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“Dollars For Docs” – What It Really Means

A few weeks ago I received an invitation to an October 1 symposium on Latuda, a new antipsychotic from Sunovion (formerly known as Sepracor).  Latuda (lurasidone) was released about six months ago amidst much fanfare—and very aggressive marketing—as a new atypical antipsychotic with, among other advantages, pro-cognitive properties.

I have only prescribed Latuda to three patients, so I have only limited experience with it.  (In case you’re wondering:  one success, one failure, one equivocal.)  However, I have read several papers about Latuda, and I am interested in learning more about it.  The symposium’s plenary speaker is Stephen Stahl from the Neuroscience Education Institute.  Dr Stahl has received money from Sunovion (which is obvious from his publications and disclosures) but he is also a very knowledgeable neuroscientist.  I figured he would be able to describe the differences between Latuda and the other atypical antipsychotics currently on the market.  So I accepted the invitation.

However, upon further thought, I wondered whether my attendance might represent a “payment” from the Sunovion Corporation.  I was not offered any money from Sunovion to attend this event (in fact, you can see my invitation here: page1, page2).  Nevertheless, according to the Physician Payment Sunshine Act, which was passed as part of PPACA (i.e., “Obamacare”), all pharmaceutical companies and medical device manufacturers, as of 2013, are required to report payments to physicians, including direct compensation as well as “food, entertainment, research funding, education or conference funding,” and so forth.

Despite the mandatory 2013 reporting date, several companies have already started reporting.  Other major drug firms to self-report thus far include AstraZeneca, Eli Lilly, Merck, and Pfizer.  Their reports have been widely publicized at sites such as “Dollars For Docs,” which “allows the public to search for individual physicians to see whether they’ve been on pharma’s payroll.”  Several other sites encourage patients to use this site to ask “Does your doc get money from drug companies?”

A quick search of my own name reveals that I received $306 from Pfizer in the year 2010.  Wow!  I had no idea!  What exactly does this mean?  Am I a Pfizer slave?  Did my Pfizer rep walk up to me on 12/31/10, hand me a personal check for $306 and say, “Thank you, Dr. Balt, for prescribing Geodon and Pristiq this year—here’s $306 for your work, and we look forward to more in 2011”?

The answer is no.  I received no money from Pfizer (and, to be frank, I didn’t prescribe any Pristiq last year, because it’s essentially Effexor).  As it happens, during 2010 I worked part-time at a community mental health clinic.  The clinic permitted drug reps to come to the office, bring lunch, and distribute information about their products.  We had lunches 1-2 days out of the week, consisting of modest fare:  Panera sandwiches, trays of Chinese food, or barbecued ribs.  Most of the doctors didn’t have time to eat—or if we did, we scarfed it down in between patients—but we would often talk to the reps, ask questions about their drugs, and accept product literature (which virtually always went straight into the trash), reprints, and educational materials from them.

We were visited by most of the major drug companies in 2010.  (BTW, this continued into 2011, but we are no longer allowed—under our contract with the County mental health department—to accept free samples, and we no longer accept lunches.  Interestingly, my Pfizer rep told us that payments would be reported only as of 1/1/11 and NOT earlier; obviously that was untrue.)  All of the lunches were generally the same, and consisted of inexpensive, modest food, mainly consumed by the clinic staff—secretaries, administrators, assistants—since the doctors were actually working through the lunch hour.  I have since learned that the formula for calculating doctors’ payouts was to take the full cost of the lunch (including all staff members, remember), divide it by the number of doctors in the office, and report that sum.   That’s where you get my $306.00.

[In the interest of full disclosure, in my four years of practice post-residency, I have only been offered one “material” non-food gift: about three years ago, Janssen gave me a $100 voucher for a textbook; I used it to purchase Glen Gabbard’s psychodynamic psychotherapy text.]

Anyway, back to the Latuda symposium.  Knowing what I now know about drug companies, I wouldn’t be surprised if Sunovion reports a $1000+ payout to me if I attend this half-day symposium.  (Facility rental + A/V costs + Xeroxing/handouts + coffee service + refreshments, all divided by the # of docs in attendance.)  I frankly don’t want my future patients searching my name on Dollars For Docs and finding I received a huge “payment” from Sunovion in Q3 2011.  On the other hand, I would like to learn more about Latuda and whether/how it differs from other antipsychotics on the market (including generic first-generation agents).  If possible, I would also like to question Steve Stahl directly about some of what he’s written about this drug (including his Sunovion-funded articles).  What better forum to do this than in a public symposium??

[Note: please see ADDENDUM below.]  I have contacted two different Sunovion sales reps to ask whether my attendance will be “reported” as a payment, and if so, how much.  I have not received a response.  I also called the RSVP number for the symposium.  The registration is being managed by Arbor Scientia, a medical communications company contracted by Sunovion to manage these events.  I was directed to Heather of Arbor Scientia; I left her a message but have not yet received a return call.

So at this point, I am looking forward to attending an event to learn more about a new drug—and the opportunity to challenge the experts on the advantages (if any) of this drug over others—but in doing so, I might also be reported as having “received” a large payment from Sunovion, perhaps even larger than what Pfizer reported they paid me in 2010.

Patients should recognize that sometimes the only way for their doctors to learn about new drugs is to attend such events (assuming they can remain objective, which can be hard when the wine is freely flowing!).  Admittedly, there are doctors who accept much larger sums as speakers or “key opinion leaders,” but organizations like ProPublica should differentiate those doctors (with whom I, personally, have an ethical gripe) from those who are simply workaday folks like me who want to get as much information as they can, provide effective and cost-efficient care—and maybe inhale a free sandwich every once in a while.

ADDENDUM Sept. 26:  Today I received a phone call from Arbor Scientia (from a number that is actually registered as NEI’s main number—as it turns out, they are located in the same building) to assure me that Sunovion adheres to the Physician’s Sunshine Act provision: namely, that they’ll report “payments” to doctors only after January 1, 2012.  (See also here.)  Interestingly, my local Sunovion rep had told me 1/1/11.  (This is only somewhat reassuring: my Pfizer rep had told me they would start reporting as of 1/1/11, but clearly my “payments” from 2010 were reported.)

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48 Responses to “Dollars For Docs” – What It Really Means

  1. DL says:

    Why the eagerness to report these “payments”, and to apparently inflate them? Surely they write it all off regardless, so what’s the point? To pretend they are good corporate citizens? To get ahead of some unknown curve? Just seems the more government attempts to be “helpful” (numerous new health care regulations) the more they make everyone’s life (and health) worse. Why not allow doctors to make comments on these “payment” entries? You know, even at one of the most ridiculous agencies for “protecting” the public (Consumer Product Safety) a manufacturer is notified and can provide a “rebuttal” of sorts when someone makes a complaint about a product. It would seem to me that is “payment” is not defined, then the payee should be able to define it.

  2. stephany says:

    Well isn’t this an intrigue! who would have thought the pharma cos take names, dates and events and count you all in their reports (tax write offs!) I bet you were shocked to see your name since it was a meal you attended and not pocketed cash. More surprised to know I never checked your name in D for Docs! lol good thing you caught it first! 😛

  3. marilynmann says:

    I don’t get why this is the only way to learn about this drug. Isn’t there peer-reviewed literature you could consult?

  4. stephany says:

    If you are a listed practitioner and believe you are listed in error, please contact us at ornstein.weber@propublica.org

    I’d contact them, if you were unaware of this report of your name and Pfizer, because it really does not make sense that they include doctors at dinners or learning events….

  5. steve says:

    As an aside, as a psychologist who currently works, as you did, in a community mental health center with harried professionals and office staff, I would note that such gratis lunches go a long way towards breaking up an often stressful day for all levels of staff. The chance to have a good sandwich while asking questions, often pointed, with drug reps or even M.D.’s who work for the pharma company, is a perk with several benefits. My state, MA, has passed legislation curtailing this practice, suggesting such meals unduly influence medication choice. Perhaps a free weekend for physician and spouse at a golf resort in Tucson while rubbing shoulders with Big Pharma might do so but a turkey sandwich eaten by an underpaid receptionist is another mater.

  6. aek says:

    Do you have access to academic detailing? Have you availed yourself of it? If so, what is your perception of its usefulness?

    http://en.wikipedia.org/wiki/Academic_detailing

  7. I’m skeptical that you’ll learn much meaningful information. Last June, Dr. Andrew Sewell of Yale reviewed the literature on Latuda’s supposed pro-cognitive activities and was not much impressed: http://bit.ly/q2WSrR (this article is free–no subscription is required to the Carlat Psychiatry Report for this one.

    The cognitive studies can be spun many ways, and this conference will clearly spin them promotionally. I anticipate they will get many more doctors prescribing the drug. A better way than going to such a conference is to watch a web-based lecture by Dr. Stahl, and you won’t have to deal with having to make financial disclosures.

    • stevebMD says:

      Dr Carlat,

      You are probably right, there will be nothing new presented in the symposium– most likely nothing newer than what’s discussed in Dr Sewell’s article. The attraction of a symposium, however, is that it gives participants the opportunity to ask questions of Dr Stahl directly, in person. (Or is that sacrilege?) I guess I could email Dr Stahl myself, but I appreciate the input/discussion that a larger audience would provide.

      Have we reached a point in psychiatry where direct interaction with KOLs– to clarify and understand their pronouncements about new medications– is only possible under the auspices of a pharma-sponsored “promotional event” (and one for which the participants are reported to their patients as recipients of pharma money)?

  8. stephany says:

    Dr.Balt, when you go, could you ask him a pointed question: Ask him WHY Latuda works? and how?

    When I have asked so-called experts Qs like that they cannot answer, which round -bins their talk in my opinion in this case he will be walking around egg shells trying not to promote the product, but to teach abt the product and how it actually would benefit with REAL reasons, scientific ones….if they even exist.

  9. john b. says:

    Life is complex. Now perhaps you can see that apparent ‘payments’ from companies do mean that they’ve purchased your prescribing patterns. It could happen for some, but even those physicians with whom you have a theoretical gripe may actually convey information (which is all FDA regulated). Sites like you describe capitalize on sensationalism.

    • stevebMD says:

      John B,

      Good point. My “gripe” is not so much with the fact that some experts receive money to lecture their peers about new medications, but that some “experts” (who are not really experts) seem to do it solely for the money. And, moreover, that drug companies capitalize on the fact that many docs who attend these programs assume, without questioning, that the speaker is giving them the God’s truth. (Actually, if Joseph Biederman is the speaker, they’re almost right, but I digress…)

      This Sunovion program seemed to be a good opportunity to hear someone (Stahl) who seems to know what he’s talking about, and, hopefully, to engage in a dialogue with him & others about this new medication and its competitors. It would be a shame if Sunovion reports me as having received “income” for what is (at least for me) a purely educational event.

      Maybe I should offer to bring my own coffee and a bag lunch?

  10. john b. says:

    you could. i don’t know the content of Stahl’s program, but the regular programs (which i do present) are totally FDA regulated and allow no room for additional information, let alone unbalanced information. personally, i focus mainly on side effects.
    I might suggest you ignore sites that are designed to intimidate physicians (and are rather insulting to them in my opinion) and do what you wish. I’ve received many items from companies whose products i’ve never prescribed.

  11. John b.

    The FDA has to approve the slides, but the pharma folks are experts at slipping in “facts” as if they were established, when they are in fact not established (http://davidmallenmd.blogspot.com/2011/08/plausible-deniability.html).

    I still go to these talks occasionally. Some of them are informative, but you have to look up the information they give you from alternate sources to keep them honest. The Medical Letter seems to be relatively objective.

  12. dinah says:

    Good news: I’m clean (I checked).

    You eat a lot for a slim, athletic Californian. It costs $306 to feed you an occasional lunch! Wow.

    I got a postcard for some NEI conference today— in Colorado at the Broadmoor, I think, in November. It looked really good. Is that the one? Can you get Pfizer to spot me the expenses since you have an in with them?

    I’m just teasing, of course (aka: jk)

    • stevebMD says:

      The Broadmoor, very nice.

      Anyway, congrats for checking out “clean.” I posted the Pfizer thing as just sort of an “isn’t-this-interesting” kind of observation– I am fully aware that the $306 simply came from the several lunches Pfizer sponsored in our clinic, which I happened to attend as a clinic employee.

      However, since I wrote this post yesterday, it has come to my attention that journalists (like Charles Ornstein, who tweeted my article) and legitimate news outlets still believe that all these “payments” represent direct payments “to doctors to peddle pharmaceuticals.” (See this page, about halfway down.) This is the problem with the “Dollars for Docs” list: some docs were paid to sell drugs, while others– like me– were simply caught in the crossfire.

      If the journalists who made the database can’t tell the difference, how can we expect patients to do so?

  13. leejcaroll says:

    Its not the doc who receives $306.00 but the ones who receive $3,600 or $30,600 that worry me. You know darn well thats got to be for more than a few Panera sandwiches and the guys you should be worried about.

  14. john b. says:

    What do you think a doctor who receives $30,600 would do to worry people?

    • doctorz says:

      John B., surely you are not so blinded to believe that such sums of cash don’t influence prescribing practices. You may be an exception as an admitted speaker for Big Pharma, but let me ask, prior to the FDA requiring disclosure, did your slides include your relationships with pharmaceutical companies. I’ve attended these for the last 25 years, and I can attest that prior to the mandated reporting, they were never revealed in any of the programs I attended.

      • john b. says:

        Hmm. If those sums of cash are to influence my prescribing practices, then they are sorely wasted sums of cash. I can assure you. To answer you question, I have always disclosed all relations with pharmaceutical companies in slides and other presentations. In pharmaceutical talks it is always clear that I am there because the company is paying for me to be there. I don’t know that I’m an exception, but I think people who do not act appropriately shouldn’t serve as stereotypes for the majority who do.

    • doctorz says:

      This article says it all on this subject…http://www.medscape.com/viewarticle/731028
      I particularly got a kick out of the highest paid speaker in the industry that he actually prescribes more generics than the trade psychotropics he presumably promotes. My question is, Why not give lectures extolling the virtues of generics…for free?

    • doctorz says:

      John B, do you mind leaving your name so I can check your pharmaceutical income?

  15. Jeff Mudrick says:

    As a regular reader of your blog, I was surprised by your position on this topic. First, there are plenty of resources available for learning about new medications beyond rep lunches and Steven Stahl-led conferences/marketing extravaganzas. Stahl is the PT Barnum of our field–a master showman whose gimmick of reducing complicated neuropharmacology to simplistic, visually appealing graphics flatters his audience (we psychiatrists who love to feel in command of challenging material) and enriches his employers (drug companies who see dollar signs every time he attributes theoretical antidepressant or procognitive effects to whichever unique serotonin receptor subtype interaction has been tacked on to the latest atypical antipsychotic). Sunuvion would give anything to have you at that conference to be “educated” about their product. While I see you as a refreshingly independent voice in psychiatry, I can’t imagine even you are immune to the sophisticated marketing offered up at such a conference. And while I’d love to see you stand up and take Stahl to task at this event, this is not likely to be a venue where or a person from whom you will receive a measured and intellectually honest response. It would be like going to a Tea Party rally expecting to stimulate reconsideration of the wisdom of deficit reduction. I hope you won’t support this type of marketing as education with your attendance at the Latuda conference. And if you do attend, I think it should be reflected as a payment from Sunovion, as they will be comping your portion of facility, materials and KOL speaker fees in exchange for the opportunity to plant some nugget of pseudo-scientific rationale in your mind to support your future prescribing of Latuda.

    • stevebMD says:

      Jeff,

      You’ve (almost) read my mind. I simply figured this would be a good opportunity to see Dr Stahl (the myth, the legend, etc.) on Sunovion’s dime. And no, I don’t expect to have the chance to ask any questions of Dr Stahl, and I’m certainly not in a place to “take [him] to task.” (But I might be able to ask him to autograph my copy of Essential Psychopharmacology!! [wow, that book costs $203 now????? Amazing… that might deserve a blog post of its own….]) I want to experience the spectacle of a true drug marketing blitz. The Sunovion booth at this year’s APA featured a dark walk-through tunnel with video vignettes of patients describing their transformations, a 3D display of Latuda’s “unique” mechanism, and dozens of iPads showing patient cases and dosage recommendations. (I think there was a smoothie bar, too.) Surely a half-day symposium featuring “animations… to bring the scientific story to life, … [an] immersive learning experience, … [and] a competitive, yet fun, atmosphere through games” about Latuda is certainly worth attending, especially if it’s walking distance from my home.

      Am I “immune to the sophisticated marketing”? That’s a good question. I’m not naive enough to sit here and say “Absolutely!!! I can see right through it!!!” To be honest, I still think Latuda might be a revolutionary new drug. And who knows, I might feel that way as a result of what Stahl has already written about it. However, for me, the proof is in what the patient says, no one else; and I absolutely do consider cost as a factor in what I prescribe (which is why I’ve only used Latuda three times).

      To your point, however, Sunovion has done a far better job in marketing Latuda than Novartis or Merck have for Fanapt or Saphris. And here we are discussing it. And not the others. Hmmm…

  16. SD says:

    Why can’t pharma companies offer modest meal to physician to inform about their products. After all pharma companies are spending billions of dollars every year trying to develop new medicine to improve our quality of life or even save our lives. Remember when you were sick last time, did you take medicine to get well? Or would it be ok to doctor just ask you to go back home snd rest as an answer for your visit. Did you ever had a loved one that survived cancer or is still alive due new medicine that has been developed by big pharma. Think about it. Maybe pharma is not that bad after all and maybe a modest lunch will be the only way that pharma company is able to get in front of your doctor to educate on new medicine. If a sandwich for a physician will change the prescribing habits of your doctor that is pathetic and maybe it’s time to find a new doctor. There is a lot more good what pharma does than the skewed articles will tell you.

    • Rob Lindeman says:

      “[M]aybe a modest lunch will be the only way that pharma company is able to get in front of your doctor to educate on new medicine.”

      It’s not.

      “If a sandwich for a physician will change the prescribing habits of your doctor that is pathetic and maybe it’s time to find a new doctor.”

      Good point. And yet the pharm house isn’t offering you lunch just cuz you look like you could use a good meal. They know they need to do this to move product.

      • SD says:

        Have you ever considered that maybe it is the product conversation that might chance the doctors habits not the sandwich that they are eating. Also reps are also required to inform physicians about possible side effects or interaction that could save you from a trip to hospital. Pretty important if you ask me.
        How about if our senators make public record available of all the information regarding their meals, donations, salaries, other compensation etc. that they receive every day/month/year.

      • Rob Lindeman says:

        “Have you ever considered that maybe it is the product conversation that might chance the doctors habits not the sandwich that they are eating.”

        I’ll assume that’s a question. Yes, I’ve considered it, and rejected it. However, if the rep were young, female, and hot, I was more receptive to the message. Why do you suppose the reps are so often young, female, and hot? Just askin’ (using question marks, too!)

      • SD says:

        Sounds like you are one of those unfortunate physicians that prescribe medicine based on the quality of tge sandwich you you are being served or based on the looks of the pharma rep or you one of those people that really dont know what’s going on in the physician office and you are there to been seen by medical staff at the expense of the us government. Either case I am happy that you are not my doctor or I am not your physician.

      • Rob Lindeman says:

        At last we agree! I too am glad we don’t know one another!!!

  17. doctorz says:

    Steve, I just checked myself and much to my surprise, I got tagged for $428 in meals, also from Pfizer in 2010. This is absurd. I went to a chinese restaurant for 2 speaker programs, in which the food and the lecturer were horrible. Have not been to another since. Also, they sponsored cheap lunches a couple of times at our clinic that year. So these charges seemed excessive for what I received. During this period, I was medical director of our clinic, and I wondered if the meal costs were only attributed to supervisors. However, I looked up a number of our medical staff and all were also reported for similar amounts, all by Pfizer…perhaps their expense reports warrant auditing.

  18. Presently drug free says:

    From a patient perspective my concern is less about the possible influence from a “free” lunch and more about the expense of all these lunches, dinner talks at expensive restaurants, talks at resorts, etc. All of these expenses increase the costs of the drugs which of course mean patients pay more for drugs, insurance companies will increase our premiums to cover their increased expenses and so on. It’s the patients who get screwed.

    There is so much waste and unfortunately we’re all left holding the bag. I’m sure the same information could be provided in an interactive webinar at a fraction of the cost of what it would cost to pay for physicians to travel to hear it. BYOB. So, for that reason I’m glad they’ve cut some of the wasteful spending although I’m sure they’re finding ways to replace it with other wasteful spending.

  19. JanePhD says:

    You guys and your lunches! My husband has been a practicing physician for 28 years and has never consumed a sponsored lunch or dinner. He does, however, pack his own lunch at 5:30 every workday morning.

  20. Mark says:

    While “Dollars for Docs” may get headlines, Propublica is neither journalistic nor independent. Propublica receives its funding from the Sandler Foundation, which funds left-wing “Progressive Infrastructure” causes like the Center for American Progress (Soros funded) run by John Podesta pushing the Healthcare Reform Act, which, in turn, created the Physicians’ Payment Sunshine Act. The Sandlers are major donors to the Democratic Party and are top funders of ACORN, MoveOn.org, the American Civil Liberties Union and other far-leftist groups like Human Rights Watch among others.

    The problem in America is healthcare has been politically hijacked by a group of pseudo-political journalists doing business for a blatant social-driven agenda that corrupts journalism itself and dissupts patient healthcare delivery. Propublica needs to come clean on its “Dollars for Democrats”.

  21. harpy says:

    sure, bitch and moan now, but where were you when they were writing and passing this legislation? pay attention! this was done for your benefit. if you feel it’s unnecessary, please, write to your local congresscritter.

    and it’s nice of Lilly and Pfizer etal. to say their disclosures are “voluntary.” all that means is that they put it up just before their corporate integrity agreements kicked in. kinda like when the cops ask if you’re gonna come quietly…

  22. SG says:

    Mark — That’s some great information to know about Dollars for Docs.

    Unfortunately, I hope that information doesn’t smear the very vital concept of patients knowing if their doctor is getting serious cash from pharmaceutical companies. I honestly think it’s a right for patients to know that, as we all know of the very real tendency of a doctor’s prescribing habits to be corrupted by big-time pharma payouts.

    If anything, such a database makes it clear to doctors that they’ll have to answer to their patients about any money they earned from pharma companies, and that can only be a good thing in my mind.

    However, I also agree with Steve that the database needs some tweaking. It would be tragic for honest physicians like Steve to lose patients (and tragic for patients too) if he was viewed negatively just because he worked at a clinic that allowed drug reps to give out free food, even if he didn’t eat it! Yes, one could read between the lines and see that his “payout” was quite meager, but I think the database should go further and at least give out a disclaimer of just how meal costs/payments are calculated by drug companies, as Steve has done.

    • observer says:

      Exactly how is the “very real tendency” established? If the tendency is so real and doctors are so easily influenced, then Steve isn’t so clean either.

    • Mark says:

      I think transparency is great and consumers should be given MORE relevant information – not less – to make meaningful decisions regarding their health and care. However, the average patient does not understand nor can assimilate what it is they are viewing in a medical context of their diagnosis and treatment that is already tailored to them, the individual patient since doctors are accountable organizations.

      Most all doctors do not get “cash” from pharmaceutical companies. The medium of exchange is more typically like a $5 cold piece of chicken (one for them and one for each of their staff members so they can be more productive and stay within the office to return patient calls and administrative requests between 12-1PM). That chicken arrived at 11:45AM, staff usually eats first, in exchange for about 1 or 2 minutes of product information by a manufacturers rep to the doctor that occurs at 1:05PM because the physician is overbooked that morning with medicare patients that use a 10 minute health visit and turn it into 30-40 minute social discussion, is behind on physician order entry, lab work incoming, follow-up/callbacks, and paperwork charting documentation (for legal CYA), additional patient phone requests (of which they do not get to bill for time like lawyers and accountants), and gatekeeping diagnosis requests from payers like the state medicaid agency for a prior authorization requests because a patient cannot get a prescription filled they wrote yesterday or earlier that morning who needed a very important drug and can’t get it dispensed until paperwork is submitted which may take that state medicaid or managed care agency up to 72 hours to review and approve/deny it even after that patient failed other documented agents.

      Let’s get real: government payers and managed care plans have more effect on patient prescription options/therapy (usually a generic with limited plan choices, most often the lowest cost, sometimes even off-label agents required by plan payers that is outside of approved diagnosis/treatment regimens, and yes, even sub-therapeutic regimens placed on an approved drug list that the doctor knows the patient is probably going to fail anyway, but needs to use it first to get a preferred, dare I say, branded agent) available to the patient well before a manufacturer’s branded product is used. Over 85% of prescriptions today are for generics and most of the time a branded is written well after 1 or 2 documented failed patient experiences on the least expensive options, which can drive up health care utilization costs (additional labs, repeated patient visits), etc. for chronic and other diseases. Doctors inherently know in their treatment algorithm that if a patient cannot access a more expensive branded medication, their efforts have been wasted in clinic visits.

      I have never seen a doctor corrupted by big pharma payouts, and in 99% of doctors will it never happen. For the rogue 1%, that is why each state has a medical review oversight board and often times drug utilization review committees are involved inside and outside the doctors’ organizations.

      These doctors are the people in our society who graduated top-of-the-class and go into medicine to make meaningful impact in the world, and are not money-driven like wall streeters or politicians. Let’s give doctors their due and restore the physician-patient relationship, not divide it with innuendo and leapfrog conclusions from ProPublica or any other print outfit.

      • SG says:

        “For the rogue 1%, that is why each state has a medical review oversight board and often times drug utilization review committees are involved inside and outside the doctors’ organizations.”

        Uh, the problem is that the “rogue 1%” seem to make up a large portion of the top 1% of psychiatry, and their efforts have huge lasting impact on thousands of psychiatrists and millions of patients. Take Alan Schatzberg, for example. He “co-authored” a ghost-written textbook to pimp Paxil to general practitioners. And Alan Schatzberg was once the APA President!

        And what about Joseph Biederman? He is almost single-handedly responsible for the explosive increase in childhood bipolar disorder diagnosis, largely because of his massive conflict of interest with J&J/Risperdal. Hell, between 2002-2005 he got J&J to pay $2 million to create the J&J Center for Pediatric Psychopathology at Mass General Hospital, which was, in his words, “a strategic collaboration” that would “move forward the commercial goals of J&J.”

        And what about none other than Tom Insel, director of the NIMH? There’s good reason to believe he helped barfbag Charles Nemeroff get a sweet new gig at U of Miami after he was fired from Emory for failure to disclose his pharma payouts. Read about it here: http://1boringoldman.com/index.php/2010/06/15/who-is-not-telling-the-truth-yes/

        And considering Nemeroff’s CV is stuffed with hundreds of studies (who knows how many of them are bogus, ghostwritten fluff?), his impact is enormous. A pattern has emerged that the most highly prolific psychiatrists (Nemeroff, Biederman) are often the most corrupt, thus the impact of a small group of men is exponentially huge.

        And Insel is the man who, along with a few of his elite cronies, is shaping the future of psychiatry with huge pronouncements and prognostications based on the flimsiest of research findings. He’d love to refashion psychiatry as clinical neuroscience, even though the science isn’t exactly ready for prime time to back up such a refashioning. Seems the only science he likes funding with NIMH cash are dead-in-the-water studies like Mahukar Trivedi’s IMPACTS study (5 years and $3.5 million later, it’s still not even started) and hugely flawed studies like the STAR*D trial (need I say more?). And yet Insel has recently given fresh NIMH money to Trivedi to start a study on genetic biomarkers (obviously so Insel can bang the PR drum about how psychiatry is “moving forward” into bold new genetic territory). Wow, Insel’s right up there with the government when it comes to responsible spending. THIS is what we want out of our top 1% of psychiatric leadership?

        And what about those medical review oversight boards? I don’t know about you, but I don’t know of any real punishments for any of these guys. Nemeroff is still working a cushy gig at U of Miami and Insel is still director of NIMH. The only one who received something of a lasting punishment was Schatzberg, who was censured at Stanford and stepped down from his position as psychiatry chair over the Mifepristone/Corcept debacle. However, he still has his license and is still conducting studies like the iSPOT-D study. And Biederman’s disciplining at Harvard was little more than a slap on the wrist (he got to keep his millions in pharma payouts, his license, and his job).

  23. Leslie says:

    I don’t believe that the average patient is as ignorant as Mark portrays us. Give us a little credit, here.

    I wouldn’t be torn up over a report of $300. Even a high payment doesn’t necessarily mean that that the physician is prescribing the wrong treatment. We are capable of recognizing that. If it’s a high payment, though, I think that’s important info to know in the decision making process.

    Do I care if physicians eat a pharma provided sandwich, no. I’ve had a couple myself. One hospital I used to work at had food provided by some pharma company almost daily and most of the time as others have indicated it wasn’t the physicians eating the sandwiches. I got a little grossed out by the vulture like way in which the rest of the staff descended upon any morsel of “free” food, so mostly I avoided it. But, again you multiply all this “free” food by all of the clinics and hospitals who received it and you’re talking about a lot of expense which will be passed on to us and insurance companies. I think curtailing some of that is a good thing.

  24. doctorz says:

    Mark, you lost me after “consumers”.

  25. SteveB, thanks for presenting an important angle on this topic. Although I agree with Dan Carlat and Jeff Mudrick above, I appreciate that disclosure of trivial or unintended financial transactions feels unfair and absurdly picayune. Maybe a threshold of, say, $1000 for public reporting would allow occasional lunches to be eaten in peace, and clearly differentiate them from lucrative speaker and consultation fees.

    There are subtler issues here though. First, even cheap lunches are promotional. Even if they’re eaten by office staff, and even if you can’t consciously recall the company or its product. None of it would happen if not for industry marketing departments. The influence may be minor, it may be hit or miss, but it *is* intended to influence. And presumably there’s a ROI, so in some sense it works.

    I’m struck, too, how your example nicely illustrates the crucial breakdown of us-vs-them thinking. Your intentions are good, yet your hands are (a little) dirty. That’s true for everyone, including sticklers like me. None of us is perfect. Perhaps ProPublica’s tone draws lines and creates “bad guys,” when we’d be better off conceding that we all like free lunch on a busy day, attention from attractive salespeople, and all the rest. Better than lists of good guys and bad guys would be sober discussion of professional ethics for fallible humans like us, subject to conscious and unconscious influences by companies that are not “bad guys” either. The responsibility lies with our profession, not industry or investigative reporters.

  26. SG says:

    “Maybe a threshold of, say, $1000 for public reporting would allow occasional lunches to be eaten in peace, and clearly differentiate them from lucrative speaker and consultation fees.”

    Not a bad idea at all! I think the Propublica database is a great start, but I agree it needs to be tweaked. Your $1000 cut-off idea makes sense, so only the most egregious doctors are exposed.

    “The responsibility lies with our profession, not industry or investigative reporters.”

    Again, agreed. But I must say that the psychiatric profession has been, shall we say, a little less than zealous about self-regulation! It really has come to the point where it takes journalists like Robert Whitaker and Propublica to do what psychiatry should have done decades ago: expose massive corruption and bad science. I’m not anti-psychiatry (neither is Whitaker, for that matter), I’m anti-BAD SCIENCE. With bad science, everybody (patients and physicians) loses, and this has been going on for far too long. Only good science will maximize the therapeutic benefit of psych meds and patient outcome (and yes, that includes multi-year longitudinal studies of psych med safety/side effects). If it takes “outsiders” like Propublica or Whitaker to finally prod psychiatry to get its act together, so be it. Psychiatry had its chance to reform itself decades ago, and it failed miserably.

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  30. leejcaroll says:

    Steve, hope all;s well. Haven’t seen any posts from you in a while.

    Thought this was interesting, and appropriate:

    http://www.medscape.com/viewarticle/780835?nlid=29165_329
    Psychiatrists Top List of Big Pharma Payments Again

    “…On March 12, the investigative journalism group ProPublica released the names of the 22 physicians who, since 2009, received more than $500,000 from these companies in speaking and consulting fees. Mirroring the organization’s first report released in 2010, psychiatrists dominate the list….”

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