Doctors Under Influence: Drugs That They Are Tripping ON

2013, unveiled the tomfoolery of one of the biggest pharmaceutical company in Britain, GlaxoSmithKline (GSK). This deep incision on pharmaceutical companies and doctors was made by a report published in the Guardian, by Dr. Ben Goldacre. The company spent £1.9m in 2012 on doctors’ speaking and advisory fees. His greed-shaming aimed at discontinuing inducements to doctors and coincided with a rare public pledge to end by 2016, the practice of paying tens of millions of pounds to physicians for lectures, flights, hotel bills and conference attendances. The sum of all the expenses ended up being £900,000 in 2012. This explanation from GSK surfaced “five months after it was accused of behaving like a criminal godfather in China; bribing doctors with cash in return for prescribing its drugs”.

GSK is currently ranked as world’s third largest company in drugs with gross profits (pre-tax) of £6.7bn in 2012. According to Sarah Boseley, this pie gets shared at an average of £1,252 per annum in consultation and advice for each of the 1517 UK-based doctors studied in her report and an average of £868 per trip for 1,022 doctors and other healthcare professionals; to attend scientific conferences and meetings. Her 2013 analyses contrasted GSK with AstraZeneca in the ways physicians were paid by two British pharma-giants. While GSK reported above mentioned payments as inclusive of those being made to both UK and non-UK physicians since it recognized many of the doctors on its panel for advice and consultation as global experts; AstraZeneca reported spending separately from its UK office and those from its “global teams and international affiliates.” The UK office paid £671,400 in fees to 903 doctors plus £30,200 for their travel and hotel bills. Some doctors carried out more than one engagement. Their average earnings including expenses came to £776.96. But those who were paid by the global teams did far better. A total of £563,000 including expenses was paid out to 93 individuals at an average of £6,053.76. However, these 93 people were involved in 304 activities, which meant an average fee of £1,851.97 including expenses.

Aileen Thompson, Executive Director – Communications at Association of British Pharmaceutical Industries (ABPI); was all praise for the drug manufacturers’ Code of Practice that has lasted 50 years and found common ground with proposals on transparency and disclosure as floated by National Health Service, England (NHS). These discussions centered on pharmaceutical companies and doctors’ collaborations and industry’s ties with health care organizations (HCO), while pushing the envelope containing the Code of Practice as a “robust” framework that has already started to strip the cloak off these longstanding shady ties. The industry boasted of disclosing since 2012 the aggregate payments made to healthcare professionals (doctors, nurses, scientists) in the UK. It promised to publish details of payments and transfers of value made by industry to individual healthcare professionals and healthcare organisations during 2015 which will be released in June 2016 on a single, searchable database hosted by the ABPI. Till very recently and in existence of The Code, drug companies were only required to publish their total outlay on doctors. Realizing drug manufacturers’ transnational clout, the European trade body is also following suit to compel them to publish the names of the individual doctors they pay. Looking in the crystal ball, the ultra-secretive Transatlantic Trade and Investment Partnership (TTIP) may have something up its sleeve for users of pharmaceutical drugs in the western hemisphere but that’s all the information available for now.

Let’s Hop Over Atlantic To Apply An American Lens To The Issue.

This could now reveal if the doctor is a sellout or not. Viewers/patients can see the exact amount(s) he received since August 2013 to December 2014.  NPR’s recent report quoted Pro-Publica’s project Dollars for Docs, worked along with drug manufacturers ‘tracking drug company payments to doctors since 2010’. They developed an online tool which contextualized a trio among device companies, physicians and the drugs, backed by a law, the Physician Payment Sunshine Act, a part of the 2010 Affordable Care Act. Currently, the tracker houses seven companies, the law requires more transparent and open reporting of payments and analysis made by all device and pharmaceutical companies. These companies need to be unconventional and open about their payouts made for promotional lectures to professional consultations; business related travelling to souvenirs; and professional social gatherings to gifts. This scrutiny for tracking  does not include open Payments or research payments as they are already a part of the government’s database of industry spending.

Could It Be That Exorbitant Drug Bills Footed By U.S. Consumers Are Feeding Into Drug Marketing That Includes Ties Between Pharmaceutical Companies And Doctors?

Irrespective of whichever side of the fence you are, drug manufacturers were bound to come under microscope. Politicians had frequently lambasted pharma industry for ripping off American consumers with prices that are comparatively highest in the world although U.S. spends more on per capita health than any other country on the planet.

Much like big corporations historically reported for illegal practices, impunity, and almost getting away with anything; drug companies have been long accused of misleading advertisements as well as making in-roads in medical education system. It takes just a few minutes of prime-time TV to feel the relentless onslaught viewers have been under.

Steps-to-contain-the-gap

The Industry has retorted with enormous annual research and development (R & D) costs as a determinant of their pricing. Dr. Marcia Angell, former editor of the New England Journal of Medicine, and a member of Harvard Medical School’s Department of Social Medicine, in her recent book published in 2005, ‘The Truth About the Drug Companies: How they Deceive Us And What To Do About It’ revealed that research and development  costs were only 2.5% – 3% of the $200 billion annual sales in U.S. She presented data provided by Novartis, listed among the biggest names in drug companies liquidated a heavy chunk to marketing and distribution, i.e., 36 percent of its revenue and comparatively a little amount on administration and general overhead, i.e., 5% of its revenues.

Many physicians report to be guided by a genuine belief in a drug’s effectiveness and patient(s)’ interests in prescribing a particular brand, and not the perks they receive from industry. This is in contradiction with research that links prescription with perks received by MD, even meals have been found tempting enough! It’s hard to find a waiting area of an average practice without coffee mugs, stationery, and high-tech gadgets with drug companies inscribed all over. Even the cable transmission is likely to be beaming something pharmaceutical or medicalized. Practice owners may argue that stronger, more equipped practices mean a better quality of care for patients. What they may not divulge is that it means more bucks too! What’s more striking are revelations in ProPublica report that indicates accepted “normality” of physician-pharma nexus. Those avoiding it, if at all, were statistical outliers.

It’s not all about middle-aged to older, bespectacled physicians. It starts much earlier, during medical schools and/or under an influence of peers and role-models. The degree of compliance with Accreditation Council on Graduate Medical Education (ACGME) guidelines on interaction between trainees and industry has been studied by Robert L. Goodman in his paper on medical students’ and residents’ attitudes. He considers vulnerabilities of medical schools and Continuous Professional Development Programs to various temptations that betray the very ethical foundations of the medical profession. Most pervasive themes have been summarized as “(1) interactions between trainees and industry are common; (2) students and residents are relatively permissive regarding the acceptance of gifts”. The same paper cites “a survey of third-year medical students (Sierles et al. 2005) that found almost 97% of students had attended a lunch sponsored by a drug company, and 50%, had attended a dinner, with the mean exposure to gifts or promotional activity of one per week. Over 90% were asked or required by a physician to attend at least one sponsored lunch. Slightly over 80% believed that they were entitled to gifts. Importantly, of eight schools surveyed, seven had no written policy regarding student-industry interactions, and 95% of students did not know whether their school had such a policy”. Another citation was “a survey of first- and second-year primary care internal medicine residents” (Steinman, Shlipak, and McPhee 2001). Approximately “90% of residents responded that lunches, dinner lectures, and prescribing guides were appropriate or “somewhat” appropriate. “Slightly over 60% of residents responded that contacts with industry did not influence their own prescribing, while only 16% believed other physicians were not influenced”. In a third such citation on “primary care residents (Sigworth, Nettleman, and Cohen 2001), they were asked to empty the pockets of their white coats, and 97% of residents were carrying at least one item with a pharmaceutical insignia”.

Goodman in his article almost suggested what could be an important part concluding this piece. It indeed merits addressing the issue during formative years at medical school via “Ethics curricula that must include instruction and discussion of published guidelines regarding gift-giving to physicians,” that “Residents must learn how promotional activities can influence judgment in prescribing decisions and research activities through specific instructional activities,” and that “Programs and sponsoring institutions must determine through policy, which contacts, if any, between residents and industry representatives may be suitable, and exclude occasions in which involvement by industry representatives or promotion of industry products is inappropriate”. But the regulatory challenges that straddle legislatures and pharmacies in western hemispheres are multifaceted. Neither NHS nor Medicare are ideal but offer tools that could throw more light on ways in which drug companies shape physicians’ judgments for higher rates of prescription. With petite authentic information relevant to the issue, drug companies’ share and expected conduct in the promised Garden of Eden of TTIP is impossible to evaluate, for now.

Let’s pretend for a while that prescription drug abuse is like an elusive giant squid. Even that’s been sighted! The science of medicine and its practice will always remain few of the most complex realities with fewer right answers for everyone. But Patients are neither asking for free lunch nor an all-in fiesta. They just expect a little say in designing the menu when they want it.

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