These Two Make Quite a Team

The drug, which had been approved by the FDA only for treating seizures and one other rare condition, had been deceptively marketed for treating depression, migraine headaches, back pain and other disorders. The California attorney general, who announced the settlement, said that Warner-Lambert (later acquired by Pfizer, which said the illegal practices had occurred before it bought Warner-Lambert in 2000) had paid kickbacks, run continuing medical education classes that "lacked balance," provided expensive "perks" to attending physicians, subsidized the production and dissemination of "anecdotal reports favorable to off-label use of Neurontin, but which had no scientific value," and provided incomplete information to a drug reference compendium. Several other major pharmaceutical companies are either being investigated or sued for allegedly improper marketing.

But these investigations have not focused on the ways that drug companies recruit physicians to promote their products. Companies regularly invite opinion leaders and academic physicians to resorts or plush hotels and train them to be speakers for the company. On Aug. 22, for example, 300 doctors attended an Aventis speakers' training session in a Chicago hotel to promote Ketek, the company's latest antibiotic for sinusitis. These speakers are flown to meetings, sometimes just to give a single lecture in other posh restaurants or conference facilities. Pharmaceutical companies spend more than half a billion dollars on these activities every year.

In October 2002, the inspector general's office for the Department of Health and Human Services gave notice that it was considering a proposal for tougher rules on pharmaceutical marketing. But the American Medical Association and the Pharmaceutical Research and Manufacturers of America, the organization that represents most of the industry, lobbied hard to protect companies' speakers bureaus, and the inspector general's final guidance left them untouched.

Becoming a speaker for a company is seductive, not only for the money, but for the prestige of traveling around to give the talks. Generally, when physicians are recruited, they are told that they are not obliged to mention any of the sponsor's drugs. But there is a natural sense of obligation to reciprocate for the $1,000 to $4,000 honorarium or fee. Some physicians say they feel subtle pressure to promote products because they want to stay on the speakers list; others hold back from criticizing companies whose fees they receive. Then there are physicians who promote off-label drugs in their lectures.

The companies aren't the only ones to blame for the current state of affairs. As manager Casey Stengel said after his New York Yankees won the 1958 World Series, their ninth with him as coach: "I couldn't have done it without my players." Likewise, drug companies couldn't meet sales goals without the thousands of doctors who have, in essence, become drug reps.

Of course, the proper use of pharmaceuticals is central to modern medicine and can save and improve lives. But physicians who promote the inappropriate use of drugs are raising the cost of medical care and impairing the public's trust toward the profession. Scour the oaths that physicians take when they graduate from medical school and you'll find mention of obligations to patients, not drug companies. Should physicians be engaged in marketing efforts for industry? Not in my book.

Author's e-mail:

jerome.kassirer@tufts.edu

Jerome Kassirer is a professor at Tufts University School of Medicine and editor in chief emeritus of the New England Journal of Medicine. He is author of "On the Take: How Medicine's Complicity With Big Business Can Endanger Your Health" (Oxford University Press).