http://www.latimes.com/features/health/la-he-reforms6aug06,1,2797596.story?ctrack=3&cset=true
SOLD ON DRUGS
And now, a push for change
Legislators have begun to question the drug industry's pervasive influence
in healthcare. Some doctors are backing them up.
By Melisa Healy
Los Angeles Times Staff Writer
August 6, 2007
PART 4 (of six)
FOR Dr. Howard Brody, nearly three decades of family medical practice has
afforded a clear view of the rising tide and spreading effects of drug
industry marketing. As Brody entered the profession in 1977, that tide was
coming in gradually. In the last decade, it has surged to account for at
least $30 billion a year in spending.
Now 58, Brody sees a shift in the marketing tide. In recent years,
politicians, consumers and physicians have begun to question sharply the
effect of drug makers' commercial appeals. Medical societies and patients
groups are quietly debating the wisdom of their dependence on drug
companies' largesse. Doctors are rethinking, or at least disclosing, their
ties to drug companies. Legislators are drafting and passing bills aimed at
blunting the effects of prescription-drug marketing.
Along the way, Brody has evolved from family physician to medical ethicist.
Now a professor of family medicine and director of the University of Texas'
Institute for the Medical Humanities, Brody has been among those who have
fomented a backlash.
For several years in his earliest days as a family physician in Michigan,
Brody received a long line of drug representatives bearing gifts, jokes, an
occasional journal article and, most important, drug samples. The exchanges
troubled him in ways that, as a young doctor in the late 1970s, he found
difficult to put his finger on. But when he joined the medical faculty at
Michigan State University and had the choice of opting out of such meetings,
he did so with relief.
Two decades later, Brody read a commentary in the Journal of the American
Medical Assn. that stirred up the same disquiet he remembered from his days
meeting with drug reps. The 1997 JAMA editorial, "Thyroid Storm," told
readers of a disputed study comparing thyroid medications. The study was
conducted at UC San Francisco and was sponsored by Boots Pharmaceuticals
Inc., a firm with strong commercial interests at stake. The study's findings
came to a conclusion contrary to the sponsor's interests, and Boots
threatened legal action if the study was published.
";The research community is getting progressively more entangled with
industry, as became evident to me when I tried to find thyroid experts to
review the paper who did not have financial ties" to Boots, wrote then-JAMA
editor Dr. Drummond Rennie. The American Thyroid Assn. failed to rally to
the researcher's aid, leaving "the sad impression that the ability of the
association to influence these events was weakened by its heavy dependence"
on the drug maker's financial support, Rennie wrote.
Brody found Rennie's account of the episode deeply shocking. But this time,
his uneasiness found its voice. Starting in 2001, Brody began suggesting, at
professional meetings and in conversations with fellow physicians, that the
marketing of pharmaceuticals to doctors -- indeed the pervasive influence of
drug makers within the medical profession -- had gone too far.
His colleagues' response was "very negative, very hostile," he recalls. "It
really sounded like, 'Who are you, sounding so scolding? You think you're
better than us. How dare you?' There had been this gradually creeping
seduction going on all these years . . . and the pharmaceutical industry had
happily supplied us with justifications for it. We doctors lapped them up
eagerly."
But by 2004, those days were ending. The Annals of Family Medicine published
an essay by Brody, "The Company We Keep: Why Physicians Should Refuse to See
Pharmaceutical Representatives." (Brody went on to write a book, "Hooked:
Ethics, the Medical Profession and the Pharmaceutical Industry," published
this year.) Former New England Journal of Medicine editor Dr. Marcia Angell
published "The Truth About the Drug Companies: How They Deceive Us and What
to Do About It." Her fellow NEJM editor, Dr. Jerome Kassirer, continued with
"On the Take: How Medicine's Complicity With Big Business Can Endanger Your
Health."
At a 2004 meeting of the American College of Rheumatology, physicians
reeling from public outcry over the market withdrawal of the arthritis drugs
Vioxx and Bextra vowed to wean their organization from its heavy dependence
on pharmaceutical funding, setting off similar self-examination among other
medical societies. While acknowledging that pharmaceutical sponsorship
accounted for 34% of the group's income, its president at the time, Dr.
David Wofsy, declared that the group's leaders, its young physicians, its
political principles and its silence were "not for sale.";
In statehouses across the country, lawmakers began to hammer out laws aimed
at blunting the reach and effect of drug makers' marketing efforts.
To date, at least 30 states have enacted laws, or have considered
legislation, that would do so. Those include bills requiring the disclosure
of gifts and payments by drug makers to physicians, limits on pharmaceutical
companies' access to prescription information used for marketing purposes,
advertising restrictions and limits on pharmaceutical sales representatives'
gift-giving to doctors. California and Virginia have joined Vermont, Maine
and Minnesota -- three states that have enacted the most sweeping laws on
drug marketing -- in requiring reports disclosing drug makers' spending on
advertising and marketing activities.
On Capitol Hill, a handful of lawmakers have launched hearings on the
subject and suggest that legislation could come next. After presiding over a
June 27 Senate hearing titled "Paid to Prescribe?," Sen. Herb Kohl (D-Wis.)
suggested he would ask the prestigious Institute of Medicine to weigh in on
the subject. He warned drug industry representatives to expect "progress"
from a newly Democratic Congress.
The bid to curb drug industry marketing is hardly a juggernaut. Many of the
state initiatives have been challenged as infringements on free-speech
rights. Some have met resistance from physicians. Virtually all have been
opposed by the drug industry, which, according to estimates by the Center
for Public Integrity, has spent $758 million on lobbying -- more than any
other industry -- since 1998.
Among rank-and-file doctors, Brody sees "almost a sea change" in attitudes
toward drug marketing. For veteran physicians, the hostile defensiveness is
no longer a reflex, he said. Among younger doctors and medical students, he
sees genuine interest in reducing the influence of drug company marketing on
the front lines of medicine.
Medical schools such as Stanford, University of Pennsylvania, Yale and, most
recently, UC Davis and UCLA have sought to tighten rules governing
relationships between physicians and drug makers, including a prohibition on
the acceptance of even small gifts from drug reps.
Many medical students also have organized to resist the commercial
entreaties of drug makers. Since 2002, the American Medical Students Assn.
has banned pharmaceutical advertising and sponsorships of national and
regional meetings, as well as advertising on its website or in its magazine.
The group's "PharmFree" campaign urges medical students to shun seminars and
lunches sponsored by drug companies.
The sea change Brody perceives appears to have come too late to head off the
swelling wave of state initiatives and public calls for reform. Although
doctors understandably resist the efforts of politicians to regulate the
practice of medicine, Brody said they should have seen this coming. "The
more we're seen as feeding on the largesse of the pharmaceutical industry,
the less grounds the public has to have confidence in our putting their
interests first, and the more they're going to try to step in and mandate
reforms," Brody said. "I have to say, 'Gosh darnit, what did you expect,
guys?' "
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