Take me out to the ballgame

This is a subject I promised to address on another blog, so here goes.

There's been a lot of attention lately to so-called Direct to Consumer Advertising of prescription drugs (DTCA). The term DTCA implies something interesting that a lot of people don't know about -- there is a whole lot of other drug advertising and marketing going on, not to consumers, but to doctors.

Every major drug manufacturer in the U.S. has assigned to essentially all physicians in specialties that prescribe their products a person called a Detailer. A friend of mine happens to have gone over to the dark side and is now practicing that noble profession. He has the use of a box at Yankee Stadium to which he takes doctors and their spouses (or other preferred companions); a country club membership so he can play golf with them; and an expense account for restaurants and catering, which he uses to set up nice meals for the M.D.s and their spouses or OPCs, which they pay for by hearing a brief lecture about the miraculous benefits of some drug or other that his company sells.

He also visits the doctors in their offices, where he gives them high quality office supplies printed with the brand names and advertising slogans for the latest potions his company is pushing, and lots of free samples they can give to their poor and needy patients. (Alas, some doctors have recently been caught selling their free samples. Tut tut.) I don't know what else goes on in those visits usually, but I have on tape one instance in which the doctor invited two drug company sales representatives to sit in on the visit while he interviewed a patient with HIV who was taking some of their pills. He didn't tell the patient who they were or why they were there. Come to think of it, I'm not exactly sure why he let them be there myself, but it's obvious why they wanted to: they got to hear the patient talk about the experience of taking the drugs, what he liked and didn't like about them, what he believed about them, etc. All useful information to a salesperson.

This relationship between the doctors and the drug companies begins in medical school, before the budding healers get their M.D. A recent survey (McCarthy et al, Academic Medicine, Nov. 2004) found that nearly 100% of medical students had been exposed to pharmaceutical industry marketing before they even got to their clinical experiences in the third year. They were given free meals, free textbooks, "pocket texts," and various baubles. This goes on right through the residency, where drug companies pay for lunch (and give a pep talk about their products), provide guest lectures, throw dinner parties, and keep handing out the trinkets.

Once they're in practice, doctors have to show they're staying up-to-date on the latest medical knowledge, and they have to get what are called Continuing Education Units to prove it. The drug companies are only too happy to fill the need, paying for doctors attend conferences in places that just happen to be tropical resorts, where the companies provide the content; paying for those dinners at nice restaurants I mentioned before; and sponsoring various more sober and serious workshops.

Medical journals are full of drug advertising. According to a recent study by some Finnnish researchers (Pharmacoepidemiology and Drug Safety, Nov. 2004), out of 883 marketing claims in medical journal advertisements, 68% included "vague or emotive statements," and not a single claim was supported by strong scientific evidence.

But wait, there's more. Drug companies write review articles for medical journals, which by some strange coincidence strongly support prescribing their products. Then they pay prominent physicians to pretend to have been the authors of the articles. I am shocked, shocked, that prominent physicians would participate in this dishonest practice! Of course, that's one way they get to be prominent -- by having their names on review articles in medical journals.

Now, as of this writing, there are various efforts underway to restrict or eliminate some of these practices, by regulation, institutional policy, promulgation of (unenforceable) standards, or shaming. The status, extent and effectiveness of these efforts is a complicated picture, but basically, not much has changed, at least not yet. We'll see where it all goes.