Two more from Dollars for Docs: Psychiatrists Rule the Hired Guns, and "Thought Leaders" are Cash Cows

Psychiatrists are at the top of the Hired Gun list

According to Medscape, psychiatrists accept more money from drug companies for promotional speaking than any other specialty listed on ProPublica's Dollars for Docs database.

"Of the 384 physicians in the $100,000 group, 116 are psychiatrists. Leading all psychiatrists was Roueen Rafeyan, MD, in Chicago, Illinois, who received $203,936 from Eli Lilly, AstraZeneca, Johnson & Johnson, and Pfizer, mostly for professional education programs."

While discouraging, this does not surprise me, since American psychiatry has fallen into a practice style that relies on medication at the expense of getting to know patients. The slogan of the modern psychiatrist has become "I prescribe, therefore I am," and drug companies are quick to approach them with offers of cash payments in return for prescriptions. While this deal is never made explicit (it would be considered an illegal kickback), in fact the expectations underlying these financial relationships are painfully clear.

NPR Shows how "Thought Leaders" are really "Prescription Writers"

NPR ran a nice piece (which can be read here) scrutinizing whether drug companies hire speakers because they are experts, or rather because they prescribe a lot of their drugs and are good at getting other docs to follow suit.

First, they interview child psychiatrist Lance Clawson. According to this entry on the Dollars for Docs website, Dr. Clawson has spoken for Eli Lilly, which paid him $56,800 in 2009 and $7,661 in the first three months of 2010. Clawson tells NPR that he feels no guilt about these talks: "I'm going out there and trying to educate other doctors about how to treat ADHD appropriately and safely," he explains. Since Clawson said he is talking about ADHD I assume he is promoting Strattera, which is Lilly's only FDA approved ADHD medication. Strattera is, indeed, effective for ADHD, but is significantly less effective than stimulants. During Dr. Clawson's talks, I therefore wonder how much time he devotes to educating his audience about this study, which showed that Strattera is significantly less effective than Concerta, or this study, showing that Strattera is much less effective than Adderall XR. Since hired guns are forced to use only the company's slides, I suspect that Dr. Clawson educates doctors the Lilly Way, rather than the Evidence-Based Medicine Way

NPR then interviews a current drug rep who knows exactly why doctors such as Clawson are chosen as "thought leaders"--because they have lots of patients to whom they will prescribe lots of the company's drug.

According to the rep: "I think nowadays a thought leader is defined as a physician with a large patient population who can write a lot of pharmaceutical drugs. Period." Furthermore, according to NPR's sources, reps very closely monitor the prescriptions of speakers after they are paid to give talks, and, according to one rep, paying a speaker $1500 to give a talk may well yield $100,000 or more in extra prescriptions.

I'd be curious to get the prescription reports for Dr. Clawson's practice after he gives his talks! I'm sure his rep has the data squirreled away in the company laptop.

ProPublica's Dollars for Docs Website

The non-profit media organization ProPublica just 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.

Seeking Editor for “The Carlat Medical Report”

Yes, I know this is a piece of rank commercialism. But it’s for a good cause.

I plan to launch a new CME newsletter called The Carlat Medical Report. It will be similar in format to my two existing newsletters (The Carlat Psychiatry Report and The Carlat Child Psychiatry Report), but it will cover topics in general medicine. Think of it as The Medical Letter with an attitude.

I’ve been casting about for an editor-in-chief through the usual channels of contacting friends and colleagues but I've had no luck so far, so I thought I’d post the job description here.

I plan to publish the newsletter monthly or so, depending on the energy of the editor. It will be available in both print and online versions. My company, Clearview Publishing, is ACCME accredited, so readers of the newsletter can get plenty of AMA PRA Category 1 credit. There will, of course, be no pharmaceutical industry funding of any sort, directly or indirectly—no sponsorship, no ads, no inserts. Furthermore neither the editor nor any of the writers can have any financial relationships with pharma.

A word about my no pharma policy. I am philosophically and politically opposed to industry sponsorship of medical education (no duh!), but I am not opposed to industry sponsorship of clinical research. In fact, I value the opinions and expertise of my colleagues who work with industry, either as researchers or as research consultants. In The Carlat Psychiatry Report I sometimes interview experts with hefty industry disclosures. I rationalize it because I feel that in an interview format I have more control over the content and can steer the conversation in a non-promotional direction. This allows readers to reap the benefit of industry know-how without being subject to the subtle (or not so subtle) commercial biases that sometimes appear in the articles and talks of academics with industry ties.

Anyway, to get back to The Carlat Medical Report, below is the formal job description along with compensation. At $1000 per month, you will not get rich being the editor of this newsletter (it will take a few hours a week of your time). But you’ll get your name out there, you will meet a lot of interesting people, and you’ll be part of what is clearly a growing trend in medical education—great practical CME without the industry hype.

If you’re interested, email me directly at drcarlat@comcast.net.

Newsletter and Job Description:

The Carlat Medical Report will be published monthly, and each issue will focus on a specific therapeutic area in medicine. There will be one or two in depth articles, one interview with a national expert on that month's topic, and 3 or 4 short "research updates" summarizing the most important articles (on any medical topic) published during the prior month. The writing will be informal, mirroring the way a doctor would discuss recommendations verbally with another doctor. Problems with excessive pharmaceutical company influence in medical practice will be discussed explicitly when relevant.

Editor-in-chief compensation and responsibilities.

--Must be an MD or DO
--Compensation: $1000 per issue honorarium
--Will be the identified "face" of the newsletter--"Mary Smith, MD, Editor-in-Chief" would be prominently displayed below the masthead and the editor's photo and email contact would be on the home page of the website. Reader and press inquiries would go directly to editor.
--In conjunction with publisher, will put together a stellar, non-industry affiliated editorial board for the newsletter.
--Will decide on content for each issue
--Will write one of the in depth articles (about 1000 words) for each issue
--Will assign other articles and research updates to other writers
--Will be responsible for interviewing the Expert of the Month (or may assign this to someone else)
--Agrees to no financial relationships with pharmaceutical or device companies within the last year and during editorship tenure
--Estimated time commitment required: about one day per week.