Doctored Results
Kippen, Alexander
Doctored Results How drug companies bribe doctors and medical journals by Alexander Kippen In the sunny television world of “Trapper John, M.D.” and “Marcus Welby,” the patient’s needs...
...they even foot the bill for spring break beach trips, all in an effort to ingratiate themselves at the dawn of doctors’ careers...
...That hot button ranged from alcohol to boxing tickets to women...
...In a 1982 study by a Harvard Medical School doctor, a majority of doctors surveyed-all of whom claimed to be uninfluenced by drug advertising-rated two drugs, which had been judged inferior in the scientific literature, equal to or even better than competing, superior drugs...
...Victor Kiam in a white coat...
...The problem is that there are too many companies with too many drugs that do virtually the same thing...
...Doctored Results How drug companies bribe doctors and medical journals by Alexander Kippen In the sunny television world of “Trapper John, M.D...
...But the plan was foiled...
...This way, the company “can turn a blind eye to marketing tactics unless someone gets caught...
...Let’s make a deal In defending the symposia, drug companies point to the educational benefits of bringing doctors together to discuss their research...
...Only a leak to the newspaper stopped the scheme, points out Dr...
...Thanksgiving and Christmas just aren’t the boon to the medical business that they are to the rest of the commercial sector...
...2) Minnesota Timberwolves tickets for games on January 26, March 10, or April 15, 1990, and ‘pregame warm-up’ that will include food and beverages...
...So on November 8, 1989, Leyden Community Hospital in Northlake, Illinois presented its doctors with a “Holiday Surgery Scheduling Incentive Program...
...These are all only apparent conflicts of interest...
...But in explaining herself to the St...
...Ayerst mailed doctors a four-page package stamped “Patient Profile Program...
...Massachusetts Assistant Attorney General Marek Laas led the fight against Ayerst...
...One defender of supplements, Kenton Finch, the vice-president and publisher of both The American Journal of Medicine and The American Journal of Cardiology, says that few doctors have time to swim through all the medical information flowing from clinical research...
...At the symposia, Perez followed the same rules he used when making regular visits to doctors in Texas: “Hit ’em fast, hard, and continuous” until they warm up to the detailman and whatever he’s selling...
...More than a dozen respected medical journals now print what are known innocuously as “supplements”-veiled drug company advertising that demonstrates how intricate the medical influence racket can be...
...So why do respected journals go along with the scam...
...Michael Manning, chief spokesman for the Illinois Department of Professional Regulation, calls the hospital’s offer “tacky” but not illegal...
...Unlike the bright fictional world of heroic medicine, much of the real medical world is fraught with questionable sales gimmicks...
...Leber says Searle “has a written policy that we do not offer any enticements in any way” to doctors...
...Laura Leber, a company spokeswoman, called the offer “a single isolated incident involving one sales rep . . . who was reprimanded”-but who still works for Searle...
...In addition to Calan SR, that handful includes an older drug called Inderal, produced by what is now the Wyeth-Ayerst Company in Skokie, Illinois, a subsidiary of the firm that makes Anacin...
...The memo promised that “any physician who performs 10 major surgery cases between November 23, 1989 and January 31, 1990 will Alexander Kippen is a contributing Washington reporter for CNN and Canada’s Global Television Network...
...Grosenick claims the dinner and the games would have provided perfect opportunities for her to describe the wonders of Calm SR...
...and “Marcus Welby,” the patient’s needs and interests are paramount...
...Once he’d earned a regular customer, Perez would send the doctor’s name and background information along to McNeil corporate headquarters in Springhouse, Pennsylvania and-presto!-the doctor would turn up on the list to promote company drugs at the next symposium...
...The result, says Wolfe, is that drug companies “try to compete on something other than the merits of their products...
...It was easy to rig the game...
...Unfortunately, in the real medical world, “you are making decisions for patients, not based on what’s best for them, but on what’s best for you...
...Searle was predictably contrite...
...It’s an insight into what these people are willing to do to bring in big bucks...
...says Perez...
...Maybe your doctor is just like Dr...
...Money...
...Wolfe of the high-pressure sales techniques...
...The influence of the supplement process is a little more complicated-and a lot less subtle-than that...
...Perez would simply declare him the winner and deliver the prize, which might be a camera, a pen and pencil set, assorted cheeses, or-best for Perez-dinner for two at “the fanciest restaurant in town...
...Paul, Minnesota, were invited to take “The Calan SR Challenge’’ by a local saleswoman from the G.D...
...Once Perez had scoured a symposium for prescriptionhappy doctors, he would use one of several gimniicks to win them over...
...Last fall, doctors at the Aspen Clinic in St...
...Doctors are gentle but strong, driven to fight disease (and immorality) with unyielding vigor...
...Perez said he would have McNeil send free samples directly to doctors’ homes...
...They don’t bother to mention how the symposia serve as the starting point for what becomes a devious promotional strategy...
...The vice-president defined “major surgery” as any operation performed on a patient under anesthesia...
...He recalls that many favored McNeil’s prescription Tylenol IV because it contained a full gram of codeine...
...Let’s say your doctor has just recommended that he cut you open and pull out an organ...
...According to the offer, the doctor would win points toward an Ayerst reward for every patient profile that accompanied a prescription for Inderal LA...
...As soon as someone comes into medical school it starts...
...Pail Pioneer Press, Grosenick said she was surprised by the reaction...
...Although there is some evidence that they do...
...Instead, they create a very competitive atmosphere in which sales quotas are emphasized and methods ignored...
...The system of peer review distinguishes scholarly writing from highpriced propaganda...
...When a local newspaper shined a spotlight on the deal, it was swiftly canceled...
...In an effort to stay competitive with cheaper copies of propanol01 that came on the market in 1985, Ayerst developed a slightly different version called Inderal Long Acting Capsules...
...Ayerst gave doctors preprinted Inderal LA prescriptions that patients could trade in at pharmacies for a free two-week supply of the drug...
...With a little luck, people would soon be going under the knife right and left...
...But when all the drugs are pretty much the same, who’s going to bother to switch...
...More troubling, Ayerst doesn’t.mention that dramatically slowing or stopping use of Inderal can be dangerous...
...In 1984 Inderal’s manufacturer lost its patent on the hypertension drug, known generically as propanolol...
...Usually, she said, “doctors want something in return” for listening to detailmen...
...Mary Grosenick, known as a “detailman” in the jargon of drug salespeople, mailed a preprinted Searle promotional sheet to clinic doctors, outlining the challenge: Prescribe Calm SR to 20 newly diagnosed hypertension patients by the end of 1989...
...After being offered a number of free pizza lunches by a detailman, the doctor warned, “You’re not doing enough for me . . . you get little pizzas...
...With state funds covering potential Inderal LA purchases, there were grounds for prosecution under the state’s “Bribes and Kickbacks” statute...
...I would look for the heavy hitters” says Jody Perez, a former Texas detailman for Johnson and Johnson’s pharmaceutical subsidiary, McNeil Laboratories...
...I’d find out what their hot button was...
...A supplement-a magazine printed separate from but very similar in appearance to its parent medical journal-is a compilation of information presented by doctors at any of the numerous symposia held around the country, usually at a drug company’s expense...
...For example, he’d hold a contest to see who could guess the number of pills in a jar...
...Salesmen from drug companies and representatives of medical equipment manufacturers buy students things like medical textbooks, doctor’s bags, and their first stethoscopes...
...The hospital’s administrators didn’t have the ethical sensitivity to realize it was wrong...
...Then again, maybe he’s more like Dr...
...If conscience isn’t keeping Leyden’s administration in line, neither is the law...
...If you prefer, you may use your accumulated program points to receive diagnostic equipment of the highest quality or the latest editions of important medical texts...
...In late December, an item in the Chicago Tribune mentioned the promotional offer, and Leyden quickly withdrew it...
...If the target doctor guessed 239 or 378 pills, who was to say he was wrong...
...If your doctor is prescribing a new hypertension drug for you, wouldn’t you like to be told that the makers of that drug have been fixing him up with willing women...
...In 1982, staff members of The American Journal of Cardiology split to form The American Journal of the College of Cardiology partly because the former decided to begin printing supplements...
...According to the survey’s analysis, their conclusions could have been based only on company claims, not independent research...
...The Powers That Be said ‘It’s fine,”’ says Wolfe, a 19-year veteran of battles against medical fraud and overpriced health care...
...According to one Washington doctor interning at a trauma center, detailmen can be quick with an answer to that question...
...This is saying that a person’s health is no different than a car,” says Dr...
...The company launched an aggressive marketing campaign aimed at doctors...
...Doctors especially liked it in liquid form, since they could then mix it into their drinks...
...Since relying on the hospital’s dispensary for these is risky, doctors came to count on Perez instead...
...Administrators, he says, “would never be stupid enough to tell detailmen to bribe doctors...
...Supplements, he says, “make it easy” to keep up with the latest drugs...
...The next week the detailman offered to take the doctor to Morton’s, a local steak house...
...After Leyden withdrew its offer, a lawyer for the hospital insisted that the promotion was an isolated and unauthorized incident-the stock explanation for organizations caught red-handed making a bribe to manipulate health care...
...Perez quit in 1982, disgusted after one year on the job selling a painkiller called “Zomax...
...Typically, a symposium is held over a weekend at some plush retreat at a cost to the drug company ranging into the hundreds of thousands of dollars...
...After more than 18 months of negotiations, Ayerst settled out of court, paying the state $195,000 in damages...
...Jekyll...
...A lot of doctors are not aware of what’s coming down the pike...
...Having settled on the target, “I’d make sure he won first prize...
...In fact, says Perez, the former McNeil Laboratories detailman, “Most physicians depend on detailmen and what the drug company tells them...
...But I don’t hear of any symposiums being held in downtown Buffalo in January...
...The issue to us was to set an example so that other drug companies would stay clear of this sort of offer,” he says...
...After the presentations come another dinner and more entertainment, and Sunday afternoon the doctors are flown home, having not spent a cent...
...But if your doctor is human enough to accept drugs and dates from a pharmaceutical company, chances are he’s also human enough to do the company some favors in return...
...There are many so-called “me too” drugs that are slightly different in molecular structure but perform the same function...
...The New England Journal of Medicine also refuses to print supplements...
...The Food and Drug Administration is now looking into whether Ayerst’s special deal broke federal laws...
...The pitch was that Inderal LA, as it became known, released gradually, meaning that you didn’t have to take as many doses...
...A marketing employee with a major pharmaceutical company in New York stresses the subtlety of relations between company administrators and detailmen...
...Similarity breeds contempt Dr...
...Canada spends about 8.6 percent of its GNP on health care...
...According to Preston, “It’s early, pernicious, and pervasive...
...Wouldn’t it make you a little antsy to discover that your Marcus Welby is hooked on drugs-and to learn that all along only he and his dealer (a major secret...
...He held out some hope, though, that this year could be different...
...Searle company, manufacturers of a high blood pressure drug called Calan SR...
...Why wouldn’t the authors of the supplement insist on the more thorough treatment...
...For starters, detailmen work the crowd, homing in on doctors known to prescribe a lot of drugs...
...On Saturday, some of the doctors will present their research before those gathered, who may number anywhere from a handful to thousands...
...In further defense of the scheme, the spokesperson argued that physicians and patients “were free, at any time, to discontinue use of Inderal LA . . . and such discontinuance in no way affected the availability of honoraria...
...As Relman points out, if the material printed in supplements is untainted by drug company influence, why wouldn’t a magazine like The American Journal of Medicine print that research in one of its regular monthly editions that do require peer review...
...A Wyeth-Ayerst spokesperson admitted that participating physicians received “honoraria” but stressed that “no honoraria were awarded based on prescriptions written by physicians for Inderal LA...
...The doctor was asked to list details about the patient and his treatment on an Ayerst form...
...Grosenick invited doctors to call her personally to accept the challenge...
...Another item high on many doctors’ lists, ironically enough, was high-potency drugs for their own recreational use...
...Wolfe blames the unsavory reward game on “grisly competitiveness...
...The vice-president of surgical services issued a memo lamenting the “anticipated decrease in the number of surgeries historically performed during the holiday season...
...According to Relman, articles submitted to The New England Journal of Medicine must-unlike those submitted to supplements-pass through a seven-step editorial process that includes one or even two stages of examination by a group of “associate editors” selected for their expertise in the topic at hand...
...Supplements to The American Journal of Medicine and The American Journal of Cardiology (the industry’s most prolific supplement printers) bring in $1,500 and $1,300 per page, respectivelyand they range from 50 to several hundred pages...
...Then the detailman can be the problem, a single isolated incident...
...Sidney Wolfe of Public Citizen, the consumer watchdog group started by Ralph Nader...
...Financial burdens like escalating malpractice insurance premiums share much of the blame in the US., but also contributing to those costs is the toll exacted by dishonest health merchants...
...Wouldn’t you like to know that part of his reward for eviscerating you will be a shiny new office fax machine...
...That was a record 11.1 percent of that year’s GNP-the highest proportion in the world...
...At one symposium, Perez met a San Antonio doctor, also married with children, who was more direct...
...In addition to their array of material enticements, detailmen often include supplement excerpts in the bag of goodies they bring to a doctor’s office when pitching pills...
...One married, middle-aged Texas doctor with three kids used a code whenever he wanted women from Perez...
...Barry Massie of the University of California, San Francisco says, “When someone sits in your office and hands you a reprint, it’s hard to tell the difference” between it and a peer-reviewed article...
...Of course not: As Laas points out, the doctors just handed out forms-they never had to set pen to paper...
...be entitled to their choice of one of the following promotional incentives: a) an in-office fax machine, or b) a portable cellular telephone...
...Now comes the tricky part...
...They’ll take you to New Orleans,” says one doctor, “take you on a river boat queen, with a full jazz band and all the great food and booze you could want...
...He’d ask, ‘What’s on the agenda...
...And chances are that if you knew about the shady deals, you’d go hunting for a second opinion...
...This pitch was uncovered in Rhode Island, but it could be legally challenged only in Massachusetts because Inderal is offered on that state’s Medicaid list...
...If you come through often enough, Perez says, “you’re their candy man...
...Drug fiends Some of the most questionable back-room deals can be found in the world of pharmaceutical sales...
...A sudden drop in the Inderal dosage taken by Hank Gathers, the Loyola Marymount basketball star, is being blamed for his death at age 23 during a game last March...
...Ne---special rewards for doctors...
...While the supplement itself carries fine print on the inside title page acknowledging its sponsor, there is rarely any such indication given in the supplement’s dozens of articles...
...In case a doctor has any doubt about the effectiveness of the drug in question, the detailman can pull out an impressive-looking article on the subject, copied from a supplement...
...While out to lunch or dinner with a doctor, he’d ask, “‘Do you want any juice for your coffee?’ They’d say, ‘Yeah, do you have any on you?’ I’d say, ‘No, but I can get you some.’ . . . It was just another way we could become buddies...
...Doctors hooking those 20 new patients on Calan SR would enjoy their “choice of the following options: 1) Dinner-for-two certificate...
...At first glance, the challenge is simply the old “satisfaction or your money back” deal...
...Before being banned in 1983, Zomax, according to the FDA, led to at least 14 deaths and more than 400 life-threatening reactions like respiratory trouble and kidney disease...
...The most recent figures show the United States spent more than $500 billion on health care in 1988...
...Perez would now be close enough to fill him with what he called “propaganda” about his company’s drugs...
...Under the Ayerst trademark on the cover page was a slogan that would prove ironic: “Serving the medical profession with ethical pharmaceutical products...
...In the end, good beats evil, and the patient turns out fine, back in his street clothes, smiling...
...If your doctor is prescribing a new hypertension drug for you, wouldn’t you like to be told that the makers of that drug have been fixing him up with willing women...
...And, she says, they would have answered doctors’ usual question: “What’s my reward...
...It’s a blatantly apparent conflict of interest for a doctor to get cozy with a drug company, ride on that company’s tab at a symposium, and then turn around and present his opinion on that company’s drug in a supplement...
...A handful of high blood pressure drugs fall into this category...
...Tom Preston, a Seattle cardiologist who has studied and written on medical ethics for more than 20 years, says that the bribery game is routine throughout the industry...
...Laas says he wanted the fine to be punitive but had to be careful not to push too far, since in Massachusetts, as in most states, the laws governing cases like this are so vague...
...Supplemental income Not just drug companies and doctors are being tainted by these sorts of scams...
...But it happens all the time...
...Perez remembers him saying: “Let’s go party . . . where are the chicks...
...If by March 15, 1990, “any patient is not controlled to your satisfaction,” Searle would refund the total cost of the drug to the patient...
...Nurses are pretty and altruistic...
...Arnold Relman, the recently retired editor in chief, calls supplements typically “weak in science” and says “an author who’s written a good piece doesn’t want it in a supplement if he can get it in a peer-reviewed journal...
...The trouble starts at the symposia...
...Five out of five patients surveyed agreed that would be a good idea...
...A drug company will fly in doctors late Friday afternoon and kick off the weekend with a cocktail party, followed by a dinner featuring some sort of entertainment...
...Was Leyden going to offer special low rates on cataract surgery for the indigent elderly...
...Perez said he kept a list of nurses, secretaries, receptionists, and others who were happy to go out for a night of dinner, drinks, and possibly sex with a doctor visiting town...
...The real medical world is full of shady compromises and ethically dubious deals that you, the patient, are likely never to hear about-but in which your health is the key bargaining chip...
...In open spaces provided on the sheet, Grosenick typed in a further reward-this time for the doctor...
...I want steaks, then maybe I’ll buy your drugs...
...The problem isn’t really that many doctors take the supplements seriously when they’re first printed...
...In return for 50 patient profiles, Ayerst promised that “you and a companion can fly to American Airlines destinations in the continental United States, Hawaii, and the Caribbean...
...Hippocratic hypocrisy The thicket of medical kickbacks and drug overpricing driven by doctor and drug company greed takes its toll on the healthy as well as the sick...
Vol. 22 • October 1990 • No. 9
