I am often disappointed and sometimes disgusted with how the mass media report medical issues. TV news, with the exception of The News Hour on PBS, lacks the depth and time to be taken seriously. Too often TV news turns medical topics into human interest stories that end in bathos, or it infuses the issues with partisan politics. News magazines are better, but after reading medical reports in them I have the same attitude as I have about drinking light beer: One sacrifices taste and depth in exchange for shaving off the calories found in only two teaspoons of sugar, so why bother?
But a friend sent me an issue of The Los Angeles Times containing an excellent example of how well the media can do its job on medical topics: A series of articles written by Melissa Healy in the August 6th issue, focusing on the pharmaceutical industry and how it markets drugs (available online at www.latimes.com).
The longest piece, “Wooing the Gatekeeper: Doctor, just a little something for you,” is an extensive explication of how pharmaceutical companies make doctors a major part of their marketing efforts. Included is an interview with a marketing executive from one of the companies, who said, “There is a big bucket of money in every [doctor's] office. Every time you go in, you reach your hand in the bucket and grab a handful.” After his comments were circulated on the Internet, he was fired.
Ms. Healy goes on to describe the stated approach of any of the 100,000 or so drug representatives that visit doctors. All they want to do is drop off some drug samples and brief physicians on the risks and benefits of their companies' drugs. She said that is accurate, but the sophistication of the marketing pitch aims at building a relationship that will go well beyond leaving pads, pens, and gadgets.
A survey by the New England Journal of Medicine showed that 94% of doctors have such a relationship, that 84% accept food in their workplace, 78% accept drug samples, 35% have accepted reimbursement for attending meetings sponsored by the drug company, and 28% accepted money for consulting, giving lectures, or doing research for a drug company. (The latter statistic would be much higher among oncologists.)
In 2002 the AMA and PhRMA agreed on voluntary guidelines for physicians accepting gifts and discouraged gifts that were only personal benefits. However, the article points out, while the cost of the gifts is less, the impact has not been reduced.
In fact, studies show that extravagant gifts raise a lesser sense of obligation than small gifts, which the recipient feels able and more obligated to return in kind. Also, the money drug companies spend has not changed; only the gift has changed—e.g., a textbook instead of a golf bag. The gifts buy access, the first step toward influence.
She ends the article by citing the $430 million fine paid by Pfizer for sponsoring “educational” programs aimed at promoting the off-label use of one of their drugs.
Well-Written, Focused Accessible
The article is well-written, focused, and accessible to the non-expert reader. Furthermore, its impact on me or any reader is increased significantly by the two other articles in the series that address other aspects of the topic.
“Selling the Patient. Next Step: Create the Demand” describes the sophisticated marketing by drug companies directly to patients. A study showed that of drug advertisements on prime-time TV, 58% advertised the drug as a medical breakthrough. The author of the study said that self-regulation by drug companies concerning excessive claims for their products has not worked.
The article then describes the “third party approach” to marketing. A real life example is given. Lilly had low sales of the sepsis drug Xigris, due to unfavorable results in some studies. So the company hired a public relations firm to create an “independent” organization staffed by physicians and bioethicists to decry the withholding (“rationing”) of Xigris.
The group, called “Values, Ethics and Rationing of Care Task Force,” was to develop guidelines for using Xigris aimed at physicians, patient groups, and the media; Lilly's role in it was not readily apparent. A case study by the public relations industry showed that the use of Xigris subsequently went up 36%.
Another third-party target of drug companies is patient-advocacy groups, which they “richly support.” Reports in public relations trade publications place a high value on working through these groups to provide information crafted by drug companies for patients looking for information.
Some believe that advocacy groups are especially vulnerable to drug company marketing because they serve often-desperate patients who will grasp at any whiff of hope, justified or not.
Survey of Patient-Advocacy Groups
A survey appeared in New Scientist magazine in October 2006 that studied annual reports, tax returns, and voluntary disclosures of 29 nonprofit patient-advocacy groups. Most accepted financial support from companies that were developing or producing drugs used to treat patients represented by the group. Most received support that made up just a few percent to 25% of revenue, but an exception that stood out for me was the Colorectal Cancer Coalition, which received 81% of its revenue from the drug industry. Donations from drug companies, not surprisingly, often accompany the marketing of new agents.
Ms. Healy's third article, “Building the Market: From Funding to Findings,” addresses funding of research in academic institutions by drug companies: “In doing so, they build a corps of respected university experts who have lengthy experience with a drug prospect, financial ties to the firm that paid them to study it, and, often, a direct stake in its success. These university-based physicians enjoy a public perception of scholarly impartiality as well, which can make them influential voices when they speak in favor of a medication or treatment.”
These university-based physicians often serve or testify before committees that advise the FDA on drug approvals. They then help build markets for the drugs by serving on expert committees that write treatment guidelines and standards, which can have a huge impact on sales.
Although much of this is not new to those of us in the profession, some of it, especially the data and sources I had not seen, was enlightening. But the article was aimed at a general audience that is likely to find much of it new.
One may view these articles as an attack on pharmaceutical companies, but I believe that would miss the main point. Drug companies don't get a pass; they have plenty to answer for. But the core of all three articles is the potential and actual conflicts of interest of doctors, scientists, advocacy groups, and the media—precisely those who are supposed to put the interests of the public and patients first.
One may disagree with all or parts of the articles, but the research, depth, and length of the presentation provide a broad view of the issues and put them in an understandable context. As noted earlier, the substance of the articles is enhanced significantly by the scope covered by the three pieces, a powerful journalistic mechanism. Such coverage is seldom found elsewhere in mass media.
These articles demonstrate that the media at its best can inform us and broaden our understanding of even complex and emotionally charged topics like health care. I wish we would see such work on medical issues more often, instead of what we usually get.
But we cannot look to the media for answers to the great questions in health care. Public policy, by definition, is enacted by politicians, and one hopes they act from a solid base of knowledge and compassion and a minimum of political shenanigans.
Physician associations have limited power to influence public policy, and judging from the historical actions of the AMA and the more recent narrow focus on reimbursement, that may be a good thing. But that needn't be so.
If we were as vocal and persistent in support of the needs of patients and the public as we have been for our own pecuniary interests, we could be a powerful force.
In summary, the media can be a reliable source of information or it can fritter away its gifts on superficial reporting, entertainment, or partisan screeds that make them untrustworthy sources. But the press has no answers for us. We must find and support them ourselves and speak forcefully to the public and our elected representatives as advocates for our patients.