By Liz Kowalczyk, Boston Globe Staff, 12/15/2002
During the past six months, Dr. Eugene Fierman and his two colleagues were showered with offers worth thousands of dollars.
At least once a week, the nation’s pharmaceutical firms invited them for ”educational evenings” at some of the city’s priciest restaurants, including cocktails and dinner at Radius paid for by Pfizer, an insomnia discussion at Locke-Ober, and a depression talk at Maison Robert – both on Wyeth’s tab.
Drug firms through intermediary companies paid for at least 50 hours of free continuing medical education courses, which the psychiatrists could complete by phone, mail, on the Internet, or at hotels – required courses for doctors that traditionally were the province of medical schools but now are increasingly funded by the industry.
Some pharmaceutical companies wanted to hire them as temporary advisers, including Forest Pharmaceuticals, which promised the doctors $500 each for listening to a Saturday morning talk about the firm’s new antidepressant, Lexapro, at a Cambridge hotel and then providing ”advice and feedback.”
And occasionally, drug company employees dropped off at the doctors’ rented office at Faulkner Hospital small gifts: a box of cookies from the Wyeth salesman, four classical CDs from the Pfizer representative.
With investigations into the industry’s sales tactics growing, and a new voluntary code of conduct in place that stresses educating rather than entertaining doctors, Fierman, Dr. Ann Potter, and Dr. Gregory Harris – like many of their colleagues throughout the medical profession – said sales representatives now rarely offer the most lavish gifts that were routine in past years: theater tickets, golf trips, and resort weekends.
Instead, drug makers are paying for or offering more consulting opportunities, even for one evening, continuing medical education courses, and dinners billed as educational events with specialist speakers. At the Globe’s request, the three doctors kept track of pharmaceutical-related invitations and offers they received over a five-month period. The material was enough to overflow a 1-foot-square, 2-foot-high box.
”It’s hard to resist all this money and free stuff floating around,” said Harris. ”But it’s a slippery slope, and I don’t want to be in the position of doing something that crosses the line.”
The shift in the tactics drug companies are using to establish close relationships with doctors was occurring even before the industry adopted the new guidelines in July. The amount of money pharmaceutical firms spent on meetings and events, including continuing medical education, teleconferences, dinners, symposia, and get-togethers with physician advisers, more than doubled over four years to $2.1 billion in 2001, according to Verispan, a company that tracks promotional spending.
Drug industry funding of continuing medical education courses alone last year totaled $540 million, and the national organization that accredits continuing medical education providers has become so concerned about potential bias that it plans to issue stricter rules as early as January.
Drug makers say these classes and gatherings provide physicians with crucial information about medicines that could help their patients – and allow doctors to speak to each other about their experiences. But Dr. Marcia Angell, former editor of the New England Journal of Medicine, said the danger is that companies simply disguise marketing as education, while slanting presentations toward their own products and helping to increase health-care costs.
”These companies are in the business of selling drugs, period,” Angell said. ”It’s ludicrous to think you’d look to a company for education about a product they’re trying to sell.”
Physician leaders also are concerned about what they see as a rise in consulting and question whether doctors are providing meaningful advice to the companies – something required by the new guidelines – or are merely being paid large sums to listen to a sales pitch. And federal law prohibits companies from offering doctors cash inducements to prescribe their drugs. Dr. Sidney Wolfe, director of Public Citizen Health Research Group in Washington, D.C., said some consulting fees have gotten so high that he believes they border on illegal inducements. He has referred several cases to the US inspector general.
With the focus on drug industry marketing intensifying, doctors are increasingly concerned about their interactions with sales reps, and some are taking steps to limit their visits – or keep them out of their offices entirely. But that – Fierman, Harris, and Potter discovered – is not so easy.
The doctors decline consulting offers, and they no longer attend dinners. The cookies go to Bill Johnston, the practice’s part-time receptionist, who brings them to his fellow band members. Their one concession: They accept drug samples for uninsured patients, a marketing tool on which the drug industry spent $10.5 billion last year.
In early summer, Potter felt the practice was overrun with Eli Lilly salespeople. One day, she found a 22-year-old sales representative in the waiting room talking to a patient. Potter called his manager and requested only one Eli Lilly sales visit a month. The manager said no. The reason: The doctors get too many samples, he said. They gave in to two visits a month – as long as they got to choose the sales rep – even though they know samples probably increase their prescribing of those particular drugs.
”You can’t totally drop out of this crazy system,” Fierman said.
`Dinners are exploding’
At least once a week between August and November, sales representatives invited Fierman, Harris, and Potter for cocktails and dinner. The most modest restaurants: Figs and the Newton Marriott. The most posh were Radius, the Ritz-Carlton, and the Four Seasons – all dinners they didn’t attend.
Dr. Ronald Katz, an internist in a large, busy practice on Beacon Street in Brookline, said ”dinners have exploded in the past couple of months,” which he believes are ”in lieu of trips and the most expensive things they used to do.”
The industry’s new code of sales conduct requires dinners be ”modest as judged by local standards” – a guideline some companies are complying with and others are not.
”This should not include the city’s most expensive restaurants,” said Jeff Trewitt, a spokesman for the industry trade group, the Pharmaceutical Research and Manufacturers of America. ”We want there to be no distractions. We want the focus to be on a meaningful conversation about a new medicine and its potential value and characteristics.”
Dr. Susan Black, a family practice doctor in Tewksbury, drove into the city one night this fall for a dinner and discussion at the Four Seasons on urinary incontinence in women, sponsored by Pharmacia, which makes a drug for overactive bladder called Detrol LA. She earned one hour of continuing medical education credit; Massachusetts doctors must earn 40 hours of medical education credits with an approved provider every two years to remain licensed.
”They were discussing their own research, the company’s research. And they were trying to show the drug was better than their competitor’s,” Black said. ”I thought I should go because this is a big issue for my older patients. There are some really good new physical therapy approaches and surgical approaches, but they didn’t discuss those.”
Executives at Pfizer, which has paid for dinners at pricey restaurants in Boston since July, said the choice of restaurant is a ”judgment call” made by local sales reps.
”The price of the meal is so inconsequential, given what we’re grappling with around the guidelines and what’s educational or not,” said Dr. Mark Horn, Pfizer director of medical alliances. ”I would focus on the speaker, the content, and the quality of the presentation. As long as it’s balanced and fair, I’m less concerned with the selection of the eateries.”
Many education courses
Last Thursday at 1 p.m., Fierman called a toll-free number to earn one hour of continuing medical education credit listening to a teleconference called ”Stabilizing the Dopamine-Seratonin System: A New Era in the Treatment of Psychosis” – one of dozens of free, pharmaceutical-company-funded continuing medical education courses offered to the practice during the past six months.
This course, which Fierman enrolled in at the Globe’s request, was organized by a private California company called Continuing Medical Education Inc. and paid for with an unrestricted grant from Bristol-Myers Squibb and Otsuka America Pharmaceutical. The companies in November received approval from the Food and Drug Administration for a new antipsychotic medication called Abilify.
As Fierman listened from his small office overlooking Arnold Arboretum of Harvard University, Dr. Peter Weiden, director of the Schizophrenia Research Program at SUNY Downstate Health Science Center in Brooklyn, began with a history of antipsychotics and a description of why newer drugs like Zyprexa and Risperdal are superior to older medications like Haldol. (Fewer side effects like tremors.) But he devoted more than half the hour to the benefits of Abilify, often referring to it as ”the new kid on the block.” Although companies are not allowed to promote unapproved drugs, Continuing Medical Education Inc. began offering the course before Abilify was approved, something allowed under continuing medical education rules.
Fierman said the science in the class was sound, and that Abilify might very well be the next blockbuster for the mentally ill. But he said advertising the course as an objective class on brain receptors was misleading. ”If this were a lecture saying we’re introducing our new drug, that would be fine,” he said.
Drug companies usually aren’t accredited continuing medical education providers themselves. They pay for the classes offered by medical schools and accredited third-party companies like Continuing Medical Education Inc. In this case, Continuing Medical Education Inc. suggested the class topic to the drug firms and they had no input into the content, said Steve Mandell, the company’s vice president of sales and business development.
But Dr. Murray Kopelow, chief executive of the Accreditation Council for Continuing Medical Education, which oversees the continuing medical education system for doctors, said third-party companies and medical schools may have grown so dependent on drug companies for their livelihood that they’re no longer independent providers and have lost control of the agenda – and sometimes the content.
”These relationships have complicated the situation,” said Kopelow, whose organization will consider sending physician volunteers to monitor the courses for commercial slant. ”There’s probably more bias than we know.”
Consulting offers grow
Pharmaceutical companies, physicians said, also are pushing to increase their consulting relationships with them. Drug firms for years have hired respected physicians, often referred to as ”thought leaders,” to speak about their drugs at conferences and serve on advisory boards. Some doctors earn thousands of dollars from these extracurricular activities.
But some doctors said drug firms are offering more small, one-time consulting opportunities. And Fierman, Potter, and Harris received dozens of requests from drug marketing research firms – whose clients are pharmaceutical companies – to provide their opinions for a fee on the effectiveness of proposed direct-to-consumer ads and even report on how often competitors’ sales reps visited their offices.
Other physicians reported similar offers: Novartis promised Dr. Richard Parker $300 to give ”feedback about hypertension” and Dr. Martin Solomon $500 to provide advice on hormone replacement therapy.
Eli Lilly promised Dr. Jonathan Moray $750 to attend a dinner meeting on therapy for attention deficit hyperactivity disorder and ”provide his perspective on … potential new treatment options.”
Novartis spokeswoman Christine Landy said the company ”needs this feedback to guide future marketing and research” and draw up written contracts – as required by the sales code – to clearly outline the doctor’s role. But most of these dinners include a presentation about a drug the company makes or is developing.
”The companies used to call it coming to dinner,” Solomon said. ”Now it’s called consulting.”
Potter attended a consultants dinner meeting in the spring for which she was paid $400. The company, which she did not want to name, asked physicians how to catch their attention so they would prescribe the firm’s antidepressant.
”I thought, `What am I doing here?’ It was advice,” she said, ”but it was advice on marketing.”
Alice Dembner of the Globe Staff contributed to this story.
This story ran on page A1 of the Boston Globe on 12/15/2002.
© Copyright 2002 Globe Newspaper Company.