Doctors, Drug Companies, and Doing the Right Thing

What a new study can tell us about the value of regulation

Published on October 8, 2012by Abdul El-Sayed

It’s no secret that there’s a lot of money in healthcare. In 2010, Americans spent $2.6 trillion on our healthcare, nearly 15 percent of our annual gross domestic product. And doctors, hospitals, insurance companies, and pharmaceuticals all want their piece of that multi-trillion-dollar pie.

But the business side of healthcare sets up a serious dilemma. Healthcare should ostensibly be about keeping healthy people healthy and making unhealthy people well. But at the same time, healthcare is big business in the U.S., and at its core, business is about making money. So what happens when making money is at odds with the nobler aims of improving health and wellbeing?

To understand the implications of this dilemma consider the murky relationship between pharmaceutical companies, doctors, and medical science.

Big Pharma spends billions of dollars annually researching and producing the “latest and greatest” drugs. Needless to say, the payoff only comes when doctors prescribe these drugs to their patients.

So, as you can imagine, having invested billions on the front end, pharmaceutical companies will do almost anything to get doctors to prescribe their drugs. This can mean catering lavish lunches for doctors and their staff or inviting them on free or highly-subsidized vacations to come “learn” about their drugs in remote tropical destinations around the world.

While this cozy relationship may have its perks for doctors, for their patients, not so much—these kinds of gifts influence doctors’ prescription choices, suggesting some patients may not be getting the drugs they really needed, or worse, getting drugs they really don’t. To address this concern, many of the largest and most well-known hospital systems, like Johns Hopkins, have strictly banned the receipt of gifts from drug reps—a cadre of sales people trained to convince doctors to prescribe their drugs. Unfortunately, however, no such restrictions regulate the cozy pharmaceutical-provider relationship in private physician practices around the country.

And Big Pharma has adapted. Among other means, including direct advertisement to patients, the industry has taken a more active role in the science by which the efficacy of drugs is judged. Pharmaceutical companies offer millions of dollars in funding to academic research groups to conduct clinical trials of their drugs. And with obvious incentives to show benefit, the resulting studies can be deeply flawed and disingenuous. What’s worse, when published in academic journals, they are often written by “ghost writers,” representatives of the companies themselves, rather than the leaders of the academic research groups funded to carry out the work, even though these investigators are often “first author” on the studies—academic code for the person who actually wrote the paper. That’s if the studies even get published: pharmaceutical companies are notorious for stifling results that portray their drugs in a negative light.

If there’s one saving grace, it’s that journals increasingly require authors to disclose their funding sources and conflicts of interest boldly in published articles. Until recently, however, it was unclear if it was helping—do doctors really pay attention to these disclosures when reading studies about drugs they might prescribe?

A recent study in the New England Journal of Medicine, sheds light on this question. The investigators randomly presented over 500 board-certified internists with abstracts from scientific papers of varying rigor with three types of funding disclosures: no funding, pharmaceutical industry funding, and funding from the National Institutes of Health (NIH).

The investigators found that even after controlling for rigor, internists were less likely to perceive articles funded by industry sponsors as rigorous, and also less likely to have confidence in their results. Most importantly, they were less willing to prescribe the drugs in industry-sponsored studies. The findings suggest that doctors are weary of the bias that industry-funded research might imply, and that patients are, in part, protected from getting the wrong drugs because their doctors aren’t being persuaded by bunk science.

That said, findings like these could still be leveraged by wily industry representatives to suggest that further regulations aren’t needed—that doctors are doing a good enough job of protecting their patients from big pharma’s incentives to push their product. But catering lavish meals, gifting vacations, and even directly funding clinical trials are only a few ways that Big Pharma has tried to influence physician choice. Direct-to-consumer advertising, withholding negative data, ghostwriting publications, and the many issues that arise when experts in the field are recruited (often to the tune of hundreds of thousands of dollars a year) to extol the virtues of one company’s drug or another are but a few of the murky issues that still abound.

The overarching point, though, that should be drawn from the article is that regulation works. When journals require authors to disclose funding in their articles, it has a real effect on the perceptions of doctors who read them. While certainly a loss for big pharma—they’re a win for the rest of us.

Edited by Karestan Koenen