently, the Sunshine Act takes the field by forcing transparency and accountability--and it is right to do so.

Although there are problems with the Sunshine Act, and specifically its implementation, I do not know of any informed, intelligent, reputable person who thinks it is not a step firmly in the right direction.

If anyone wants to read more, here is a great website, supported with research citations, that sums up the problems with physicians receiving gifts from pharmaceutical companies. This page also includes answers to objections posed by those who might hold lingering reservations about the wisdom of limiting the activities of pharm reps.
http://www.nofreelunch.org/faqs.htm

 

[Psai]

Hey man I'm just saying that it's funny that politicians have the gall to demand that someone else has to be transparent about who gives them money. It's better for them to advertise to people who can actually understand and evaluate the data rather than blasting advertisements on the television to ask your doctor about whatever wonder drug they just made. Oh wait excuse me, your "health care provider"

 

[DermViser]

In conclusion. First, to believe that gift-giving doesn't influence behavior (of all kinds) is naive and is not supported by the data in the context of medicine (or in much else). Second, to believe that drug company educational materials are benign suggests an inability or unwillingness to be read up on the most basic literature about the pharmaceutical industry. For these reasons, many medical schools and hospitals have rightly set up strict restrictions on the interactions between physicians and pharmaceutical reps, including but not limited to restrictions on pharm reps visiting physicians, gift-giving, disclosures of conflict of interest, etc. Most recently, the Sunshine Act takes the field by forcing transparency and accountability--and it is right to do so.

Although there are problems with the Sunshine Act, and specifically its implementation, I do not know of any informed, intelligent, reputable person who thinks it is not a step firmly in the right direction.

If anyone wants to read more, here is a great website, supported with research citations, that sums up the problems with physicians receiving gifts from pharmaceutical companies. This page also includes answers to objections posed by those who might hold lingering reservations about the wisdom of limiting the activities of pharm reps.
http://www.nofreelunch.org/faqs.htm

It also has the unintended consequence of doctors not participating in clinical research bc of a database listing everything in God's name over 10 dollars, so why bother doing it if it will be used against you. Meanwhile, PAs and NPs are not covered by the Sunshine Act, so guess where Pharma has now targeted?

You must be a future AMSA President in training. I'm sure they'll indoctrinate you well.

 

[Doudline]

It also has the unintended consequence of doctors not participating in clinical research bc of a database listing everything in God's name over 10 dollars, so why bother doing it if it will be used against you..)

You have evidence to support this extravagant claim, I suppose? (Rhetorical. I know you don't.)

(And are you really suggesting we do nothing against Big Pharma giving loads of money to unscrupulous physicians -some of which are big wigs who play with millions+ worth of money year round, mind you- to... protect clinical research? You're so disingenuous I swear to God.)

 

[DermViser]

You have evidence to support this extravagant claim, I suppose? (Rhetorical. I know you don't.)

(And are you really suggesting we do nothing against Big Pharma giving loads of money to unscrupulous physicians -some of which are big wigs who play with millions+ worth of money year round, mind you- to... protect clinical research? You're so disingenuous I swear to God.)

You actually think physicians will participate in MORE research with Pharma when everything will be scrutizined esp. by a patient who doesn't know how to even read the database? Look at the Medicare payment release debacle, where you have idiot patients thinking doctors are making million dollar+ in salary due to billing.

But no it's all those "unscrupulous" doctors. Sorry you can't see common sense from your high horse. If anyone is being disingenuous it is you.

 

[BurghStudent]

http://www.chicagotribune.com/busin...biz-20141001-story.html#page=2&panel=comments

I like the comments here. They're not fans of the ACA.

 

[calvnandhobbs68]

It also has the unintended consequence of doctors not participating in clinical research bc of a database listing everything in God's name over 10 dollars, so why bother doing it if it will be used against you. Meanwhile, PAs and NPs are not covered by the Sunshine Act, so guess where Pharma has now targeted?

You must be a future AMSA President in training. I'm sure they'll indoctrinate you well.

I believe in THEORY this was a good idea. Listing who gets free plane rides, vacations and dinner every week on pharma's dime isn't necessarily a bad thing. However, the implementation is horrible.

First, the decision to not include PAs/NPs. Well derp guess who they'll start targeting next? Even if they aren't independent, the drug company will provide some free travel under the PAs name and Dr. Smith, who heads up the practice, just happens to come along too. There's a reason all the drug company executives are stating that they "welcome this reporting"...because they already know exactly what they're going to do to get around it.

Second, they're grouping all kinds of crap in under the Sunshine Act. Why are royalty payments and patent licensing payments being reported as part of this scheme? What exactly is the point? Are we going to start arguing now that doctor's SHOULDN'T get paid for helping to develop devices/drugs/submit patents just because they're doctors? What other industry do we do this for? It's total BS but Joe public is going to look at that WSJ article and say "Whoa, they got $100 million from from Roche? I always knew those dirty doctors were in bed with pharm."

 

[W19]

Yup. Pretty much the only person who actually listens in the room is the med student - bc you're in school so you're much closer to your education and they usually review the disease process, the mechanism of action of the drug, etc. By taking these things away - won't make the drug any cheaper and in fact will hurt patients bc no more samples - as has already happened. Which sucks when you want the patient to try the drug for a bit, see if they get improvement, before having them shell out money for it. Very helpful esp. in Derm to see that the topical works, before they get the 35 g tube.

Are they taking that away or they just want it to be reported?

 

[Psai]

Are they taking that away or they just want it to be reported?

By making it something to be reported, they're shaming the people who do receive compensation which means that they're taking it away indirectly

 

[Snoopy2006]

The problem with this is the average person won't be able to interpret these numbers in context. They'll see that $140,000 number and read no further.

I see a lot of doctors having to justify themselves to the media in the future, which is sickening. The doctors who chose not to comment look oddly suspicious. I especially enjoyed how physicians had to justify receiving royalties for medical devices they helped create. Healthcare critique has gotten to the point where a physician who doesn't work pro bono is susceptible to immense public scrutiny and criticism.

 

[qtpai]

Hey man I'm just saying that it's funny that politicians have the gall to demand that someone else has to be transparent about who gives them money. It's better for them to advertise to people who can actually understand and evaluate the data rather than blasting advertisements on the television to ask your doctor about whatever wonder drug they just made. Oh wait excuse me, your "health care provider"

I think there are many ways of doing it.

Physicians could be empowered to override patient requests for drugs. With Press-Ganey and many of the new (and unfortunate) patient satisfaction stipulations of the ACA, this seems unlikely. Direct-to-consumer marketing is very unfortunate, and universally recognized as such, and that is why it is illegal in all developed countries of significance, except, sadly, the USA.

But, aren't you overrating the degree to which physicians can properly understand and evaluate the data--especially when the pharmaceutical industry has a history of cooking it, and when techniques that have nothing to do with the evidence base (i.e. gifts) play such a prominent role in the marketing process? Right now, I think pharmaceutical research is insufficiently transparent--and is thereby deceptive--to responsibly put the decision-making power in the hands of the physicians; with current journal editorial practices, pharmaceutical research is often marketing with a scientific air; are physicians sufficiently trained to counteract, with their limited time, the sleek marketing practices, specifically engineered to override the scientific process, created by individuals of (make no mistake) often equal intelligence with the physician and orders of magnitude more resources to dedicate to their persuading him or? The reasoning of the individual physician, in his or her free time, is no match for such a behemoth structure--without a regulatory structure on his or her side to balance things in the physician's favor and make individual decision-making more transparent, more evidence-based, and more useful.

We have a ****ty system, either way. But it's not an either/or thing. The pharmaceutical industry needs more regulation on several levels. This--and not free drugs given by companies with gross conflicts of interest, and certainly not a situation of physician dependence on these free samples--this is the best way to guarantee patient interests.

It also has the unintended consequence of doctors not participating in clinical research bc of a database listing everything in God's name over 10 dollars, so why bother doing it if it will be used against you. Meanwhile, PAs and NPs are not covered by the Sunshine Act, so guess where Pharma has now targeted?

You must be a future AMSA President in training. I'm sure they'll indoctrinate you well.

Yes, and when doctors participate in clinical research with a negative finding, it sometimes doesn't get published, or the research outcome is cooked or controlled by the corporate sponsor. Is it a better situation (the situation we still have now) to have industry dollars supporting research that generates a distorted research record, buttressed by the prestige of the medical profession? It may be the case that the kind of transparency that the Sunshine Act promotes hinders the innovation process--but it also promotes the integrity of science. Until regulations are in place (and fully functioning) that prevent undue influence of pharmaceutical companies over the research process, I'm not sure that discouraging physicians from participating in it using industry funding is a bad thing.

As far as PAs and NPs, you point out a serious problem. Nonetheless, because doctors are the major decision-makers and have the greatest responsibility, it was not a bad idea to start with them. One hopes that the criticisms you point out have their impact in making the law better implemented in the future, and strip PAs and NPs of what can now only be called special privileges.

There are other problems, too, that need to be addressed. Here is a recent article in the Wall Street Journal about how pharm reps are targeting hospitals, as hospitals gain greater control over physician prescribing practices. The pharmaceutical industry is hydra-headed. http://online.wsj.com/articles/as-doctors-lose-clout-drug-firms-redirect-the-sales-call-1411612207

 

[DermViser]

Yes, and when doctors participate in clinical research with a negative finding, it sometimes doesn't get published, or the research outcome is cooked or controlled by the corporate sponsor. Is it a better situation (the situation we still have now) to have industry dollars supporting research that generates a distorted research record, buttressed by the prestige of the medical profession? It may be the case that the kind of transparency that the Sunshine Act promotes hinders the innovation process--but it also promotes the integrity of science. Until regulations are in place (and fully functioning) that prevent undue influence of pharmaceutical companies over the research process, I'm not sure that discouraging physicians from participating in it using industry funding is a bad thing.

As far as PAs and NPs, you point out a serious problem. Nonetheless, because doctors are the major decision-makers and have the greatest responsibility, it was not a bad idea to start with them. One hopes that the criticisms you point out have their impact in making the law better implemented in the future, and strip PAs and NPs of what can now only be called special privileges.

There are other problems, too, that need to be addressed. Here is a recent article in the Wall Street Journal about how pharm reps are targeting hospitals, as hospitals gain greater control over physician prescribing practices. The pharmaceutical industry is hydra-headed. http://online.wsj.com/articles/as-doctors-lose-clout-drug-firms-redirect-the-sales-call-1411612207

As far as AMSA is concerned, I do not have any interest in organizations that I do not create myself. I am very tired of burning energy, doing the work of uninspired idiots. If by being "indoctrinated", you mean reading and thinking independently, and coming to the same conclusions as AMSA (and most academic institutions), then yes you are right; I do agree with some things that they say, and since many of them are bad people (probably true), this of course makes me a bad person... Or not.

Newsflash -- NIH money is drying up, so people in clinical research have to look for other resources. The pharmaceutical company doesn't write the paper - the doctor (the principal investigator) does, which is subject to peer review before being accepted. I can almost guarantee that PAs and NPs won't be added to the Sunshine Law. Unlike medicine, NPs have no moral qualms of turning to Pharma (over 96%) and will lobby to keep it that way.

 

[evilbooyaa]

If there was a surplus of research funding, I would be the first person to say that research would take a hit due to this law, as docs would be shamed out of taking any pharm funding in developing drugs or testing efficacy/safety of them in clinical trials.

However, with the massive shortage in research funding present in this country, I think it may be a lower quality of research (as the big names who routinely run the biggest trials may not want the reputation of being in bed with pharma) but someone will be willing to take a pharmaceutical company's money to have a shot at being the first author on a clinical trial.

I think there needs to be a difference marked between royalties paid as a direct result of helping to develop a medical device, and the misc. money that goes into 'speech fees/travel/general expenses/etc.'

As others have said, the general public (and even some physicians who have no experience working in developing/testing medical devices) will just see a big number, and immediately assume their doctor is working for pharma.

 

[qtpai]

Newsflash -- NIH money is drying up, so people in clinical research have to look for other resources. The pharmaceutical company doesn't write the paper - the doctor (the principal investigator) does, which is subject to peer review before being accepted. I can almost guarantee that PAs and NPs won't be added to the Sunshine Law. Unlike medicine, NPs have no moral qualms of turning to Pharma (over 96%) and will lobby to keep it that way.

Okay, since NIH funding is drying up, scientists can look to industry to support their research. With the caveat that such financial relationships will be in the open and rightly regarded less favorably. If you, or other doctors or researchers, don't like this negative view on doctors who receive industry funding, then you should advocate for industry changing its widely deplored research practices.

You should not advocate for reducing transparency, so that such research practices can proliferate, simply because it is "research." With an estimated half of all clinical trials going unpublished, it is unclear how useful a clinical trial can be when its results can be left unpublished by industry (and academia) when it produces a negative result. I think Ben Goldacre put this best in an article last year in the British Medical Journal * :

The problem of missing trials is one of the greatest ethical and practical problems facing medicine today. It also represents a bizarre paradox: we can spend millions of dollars on a trial, hoping it is free from bias, trying to detect a modest difference between two treatment groups; and then at the final moment we let all those biases and errors back in, by permitting half the results to disappear. Future generations may well look back at our tolerating this in amazement, in the same way that we look back on mediaeval bloodletting.

So, yes, your criticism of transparency in research funding is right. But if your concern is for patient welfare, you should be pointing the finger at industry and the scientific community for allowing trust in the scientific legitimacy of industry-supported studies to be undermined. The proper placing of blame provides incentives for these problems to be fixed. And this is exactly what the Sunshine Act hopes to do.

When this is done, nobody will care if a researcher accepts industry funding. I think we can both agree that this would be the most ideal situation.



* Link: http://www.bmj.com/content/347/bmj.f1880?ijkey=KJaN2gQyuYf46yS&keytype=ref