Is Drug Company Marketing Evil?

There's an active research industry ginning up studies that suggest that doctors are being unduly seduced by the blandishments of pharmaceutical company marketing. For example, one such "conflict of interest" study published in the Journal of the American Medical Association in 2006 worried that "conflicts occur when physicians have motives or are in situations for which reasonable observers could conclude that the moral requirements of the physician's roles are or will be compromised."

It is certainly true that drug companies spend billions marketing their drugs to physicians. Pharmaceutical sales reps take them to lunch, pay for conferences, and provide them with billions of dollars in free samples. Obviously, this marketing must work in the sense that it does persuade doctors to prescribe their medicines more frequently than if there were no such marketing. If it didn't work, the pharmaceutical companies wouldn't do it. Is that a bad thing? Some legislators in thrall to conflicts of interest activists think so and are proposing regulations to limit drug company marketing in various ways. Are such regulations really necessary to protect patients?

Emory University law professor Paul Rubin has an excellent column on this topic in the current issue of Forbes. To wit:

Drug company reps offer overworked doctors useful, lifesaving information in an efficient manner. The drug companies are of course motivated by profit, but economists have known since Adam Smith that the profit motive is the best way to induce someone to do something useful.

Marketing and research are both information activities; they work together to get effective drugs to patients. The two activities are not in competition for resources. The denouncers of drug companies don't understand this. One of the senators sponsoring the bill suggests that "the millions of dollars these companies spend on marketing … could be put into research." In fact, drug companies would not switch money from marketing to research. If they cannot market drugs in the best way, they will reduce spending on research. What's the point of inventing a new drug if doctors and patients don't know about it?

Academic physicians think that doctors should obtain information by reading medical journals. Practicing doctors do not have time to comb through the International Journal of Medical Sciences or the Annals of Internal Medicine. A meal with a pharmaceutical salesperson is a time-efficient way for a busy doctor to learn about new drugs, or perhaps a better therapeutic alternative, or a drug with easier dosing or fewer side effects than the old drug. Physicians interact with more than one drug rep, so they have competing sources of information. ...

Finally, by leading consumers to purchase newer drugs, marketing increases investment in innovation and thus makes research more likely.

As Rubin notes on costs, a 2007 study by Columbia University health economist Frank Lichtenberg found:

...a reduction in the age of drugs utilized reduces non-drug expenditure 7.2 times as much as it increases drug expenditure. For example, reducing the mean age of drugs used to treat a condition from 15 years to 5.5 years is estimated to increase prescription drug spending by $18 but reduce other medical spending by $129, yielding a $111 net reduction in total health spending.

Since newer drugs lead to lower overall medical costs, marketing drugs to physicians is good for patients.

Do conflicts of interest studies actually show that patients have harmed by drug company marketing? As Rubin observes:

A widely cited 2000 article in the Journal of the American Medical Association summarized 29 published studies critiquing the interaction between doctors and drug reps. Notable feature of these articles, as quoted in the summary paper: "No study used patient outcome measures." (emphasis added) That is, in all of the medical literature on drug sales, there was no evidence of harm to patients caused by doctors and drug reps breaking bread. These articles were written by physicians who by their oaths put patient welfare at the top of the list, but they were critical of the industry based on analyses that totally ignore this measure.

Rubin concludes:

It is truly amazing that this society keeps coming up with ways to demonize and penalize an industry that has provided us with so many benefits.

Amen.

If you're interested in this topic, please see my articles "Is Industry-Funded Science Killing You?" and "Goddamn the Pusher Man."

Absurd Conflicts of Interest Disclosure: I have just completed a long peer-reviewed study of the conflicts of interest literature for the American Council on Science and Health which will be published later this year. And yes, ACSH paid me to do the research and the writing.

I am also an adjunct scholar at two Washington, DC-based libertarian public policy think tanks, the Cato Institute and the Competitive Enterprise Institute. It was explained to me that being an adjunct scholar means that I don't get paid anything, but that the institutes can use my name for media and fundraising purposes. I have worked on a contractual basis as an editor of three books on environmental policy for the Competitive Enterprise Institute, all of which were published by commercial publishers.

I regularly drum up grants from non-profits to pay for my reporting habits. This is not an exhaustive list, but I have received travel grants to cover United Nations Climate Change conferences and World Trade Organization conferences from the Altas Economic Research Foundation, the International Policy Network, and TCSDaily. In addition, I once went on a junket paid for the government of the Northern Marianas Islands. I generally disclose these grants because I'm grateful for their help. No grantor has ever exercised any editorial control over my reporting.

In addition, I have spoken at scores of universities, conferences and non-profit organizations around the world--mostly for just travel expenses (although on a few happy occasions I have received a small speaker's fee).

I am very happy to acknowledge (as I did in the book) that I received grants from the Richard Lounsbery Foundation, the Bruce and Giovanna Ames Foundation, and the Alliance for Aging Research to support my work on my latest book, Liberation Biology: The Scientific and Moral Case for the Biotech Revolution (Prometheus, 2005).

I also own shares in various biotech and pharmaceutical companies (no more than 1000 in any one company, alas). I purchased all of the shares with my own money and all are held in my retirement accounts. May your deity of choice have mercy on you if you even think about taking any investment advice from me.

Past and Current Charitable contributions and memberships (that I can remember):

American Civil Liberties Union
Society of Environmental Journalists
American Society of Bioethics and Humanities
Drug Policy Alliance
Center for Reproductive Rights
Committee to Protect Journalists
Equality Virginia
National Rifle Association
Marijuana Policy Project
Second Street Gallery
Whitman-Walker Clinic
Nature Conservancy
USO
CARE

In the past I have generally, but not always, voted Republican or Libertarian. In fact, I voted for Barack Obama in Virginia's Democratic primary earlier this month.

Finally, I strongly dislike fish and lamb.

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  • highnumber||

    Finally, I strongly dislike fish and lamb.

    Now, Ron Bailey is fully discredited.

  • ||

    I'll never trust a man who doesn't love tacos al pastor.

  • ||

    Wow, my jet lag is worse than I thought. I must have read that title 5 times before realizing that "Marketing" is being used as a noun, not a verb, and that "Evil" is being used as an adjective, not a noun.

  • ||

    Strongly dislike fish? What hath God wrought? Fish is great! I just had some excellent tile fish, not to mention some lovely sushi (mostly tuna). Fish is good food.

  • ||

    Side effects may include apathy, insomnia, drowsiness, obesity, accelerated weight loss, clogged pores, excessive body odor, purple toenails, coarse body hair, hair loss, limb loss, headache and dry mouth. See a doctor if you experience any of these symptoms, as they may be associated with the risk of a specific type of birth defect.

  • ||

    Don't like lamb? Well, dammit, that's it. joe can say anything he wants about you and I'll believe it all.

  • ||

    Ron Bailey -
    I'm a pescatarian and even I like lamb. I don't eat it, but it's the only thing I consider to be much of a sacrifice.

  • ||

    All: There is absolutely nothing wrong with fish that tasting like beef or chicken wouldn't fix. :-)

  • ||

    All: Regarding lamb, I suspect that my dislike comes from my past in which shearing sheep would leave me smelling of lanolin for days. To me a lot of lamb tastes like sheep's wool smells. Yuck.

  • Jennifer||

    Six words, Mr. Bailey: "Lox and bagels with cream cheese." That is all.

  • Jennifer||

    Plus four more: "What are you, nuts?"

  • ||

    Marketing has one pupose, increasing sales. But there are multiple ways to increase sales, advertising the truth about a superior product, is one of them. The educational value of truthful advertising is not diminished because there is a profit motive behind the pitch.

    Think of your own experiences as a consumer with marketing. Haven't we all learned new things that caused us to purchase a product? Truthful marketing is a social positive because it educates people about the options that are available. It's not that complicated. Visit the Home and Garden show for a low tech example of providing information in order to generate sales.

    And if the MD gets a little nookie on the side, I'm OK with that.

  • ||

    All: There is absolutely nothing wrong with fish that tasting like beef or chicken wouldn't fix. :-)

    So you like tuna?

  • T||

    All: There is absolutely nothing wrong with fish that tasting like beef or chicken wouldn't fix. :-)

    That's it, Ron! Speak truth to all these bastards who are the pocket of Big Fish!

    I gotta disagree with you on lamb, though. Tasty goodness. I make a mean lamb curry.

  • ||

    Side effects may include sausage fingers, flatulence, and death.

  • ||

    Try grilling some fresh tuna, marinated in teriyaki, garlic, etc. It's quite steak like and very good.

  • T||

    In.

    In the pocket of Big Fish.

  • ||

    Truthful marketing is a social positive because it educates people about the options that are available.

    Amen. And while the truth is sometimes not black and white, most legal departments I have worked through in this domain are very sensitive to being able to prove (with data and everything) the kind of statements that are made in marketing messages. IN other words, you won;t see a lot of claims with '-est' or '-er' if there isn;t data to back it up.

    But maybe ignorance is bliss so long as there is no money involved?

  • ||

    Ron, I'll defend you. I'll eat fish if I'm a guest at dinner. I won't order it in a restaurant though. I prepare tuna salad sandwiches occasionally but that's about it.

  • Jennifer||

    In all seriousness, I recall reading that when the first successful birth-control pill was invented, news of it could only spread by word-of-mouth because it was at the time illegal for the company to take out ads saying "We have invented an effective oral contraceptive."

    Ignorance isn't always bliss.

  • Bingo||

    Ron, you obviously need a nice tuna or swordfish steak. Brings "it tastes like chicken!" to a whole new level.

    Or hell, some mahi-mahi tacos. Damn, I know what I'm getting for lunch.

    Also shrimp and lobster are giant sea-bugs. Gross!

  • ||

    The ass-backwards files: I didn't like cooked fish until I started to eat sushi. Maybe that is the path for Ron.

    Spicy tuna handrolls all around!

  • ||

    mmmmmmm, poke!

  • ||

    Finally, I strongly dislike fish and lamb.

    I understand all those words, but that sentence makes no sense.

  • highnumber||

    Also shrimp and lobster are giant sea-bugs. Gross!

    Bingo, Bingo!

  • ||

    I refuse to take seriously, any opinion, by an admitted ovipiscaphobe.

  • ||

    Ron, I'm confused. Paul Rubin says "A widely cited 2000 article in the Journal of the American Medical Association summarized 29 published studies critiquing the interaction between doctors and drug reps. Notable feature of these articles, as quoted in the summary paper: "No study used patient outcome measures." That is, in all of the medical literature on drug sales, there was no evidence of harm to patients caused by doctors and drug reps breaking bread."

    In other words, studies that don't attept to study the effects of drug manufacturers'promotional campaigns on patients' health prove that these promotional efforts don't harm the patients. I don't want to get totally Aristotelian on your ass, but that's a syllogism that makes me gag.

    I read Emory University law professor Paul Rubin's column and I found it glib and offputting. If you wrote like Paul I wouldn't bother reading your stuff. Link to someone else!

  • robc||

    Also shrimp and lobster are giant sea-bugs. Gross Yummy!

    Fixed.

  • ||

    Agreed Alan V.

    I would be more inclined to read him if he wrote like Paul Reubens!

  • Zeb||

    The free samples they give doctors are also nice because doctors will often give them to patients who can't afford the prescriptions.

  • ||

    I am not so concerned about the marketing of drugs so much as I am concerned about the possibility of actions taken against physicians who DO NOT PRESCRIBE enough pharmaceuticals.

    Are there records kept of how much a Doctor prescribes? If a doctor starts prescribing non pharmaceutical treatments, such as nutrition, is he in danger of being censored and perhaps losing his license?

    These stories are out there. I know an Allopathic doctor is supposed to prescribe pharmaceuticals, but if he starts to slow down or stop the prescription script flow, is he monitored?

  • Geotpf||

    libertreee-The answer to your questions is asbolutely not, unless the doctor is not prescribing medicine when he should be doing so, and even then, the chances of sanction are remote. In fact, your question is very odd. Drugs, um, do cure and/or treat many diseases.

  • ||

    There's an active research industry ginning up studies...

    The other guy "gins up studies." Your guy does serious research.

  • adrian||

    profits in medicine are bad!
    and in energy!
    and in real estate!
    and in stock market!

    lawyers are ok though.

  • ||

    AV: I understand your concern about Rubin's logic, but having just finished reading several score conflicts of interest studies (most of them dealing with clinical trial results), Rubin is basically right--the studies in fact don't even attempt to find out if patients are harmed by such alleged conflicts. The studies basically say, pharma research support and marketing "could" "pose challenges" but never really show that it has.

    Which is not to say that pharma companies are always honest, fair, good-looking and makes a mean souffle--in fact, drug companies do occasionally do bad things--think suppress clinical data on Vioxx and anti-depressants--but there is precious little evidence of allegedly pervasive conflicts of interest harming patients. If it were otherwise, the conflicts of interest activists (and I) would be declaring it to the high heavens.

  • ||

    In other words, studies that don't attept to study the effects of drug manufacturers'promotional campaigns on patients' health prove that these promotional efforts don't harm the patients.

    Did anyone make that claim? It is merely asked that given no evidence exists that indicates patient harm, why is there a call for legislation?

    You want a law? Tell me why we need one. "Because it makes me feel good" is not an acceptable reason.

  • Dave W.||

    ACSH paid me to do the research and the writing

    WHAT I DON'T KNOW:

    I don't know whether the moneyflow from pharmas to doctors is a good or bad thing. I guess it depends on whether or not it reduces vigorous competition in the pharma sector.

    WHAT I DO KNOW:

    If Mr. Bailey's research had led him to substantially different conclusions than those which he chose to draw, then he would lose the ACSH gig and probably a lot of the other stuff listed in his disclosure, as well as some stuff he probably did not list.

    WHY HE DOES THESE DISCLOSURES:

    Many in academia and private sector science want to turn conflict of interest into a paperwork requirement. The logic is: if I list certain things on a piece of paper, then I no longer have any harmful conflicts of interest and my research is good. If the conflicts were harmful to my judgement, I would have hidden them, but I didn't hide them so they aren't harmful, the logic goes.

    The one thing that Mr. Bailey gets almost correct here is when he calls this "Absurb." It would be totally correct if he had spelled the word correctly.

  • ||

    joe: "Gins up" -- it's an opinion magazine and that's my opinion after months of research on the topic.

  • ||

    Dave W. "Absurb" Spelling fixed. Thanks.

    In fact, the deal is that ASCH will publish whatever my conclusions are (subject to peer review). Otherwise, I wouldn't have agreed to do it.

    Do you have anything you want to disclose?

  • ||

    Lobster, scallops, clams, shrimp--oh, yeah. But no sea urchin.

  • Kolohe||

    J sub D-
    you were in the navy for like thirty years and you don't like fish? Wow.

  • Kolohe||

    otoh, if it's for the same reason that i don't like three bean salad, i understand

  • ||

    Fish I can give or take, but lamb?! Sweet, tasty lamb? Holy Flying Spaghetti Monster, how could you not like gyros?

  • ||

    "take or leave", not "give or take"...

  • Ska||

    Word. Sea Urchin tastes like what I would imagine vacuuming a seabed with your mouth would taste like.

    Which makes sense seeing that they live on the seabed eating whatever crap ends up down there.

    And goat is even better than lamb.

  • ||

    joe: "Gins up" -- it's an opinion magazine and that's my opinion after months of research on the topic.

    Funny, that used to be your opinion after years of research about studies showing global warming exists.

    You're good at that, Ron.

  • ||

    I think that big pharma should spend less on advertising.

    Link:
    http://www.sciencedaily.com/releases/2008/01/080105140107.htm

    FTA:

    ScienceDaily (Jan. 7, 2008) - A new study by two York University researchers estimates the U.S. pharmaceutical industry spends almost twice as much on promotion as it does on research and development, contrary to the industry's claim.

  • GILMORE||

    BEST

    DISCLOSURE

    OF

    ALL

    TIME!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

    I am sated at last. I will need no further disclosures for at least... who knows. This was more than I could of dreamed for.

  • ||

    you were in the navy for like thirty years and you don't like fish? Wow.

    Twenty actually. But another put it better than I ever could.

    ♫But times have changed for sailors these days.
    When I'm in port I get what I need;
    Not just Havanas or banana or daiquiris,
    But that American creation on which I feed!

    Cheeseburger is paradise medium rare with mustard'd be nice
    Not too particular, not too precise
    I'm just a cheeseburger in paradise.

    I like mine with lettuce and tomato
    Heinz 57 and french fried potatoes
    Big kosher pickle and a cold draught beer
    Well, good god Almighty which way do I steer♫

  • ||

    I REALLY should know better but yeah, joe--you're right. Attending several dozen scientific conferences and international meetings over nearly 2 decades, interviewing scores of climatologists and reading countless scientific papers on the topic means that my opinions were wrong--but then lots of climatologists turned out to be wrong too. Never mind that I changed my mind as I kept reviewing the evidence over the years.
    You?

  • ||

    Do people really believe doctors are so stupid that because a pharma company bought them a nice lunch that they'd risked getting sued over perscribing meds a patient might not need? Is this really the claim some are making?

    And even if you think that doctors might prescribe a name brand over a generic because of said perks you have no idea how far up the doctor's ass the patients insurance company will be.

  • ||

    My opinions have held up pretty well, actually. But then, I made a point of not diverging too far from the consensus of those scientists.

    You know, Ron, you once wrote a plausible-looking post about realizing how your political beliefs and your opinion of environmentalists lead you astray on the question of global warming.

    I was hoping you'd have learned something from that you could apply to the rest of your science writing, but obviously not.

  • Charles||

    So, joe, do you plan to actually criticize the content of this post, or just bring up Bailey's changing his mind again?

  • ||

    I think that big pharma should spend less on advertising.

    I think Coca Cola and Pepsi should spend less on advertising. I especially think Massengill should spend less. So?

  • ||

    joe: Of course your political beliefs never affect how you evaluate evidence. See "More Information Confirms What You Already Know."

    And please won't you consider giving your self-righteousness a well-deserved rest?

  • ||

    Changing your mind with the presence of new facts is a virtue many people don't have. For most, once their heels are dug in, it's over.

    About the post: Marketing drugs to Doctors seems ok to me. I have a bigger concern with marketing drugs to people that watch the nightly news.

  • The Judge||

    joe's a fucking tool

  • ||

    Well, Ron admitted once upon a time that he was wrong about global warming. Therefore he's wrong about everything else. Or at least this particular topic.

    Hey, if I pat myself on the back hard enough, I can dislocate my shoulder!

  • Dave W.||

    Do you have anything you want to disclose?

    Sure. Don't be confused into thinking that I think you shouldn't be writing about toics where you have a bias. Almost everybody has a bias. Instead of making disclosures and then pretending the bias is erased, admit and embrace your bias. Then consciously step out of it in order to predict reservations and doubts that you would have if not biased. Then consciously step back into your bias and vanquish those doubts (if you can). The more difficult this last part is, the better you are following the technique.

    Here's an example:

    Rubin concludes:

    "It is truly amazing that this society keeps coming up with ways to demonize and penalize an industry that has provided us with so many benefits."

    Of course, I agree, but still I realize that some skeptics understandably have a hard time grasping the concept that a sector as profitable as pharma could possibly be demonized or penalized. The reason is [explain away apparent contradiction on its own terms, if possible].


    The can-I-get-an-amen stuf is better for DU or FreeRepublic or Grill-Aides (to name three places I have been permanently banned from). OTOH, this is HitnRun and the dictatorship of the commentariat has now spoken. Do as we say, upon pain of hearing us repeat it endlessly.

  • ||

    joe's a fucking tool

    Would that make him a condom?

  • The Judge||

    Or a strap-on dildo ... take your pick

  • ||

    I actually like Joe's commentary. Though I don;t always agree (well, mostly not I guess), in the end, he enables one to be intellectually honest with oneself...if one is so inclined.

  • ||

    I was hoping you'd have learned something from that you could apply to the rest of your science writing, but obviously not.

    I picture joe writing this bit with his eyes closed and his chin elevated.

  • ||

    Dave W:

    Of course, I agree, but still I realize that some skeptics understandably have a hard time grasping the concept that a sector as profitable as pharma could possibly be demonized or penalized. The reason is [explain away apparent contradiction on its own terms, if possible].

    Just exactly why do you think I linked to my two feature articles on the topic immediately after my "Amen," huh?

  • ||

    J sub D | February 22, 2008, 1:37pm | #
    I especially think Massengill should spend less. So?"


    AAAAGH. Don't be a deush

  • robc||

    I was disappointed joe didnt post in the Myers-Briggs thread. I wanted to make fun of whatever group he was in, even if it was mine.

  • ||

    joe:

    My opinions have held up pretty well, actually.

    Well, in your mind, perhaps. Not too sure that would be the "consensus" you value so highly from your confreres here in the peanut gallery.

  • ||

    I can see the possibility of wrongdoing on the part of doctors here but I must say that in lean times, my family and I have benefited from those spendy free samples big pharma left for the Doc to give us.

  • kinnath||

    I was disappointed joe didnt post in the Myers-Briggs thread.

    Same here

  • kinnath||

    If journalists can do it, so can we.

    joe is absolutely a J, and almost certainly an F. I'm also going with E and S. So in total, joe must be an ESFJ.

  • ||

    This article appears to assume that "regulation" means prohibition of drug company marketing. The truth is that a doctor has a pecuniary interest in prescribing certain drugs that may not be the best suited for a particular patient. The article talks about the profit motive for the drug companies, but never talks about the profit motive from the doctor's point of view.

    Can you imagine this argument in other industries? Overworked lawyers don't have time to find caselaw supporting their position, so they rely on lobbyists to tell them which cases to use.....

  • ||

    "Do people really believe doctors are so stupid that because a pharma company bought them a nice lunch that they'd risked getting sued over perscribing meds a patient might not need? Is this really the claim some are making?"

    I think that the pens, pads, luxury spa trips and other hand outs also help convince a doctor to prescribe the right medicine.

    "I think Coca Cola and Pepsi should spend less on advertising. I especially think Massengill should spend less. So?"

    No, but I think that advertising convinces people to, "ask their doctor about brand x drug for brand y condition". It reminds me how breakfast cereal is advertised to kids so they bug the parents for the right cereal.

    Many patients are convinced they need drug x and aren't satisfied until they get it, because the commercial convinced they need it. The same thing as a patient going to a doctor for a cold and telling him he needs an antibiotic. So, to keep him quiet and make him feel like he is doing something for the patient, the doctor gives him a scrip for antibiotics, rather than telling the patient to go home, get some rest and have some soup.

    Why do we have to sit through viagra, cialis, guys throwing the football through the tire bologna, while Marlboro can't market it's wares in a similar fashion?

  • Bill Mill||

    The real evil is how flimsy the research required to get an evolutionary patent on a drug is, and it ties into the marketing of drugs. Here's how the scam works, it's really quite simple:

    Pfizer has a drug A that is effective for migraine headaches. When the patent is near expiration, they change the ratio of ingredients in the drug slightly and run trials on several mixes.

    At this point they will run and rerun studies on mixes until they find one that happens to show a small improvement in outcomes; they then register a patent for this drug B just as drug A's patent is about to expire.

    And now the game is on, and this is where the drug companies excel: they need to convince doctors that drug B is worth convincing their patients (who are generally insured) that they need drug B for that nominal improvement in outcomes, and that drug A (which is now generic and wicked cheap; it's probably cheaper by several orders of magnitude) is hopelessly outmoded. Doctors get free lunch from the drug companies *every* *day*, and get pressed on drug B very frequently.

    They, of course, claim that they are unaffected by the marketing, and that they will do whatever is best for the patient. But likely, they will overvalue drug B relative to the improvement it brings because of their exposure to the marketing.

    But, drug B is likely to be no better *at all* than drug A; the improvement shown in the study is likely to be merely a statistical outlier. But the drug company will perform studies over and over again, until they find such an outlier, and then they will hammer that home with their marketing so that they make exorbitant profits on a drug that's neither better nor different by scamming the patent system.

    (There's a great article on this in NEJM, I'll try and find it again later, I should really bookmark it)

    In this story we see that everyone (everyone!) has misplaced incentives. The drug company is incentivized to hold off on improvements to A until the patent is just about to expire, and they're incentivized to cheat the patent system, and they're incentivized to spend outrageous amounts of money convincing doctors not to question the economic value of spending 1000% more on a drug that's 2% more effective.

    The doctors are incentivized to listen to the pharmaceutical companies' pitch because they

    a) get free lunches and steak dinners and pens and pads and coffee mugs and espresso makers and free samples and so on

    b) have their prescription habits monitored. Outrageously, Pfizer knows if doctor A has been prescribing drug B or drug A because they pay a company a lot of money to get this information (which should not be available). The doctor knows that if he doesn't prescribe B, the favors will stop, or they'll get bugged more by a sales rep particularly interested in them. I cannot convey how disgusting I find this practice.

    The patients who are insured are incentivized to take drug B, because their insurance company is paying for it, so what do they care? They never see the cost of it.

    The only patients who should act in their own interest are the uninsured ones, but they're also the least likely to. They tend to be poorer, less educated, and more swayed by than insured patients are. Therefore, they're very likely to be stuck paying the extra 1000% for the 2% (*cough*) improvement that drug B gives them. Remember that their doctor probably prescribed it to them, because his prescription habits are being monitored, and because the patient probably either didn't know about the alternative or demanded to not take the generic (a surprisingly common phenomenon).

    So! Dealing with the marketing of drugs is treating a symptom of the system, but not its cause. We either need to reevaluate how we judge medical research, reevaluate how and whether to grant patents, or both.

    (I worked in the pharmaceutical research industry, my fiancee is a resident, and my mom manages a blood lab. That's my own disclosure. I should really write this up with references (I have lots), sorry for the extremely long comment.)

  • ||

    "Do people really believe doctors are so stupid that because a pharma company bought them a nice lunch that they'd risked getting sued over prescribing meds a patient might not need? Is this really the claim some are making?"

    The argument that the pharma companies are making is that doctors are overworked and unable to keep up with all the latest advances. So, it supposedly isn't doctor "stupidity" but "overwork."

  • Bill Mill||

    http://www.overcomingbias.com/2007/02/medical_study_b.html
    http://www.pbs.org/wgbh//pages/frontline/shows/other/interviews/angell.html
    http://www.wanttoknow.info/truthaboutdrugcompanies

  • ||

    As an aside, my son blushes every time the tv mentions a 4 hour erection and my daughter cringes at the tagline, "have a happy period."

  • ||

    Great minds think alike.

    zig zag man | February 22, 2008, 2:24pm | #

    ...I think that the pens, pads, luxury spa trips and other hand outs also help convince a doctor to prescribe the right medicine.

    Bill Mill | February 22, 2008, 2:25pm | #

    a) get free lunches and steak dinners and pens and pads and coffee mugs and espresso makers and free samples and so on.

    I would also add that most of the "new drugs" are no more effective and sometimes are less effective, with a greater number or severity of side effects as well.

    Chronic diarrhea, sleepwalking....Sometimes I think the cures our modern age witch doctors come up with are worse than the diseases they are supposed to help alleviate.

  • Dave W.||

    Just exactly why do you think I linked to my two feature articles on the topic immediately after my "Amen," huh?

    Okay, I'll play. I went to the links to find a discussion of whether pharma could really be fairly considered "penalized" (as opposed to say, scrutinized or criticized or taxed). The search string "pena" came up negative in both articles. Conclusion: "penalized is not discussed and the "amen" unsupported in this sense.

    That left the term "demonized" (which really smacks of hyperbole on its face to one without benefit of grants and sinecures like myself).

    At one of the linked articles, the search string merely turned up "demonstrated." So nothing in that artie.

    In the other article, "demonized" was mentioned because some other pharma advocate had concluded that pharma (more specifically academic-idustrial research relationships) said taht others were "demonizing." So I read the article (actually I think I read it when you first published it). It sounded like people were criticizing pharma:

    (i) because they thought that biased scientists had been to quick to clear COX2 drugs; and

    (ii) because research was manipulated to exaggerate improvements in drugs with small improvements; and

    (iii) because unfavorable studies on new drugs were quietly buried.

    And I was reading about these things, and I thought. Maybe they are true criticisms and maybe they are not. Maybe they are real problems and maybe they are not (pharma itself seems to have admitted thru its actions that the COX2 thingee was a substantial problem at this point in time).

    And I thought further, I thought: assuming these things are problems, what kind of people would cause these problems? And I thought: regular, fallible, sinful people. People like me and you. Peaople like clients and co-workers I have had in the past and will probably have in the future. regular folks. Imperfect folks. Folks who want to do good, but still make a buck and become conflicted when these imperatives conflict. People like the fizics phds and engineers you meet on the internet at libertarian boards. If these problems exist at all, these are the kind of people that would be causing the problems, alleged in these criticisms.

    Then I thought further.

    I thought about who would not be causing these problems. Of course, I thought about Jesus The Christ. He would not be causing these problems. He was too good. He was content to live in poverty and stuf. Good for Him. He is a good example.

    And then I thought of someone else who would not cause these problems. And I thought of . . . Satan. The red guy with the horns and the pitchfork whom I fervently believe exists. I thought, "Satan would not cause these problems because he is too bad." I thought that a scheme of the devil would be more diabolical even that the problems alleged to exist by CPSI. The AIDS might be Satan. Or cancer. Even the diabetes spike. But COX2 and overhyped new drugs. That is just not, just not . . . evil enough. It is not something a demon would do. The criticisms you discuss in that article do not, therefore, seem to be fairly considered as a form of "demonizing."

    But Stossel sed it was "demonizing." and now Rubin says it is "demonizing." Which is why, in this blog entry, I wish you would have written:

    Rubin concludes:

    "It is truly amazing that this society keeps coming up with ways to demonize and penalize an industry that has provided us with so many benefits."

    Of course, I agree, but still I realize that some skeptics understandably have a hard time grasping the concept that a sector as profitable as pharma could possibly be demonized or penalized. The reason is [explain away apparent contradiction on its own terms, if possible].


    Cause as of the right now, I don't think that pharma is "demonized" or "penalized." I think that Stossel and Rubin say it, and you repeat it, as a form of crocodile tears. I am open to persuasion otherwise. But I need a better convincer. I am not sure you can be that convincer, but you seem to be reaching out, and, of course, I want to encourage and facilitate that.

  • ||

    Many patients are convinced they need drug x and aren't satisfied until they get it, because the commercial convinced they need it. The same thing as a patient going to a doctor for a cold and telling him he needs an antibiotic. So, to keep him quiet and make him feel like he is doing something for the patient, the doctor gives him a scrip for antibiotics, rather than telling the patient to go home, get some rest and have some soup.

    You think that people need to be protected from that? We should protect people from themselves? Of course you would never get sucked in by that claptrap, but those not as intelligent or discriminating as you need protection. Got it.

    Why do we have to sit through viagra, cialis, guys throwing the football through the tire bologna, while Marlboro can't market it's wares in a similar fashion?

    That tobacco can't be advertised on TV is a result of thinking I just described. Those others aren't smart enough so they have to be protected.

    If you handle freedom irresponsibly, too frigging bad. I still want you to have it.

  • ||

    The doctor knows that if he doesn't prescribe B, the favors will stop, or they'll get bugged more by a sales rep particularly interested in them. I cannot convey how disgusting I find this practice.

    And again these little gifts are somehow worth more than the increased cost of his malpractice insurance? I mean since these doctor's are giving out drugs they don't need to and all. Those spa trips must be pretty good to risk their practice over.

    Although a dirty little secret, many doctors don't know jack about new drugs. Even in their own fields. I have heard from numerous patients about approaching their doctors about meds they saw on TV or other ads. After the doctor took the time to look the meds over they prescribed it to them. (Wasn't there a study done that said something like 88% of those that went to their doctor about a med they saw in an ad ended up needing it?) We'd like to believe doctor's stay up to date on every new developement out there, but it's just not true.

  • Mr. Obvious||

    Finally, I strongly dislike fish and lamb.

    What else would one expect from someone so obviously in the pockets of Big Cow?

    Or perhaps the Italics Consortium?

  • kinnath||

    Many patients are convinced they need drugproduct x and aren't satisfied until they get it, because the commercial convinced they need it.

  • kinnath||

    Do they make pills for premature submittal?

  • kinnath||

    Many patients are convinced they need drug product x and aren't satisfied until they get it, because the commercial convinced they need it.

    This statement covers the behavior of most of the population regarding most of the products on the market today.

    The only difference is that most people don't actually pay for their drugs. Issurance or the government does. Interfering with drug marketing is not going to make the problem better in any significant way.

  • Bill Mill||

    > And again these little gifts are somehow worth more than the increased cost of his malpractice insurance

    but it's not malpractice, it's just not *best* practice. That is, prescribing a patient a nominally 2% better drug that's 10x more expensive is not evil, it's just not optimal.

    I'm asking you to look at it economically, not ideologically.

    (Furthermore, I never supported the government controlling the gifts!

    I was just explaining the incentives. And make no mistake, they are incentives. I've eaten a free Ruth's Chris steak dinner, courtesy drug reps, and spent a week at the Four Seasons in Vegas courtesy Novartis. Don't necessarily trivialize these gifts.)

  • robc||

    Bill Mill,

    That is, prescribing a patient a nominally 2% better drug that's 10x more expensive is not evil, it's just not optimal.

    How can you say that? I know, to pick an exteme example, that I would pay 10x to be 2% less dead. That is optimal. Extra cost for extra benefit. Of course, in a more free market system both would be available on the shelf at the pharmacy and we could make our own choice (with input from our doctor if we so choose).

  • ||

    I'm an MD and I generally prescribe according to an algorhythm that includes physical attractivenes of the rep, brand of coffee and bagels provided, quantity of free samples, and honoraria bestowed at 'conferences' at sub-tropic golf resorts.

  • Bill Mill||

    But, robc, as I explain in my long post, it's not actually 2% better; or it carries 10% more side effects; or it's actually worse. Please read that post first. Sorry, I know it's long.

    (Futhermore, what you'd be paying for is not 2% less deaths, but a 2% improvement in perceived pain reduction, or 2% more people responding to the treatment.

    Furthermore, it's often carried out into absurdity, where a drug which promises a 2% improvement in response rate (that is, the amount of people who respond to it, not how well they respond) carries 100x or 1000x the price tag.

    At what point do we say "enough", even if that 2% isn't real? Is your doctor trying the generic first, because it probably works just as well for a tiny fraction of the cost? Or has he been moved by the marketing to prescribe you the expensive one and not mention the generic?)

  • Bill Mill||

    Also, Doc, I'm not saying that all doctors act according to the marketing, or that they're malicious (they're emphatically not, in fact I've been amazed by the professionalism and care of 99% of the doctors I've met).

    My beef is with the dubious drug-patent-extension syndrome.

  • ||

    "If you handle freedom irresponsibly, too frigging bad. I still want you to have it."

    Me too, freedom for everyone!

    In the case of the overprescription of antibiotics I used as an example, it is also the reason we have antibiotic resistant strains of bacteria, because antibiotics need to be taken for bacteria, not viruses and all the antibiotics should be taken. Many patients take antibiotics until the symptoms magically subside due to the disease running its course and unknowingly create resistant bacteria in the process.

    So, a patient demanding antibiotics for a virus is OK, but, it is the doctor's job to educate the patient about the disease and its treatment. Therefore, the doctor should act in the patient's and the society's best interests.

  • kinnath||

    Let's see:

    Current patent law prevents a company from value engineering a product during the lifespan of the patent and encourages the company to make incremental changes when the patent expires to get a new patent.

    Current regulations and licensing requirements in addition to drug schedules written by 500 or so laywers prevents the public from buying drugs without a doctor's prescription which must then be filled by a licencsed pharmacist.

    The result is that drug companies target the gatekeeper direclty (as listed above) and indirectly through advertising to consumers (ask your doctor about my shit).

    Gee how do we solve this problem?

    Change patent law? nah.

    Change medical regulations? nah.

    Eureka! Let's regulate advertising!

  • ||

    but it's not malpractice, it's just not *best* practice. That is, prescribing a patient a nominally 2% better drug that's 10x more expensive is not evil, it's just not optimal.

    But your acting as if doctors are just automatons. That they care so little about their patients a free golf trip will make them comprimise their care. And as far as controlling costs the insurance and hospitals will go crazy if they over presrcibe unnecessarily expensive drugs.

    Sorry, to get crazy about this but my dad is a doctor and I know from talking with him these gifts are basically meaningless to his decision making. Certainly a perk of the job but nothing that implies impropriety. He prefers the free samples that he can give to his patients.

  • ||

    I'm a doctor and I'm getting a kick out of this thread.

  • ||

    "Eureka! Let's regulate advertising!"

    Really, why not? For the reasons J sub D and I discussed upthread.

    I want my Medical Marlboros!

  • ||

    Bill Mill: You may also want to take a look at epidemiologist John Ioannides great article, "Why most published research findings are false," from PLoS Medicine. Among other things, he finds that the smaller the study the less likely it is to be true. Interestingly, many academic clinical studies are small-scale (lack of funding). See also this New Scientist article on Ioannides' findings.

    For what's worth I firmly condemned the sort of drug company chicanery (see my "Patent Absurdity" column) you're describing back in 2002.

  • ||

    Oops, forgot to change handles.

  • Dave W.||

    "Patent Absurdity"

    I firmly believe that this is the most used article title of all time.

  • anon||

    I agree that it would seem to be the patent regime that could be changed so as to cause the greatest change in the drug industry.

    But I've got to say, one wonders how many doctors and pharm reps people on this thread have actually talked to about how this process works. Knowing many on both sides, it's ugly. I'm not suggesting that a defense of the profit motive isn't warranted, but there is something to be said of stepping out of the clouds of idea and looking at the ground. I've attended this drug rep dinners and know how these reps track the scripts written in extreme granularity. It's not all bad, but it can result in some really ugly results at times. There may not be a reason for another bad law to be issued, but let's not argue against the law by pretending reality doesn't exist and relying on merely theoretical intellectual defenses of the status quo.

  • ||

    The doctor knows that if he doesn't prescribe B, the favors will stop, or they'll get bugged more by a sales rep particularly interested in them. I cannot convey how disgusting I find this practice.

    Pharmacies provide the drug companies with physician specific presription breakdowns? Really? How much do the drug companies pay the pharmacies for this info?

    Or is that just bullshit?

  • ||

    "I've attended this drug rep dinners and know how these reps track the scripts written in extreme granularity. It's not all bad, but it can result in some really ugly results at times."

    I wish I had access to my client's subcontractors information, so I could undercut them with a low ball price, just in the strike zone.

  • Bill Mill||

    > Sorry, to get crazy about this but my dad is a doctor and I know from talking with him these gifts are basically meaningless to his decision making. Certainly a perk of the job but nothing that implies impropriety. He prefers the free samples that he can give to his patients.

    Pain, my fiancee is a doctor and she's a "No Free Lunch"er. I don't want to speak for her, but I believe that doctors all believe they are immune to the marketing and I also believe that some of them are wrong.

    There's a reason why Harvard, Yale, and many other university hospitals ban pharm reps inside the hospital.

    And Ron, thanks for the links, and I'd forgotten that you'd written about the patent issue before; I mostly just wanted to point out that the marketing can be relatively evil in some cases, where it's a symptom of the larger patent problem.

    I of course should have focused tighter, but it's hard to edit inside this little box.

  • Bill Mill||

    J sub D, it's real:

    > "We got the numbers of what the physicians were prescribing. If I brought in lunch one week, I could see the following week if that lunch had an impact," Ms. Slattery-Moschkau said.

    from http://www.nytimes.com/2006/07/28/business/28lunch.html

    > The rep was so friendly, in fact, that she thanked Drexler for all the prescriptions he had been writing for Berlex's pharmaceuticals.

    > Drexler found the statement odd. He wasn't in the habit of divulging to salespeople how often he prescribed their company's drugs, so he wondered just how the rep knew. Drexler called local pharmacies and asked the pharmacists if they had any knowledge of drug reps gaining access to prescription records. But they were as befuddled as he was.

    > Then one day, a rep with whom Drexler was particularly friendly spilled the beans. He told Drexler that he and his fellow reps were provided with detailed prescription information, which was stored in their laptops, on every physician in their sales territory.

    http://www.sfgate.com/cgi-bin/article.cgi?file=/chronicle/archive/2006/08/06/CMGTSJU4NT1.DTL&type=politics

    > About halfway through the lunch, one of the representatives turned to a family practitioner-friend of Mitchell's who had accompanied him, and asked her why she wasn't prescribing much of their drug. The doctor reassured her hosts by telling them they had nothing to worry about, that she was indeed prescribing Cardizem. The inquiring Aventis representative then pulled out a "palmtop computer" and confronted the physician with exactly how little Cardizem CD she had prescribed the previous month compared with competing high blood pressure medications. The data on the computer screen, Mitchell noted, included the names and quantities of every drug Mitchell's physician friend had prescribed in the previous three months.

    http://www.guernicamag.com/features/159/inside_information/

    That's all just from a quick search.

  • Bill Mill||

    Pain: Here's a link where some doctors describe in great detail just how affected they are by marketing:

    http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0040150&ct=1

  • Bill Mill||

    replace "some doctors" with "a doctor and a pharmacist" in that last description, sorry.

  • ||

    If the pharmas whould stop direct marketing to the public, they'd save $800M anually. That could be spent on research. They should sell and advertise to doctors, leave the dumb-assed, easily led general public out of the drug marketing equation completely. Drugs are way different from most consumer products, that is why people need prescriptions for most drugs.

    Drug manufacturers not hurting, they're raking in record profits. This thread describes one reason why healthcare costs are spiralling upwards.

  • ||

    Thanks for the links. I'm not going to read them all this instant. So how do they get the info? From the government?

  • ||

    They should sell and advertise to doctors, leave the dumb-assed, easily led general public out of the drug marketing equation completely.

    The general public isn't as wise and discerning as Zig Zag man, so we need to protect them from themselves information.

    Protecting people from themselves, their own uninformed, self destructive desires is the purported reason we have marijuana prohibition.

  • ||

    Bill Mill:
    There's a reason why Harvard, Yale, and many other university hospitals ban pharm reps inside the hospital.

    Actually, I believe that these institutions are doing this because they have been stampeded by very flawed conflicts of interest studies, not because there has been any substantial showing that patients have harmed by such pharma/physician contacts. It's an anti-commercial ideology gussied up as ethics. But the weekend is here and we'll have to discuss this topic more fully sometime else.

    Have a great weekend all, even joe.

  • ||

    Is there a confidentiality problem here somewhere with the reps knowing what drugs the docs are prescribing to which patients? There's that paper they want me to sign when I see the doc? some kinda federal thingy?

  • Brian E||

    I've eaten a free Ruth's Chris steak dinner, courtesy drug reps, and spent a week at the Four Seasons in Vegas

    You got to eat courtesy drug reps?

    I hope they're hot.

    I hope they reciprocated.

    I'm in the wrong industry.

  • ||

    "The general public isn't as wise and discerning as Zig Zag man, so we need to protect them from themselves information designed to sell rather than inform."

    People are free to research any drug or treatment they want and talk to their doctors. With the serious side effects and risks of prescription medications, they carry liabilities which the consumer should be educated about.

    If the drug companies advertise thier product, they should show the public how thier product works rather than walks on the beach and guys throwing footballs through tire swings to demonstrate his boner going into the hole.

  • ||

    There's a reason why Harvard, Yale, and many other university hospitals ban pharm reps inside the hospital.

    It doesn't have anything to do with their marketing practices to doctors.

    It has a lot more to do with the fact that a pharma rep has no valid purpose whatsoever for being in a hospital (outside the pharmacy, of course). If they do anything at all on a patient floor, it is likely to violate about fifty laws, standards and policies.

    Now, some of the medical equipment reps are stone experts on their gizmos, and they get on the floors to do calibration and training.

    Once again, trust me, this is what I do for a living.

  • ||

    Drug Commercials = Car Commercials

    No information, little about the actual product, designed to appeal to emotion rather than reason.

  • ||

    "Protecting people from themselves, their own uninformed, self destructive desires is the purported reason we have marijuana prohibition."

    I can get marijuana without a prescription and I'm not being sold by TV advertisement that marijuana will cure / alleviate my disease or symptoms either.

  • ||

    If the drug companies advertise thier product, they should show the public how thier product works rather than walks on the beach and guys throwing footballs through tire swings to demonstrate his boner going into the hole.

    Every drug ad I've ever seen came with disclaimers. Am I missing something here?

  • ||

    I can get marijuana without a prescription and I'm not being sold by TV advertisement that marijuana will cure / alleviate my disease or symptoms either.

    And you can go to JAIL for that. Don't worry, it's just the government protecting you from your own uninformed, self destructive desires. ;-)

  • ||

    Yeah, disclaimers are given as a legal afterthought and treated as such in the ad, wouldn't want to educate the public only entice.

  • ||

    Gotta break away for a while, nice discussion J sub D.

  • ||

    Bill Mill | February 22, 2008, 4:37pm | #

    J sub D, it's real:

    We got the numbers of what the physicians were prescribing. If I brought in lunch one week, I could see the following week if that lunch had an impact," Ms. Slattery-Moschkau said.

    How about a more practical explanation: Pharmaceutical reps are field sales employees. They usually work from their home and determine their own schedule. The company must rely on their own reporting of time spent on the job. So really the only practical method of a) the company determining if they are getting any value from their employee, and b) the rep getting rewarded via commission and or bonuses for their efforts (not unheard of in the sales line of work I am sure you will agree), it to measure their actual sales, that being the being prescriptions sold. So the number of prescriptions (not who the prescription is written for - that would be illegal) a doctor writes for any given medication is used for that very purpose, and yes the better reps probably use the info to measure the effectiveness of their own activities. It's simply a metric the companies use to effectively manage their sales force and increase (shudder) profits. Does this process ever get subverted for illegal/dishonorable/distasteful means? Can you name one line of human endeavor that hasn't? While it's exciting to contemplate and search out instances evil men doing evil deeds, it has been my experience that the reality of the people conducting business much more mundane and consequently not nearly as entertaining. Thank goodness TV can take up the slack.

  • Paul||

    I was hoping you'd have learned something from that you could apply to the rest of your science writing, but obviously not.

    Translation: Your posts need to swing my way. Until they do, you're reporting 'ginned up' data.

  • ||

    The inquiring Aventis representative then pulled out a "palmtop computer" and confronted the physician with exactly how little Cardizem CD she had prescribed the previous month compared with competing high blood pressure medications. The data on the computer screen, Mitchell noted, included the names and quantities of every drug Mitchell's physician friend had prescribed in the previous three months.

    The info comes from the pharmacies, which by contract with the pharma companies upload their dispensing data on a regular basis. Its illegal to disclose patient-specific information. Among other things, the information is used to track volume by the pharmacy in order to calculate volume discounts, track inventory, all that shit.

    So far, we have a manufacturer tracking sales information on its product, for valid business reasons. Shocking!

    Now, every time a drug is dispensed, it has to be tied back to a specific prescription by a licensed physician. The pharmacist is required to keep records on this. It would be foolish indeed to keep this in a separate database than the rest of his inventory tracking, no? This is purely business/compliance data, as long as patient identifiers are stripped out. Why shouldn't the pharma have it?

  • some sense||

    I knew there was a reason I should have been a doctor; free dinners, free pens, free coffee mugs. Nobody ever gives me any free stuff in my business. Come to think of it, no one has ever tried to buy my vote either at election time, even though I do my best to look as if it is for sale.

    Wahhhhhhhhhhhh........

  • economist||

    joe: "I like to think we're a little bit ahead of the curve here in San Francisco"
    *farts, collects in glass, and then inhales deeply from the glass*
    Seriously, joe, I think if environmentalists didn't put forth such insane "solutions" to environmental problems (i.e. return to the stone age) then maybe people would be more inclined to listen to reasonable concerns about the effects of pollution. Instead, we get "Technology is evil and it's raping mother earth while big corporations live off the backs of the little people and kill Native Americans and force the government to not fund poverty programs so the corporations can hoard their greedy and ill-gotten gold". To which a reasonable person says "This guy is fucking crazy. Why believe anything this weirdo says?"

  • ||

    That tobacco can't be advertised on TV is a result of thinking I just described. Those others aren't smart enough so they have to be protected.

    If you handle freedom irresponsibly, too frigging bad. I still want you to have it.


    Actually, selfish bastard that I am, I only care about me having freedom -- all the whiny fucktards who want to be bossed around are welcome to that -- but if I don't fight for it for everybody else, then it will be taken away from me too. Invisible hand, not the benevolence of the butcher and baker, etc.

  • wizard of oz books||

    With many new announcement about the wizard of oz movies in the news, you might want to consider starting to obtain Wizard of Oz book series either as collectible or investment at RareOzBooks.com.

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