By Ibby Caputo
Washington Post Staff Writer
Tuesday, August 18, 2009
You may not be able to trust your mortgage broker, your car salesman or your congressman, but you can trust your doctor.
Patients might well ask themselves this question when they learn that 94 percent of physicians have "a relationship" with the pharmaceutical, medical device or other related industries, according to a national survey of physicians published two years ago in the New England Journal of Medicine.
It is unclear how much those businesses spend on marketing overall, but Integrated Medical Systems, a research firm, estimates that pharmaceutical companies spend more than $20 billion annually marketing directly to doctors.
It does seem clear, however, that many patients want a better sense of the links their doctors have with industry.
A consumer survey last year by the Pew Prescription Project, an initiative to help eliminate conflicts of interest in prescribing, showed that 68 percent of respondents supported legislation that would require public disclosure of financial relationships between physicians and industry. Seventy-eight percent believed that accepting gifts from the pharmaceutical industry influences their doctors' prescribing habits, but only 34 percent said they would be likely to ask their doctors about potentially troubling financial ties.
Short of asking, patients have few options for gaining such information.
"I think that is a genuinely difficult and awkward conversation to have," said Allan Coukell, the director of the Pew Prescription Project.
"Patients are very averse to getting into antagonistic relationships with doctors," said Cheryl Matheis, senior vice president of health strategies at the senior citizen advocacy group AARP. "They get farther if they walk an inquisitive line as opposed to an accusatory line."
"We tell our patients they should have conversations with their doctors, and we tell them they should write [their questions] down because patients usually get nervous," Matheis said.
Daniel Carlat, a Massachusetts-based psychiatrist, agrees the topic is sensitive. "When you are a patient, the last thing you want to do is alienate your doctor or cause any negativity," he said.
Carlat, who publishes a peer-reviewed psychiatry newsletter, suggests bringing up the subject indirectly.
" 'I've been reading in the paper a lot about how pharmaceutical companies pay doctors. Does that happen?' That is a nice way of opening up the topic," he said.
Carlat has written about the conflicts of interest he experienced while promoting a controversial antidepressant to other doctors for a pharmaceutical company. In a New York Times Magazine essay, he recalled putting some of his critical faculties on hold while being wined and dined with other leaders in his field.
"Doctors are not immune to marketing," he said in a phone interview. "Marketing works for people who have very little education, and marketing works just as well for people who have had 10 years of education after they graduate from college."A Matter of Trust
In 2003, the District passed a law that requires drug manufacturers to disclose their marketing expenditures to the city health department, though the information is not publicly available. Several states have passed or considered similar laws, some that include a ban on industry gifts to physicians.
In January, Sen. Chuck Grassley (R-Iowa) and Sen. Herb Kohl (D-Wis.) introduced legislation -- the Physician Payments Sunshine Act -- that would require drug and medical device manufacturers to report payments to any physician of more than $100, whether as a gift or for research purposes, and to publish the information online.
"PhRMA supports the concept of transparency," said Marjorie Powell, senior assistant general counsel for Pharmaceutical Research and Manufacturers of America (PhRMA), an industry organization. "We think that a national reporting system makes much more sense than different state reporting systems." PhRMA has endorsed the Physician Payments Sunshine Act.
While many patients would like to learn about potential conflicts of interest, some physicians and industry representatives point out that not all physician-industry relationships are bad; some are essential to the development of new therapies.
"Certain relationships are necessary, and research is a good example," Coukell said. Many people in the medical community seem to agree.
"We can't lose sight of the fact that it is potentially beneficial [to the public] for industry to interact with physicians, because someone needs to develop these drugs," said Steven Nissen, chairman of the Department of Cardiovascular Medicine at the Cleveland Clinic. "I work with many pharmaceutical companies, and I believe it is my responsibility as a physician to facilitate the development of new therapies."
Nissen said he has received tens of thousands of dollars from industry for his research and advice.
"It's a lot of money. It becomes greater over the years as you gain stature. . . . Your advice becomes more valuable," he said.
But about five years ago, Nissen said he realized he felt beholden to the companies that paid him. He said the money he earns from industry now goes directly to charity.
"The trust of our patients is so important. I never want a patient to not take a medicine because they are concerned that I might have a financial interest," said Nissen. He said that because patients are unlikely to challenge their doctors, patients would be the big beneficiaries of rules requiring more transparency.
Once there is a public database of the sort described in the Grassley-Kohl bill, he said, "you don't have to confront your orthopedic surgeon about whether he has ties to the company that makes the knee replacement; you can just look it up."
"Once the information is out there . . . patients will realize that there are a lot of physicians involved in [relationships with industry] for the betterment of patients," said Rafael Fonseca, a hematologist and the deputy director of the Mayo Clinic Cancer Center. Fonseca is on the steering committee of a new organization called the Association of Clinical Researchers and Educators (ACRE), formed in response to what it calls the "anti-industry movement."Too Much Information?
Fonseca said the conflicts-of-interest issue has made for a stressful environment in the medical community.
"There is a big fear factor among physicians," he said. "People are afraid of saying that they work with industry."
But how much information is too much?
Avi B. Markowitz, who is also on the steering committee of ACRE, said doctors are entitled to their privacy. Markowitz, a medical oncologist at the University of Texas Medical Branch in Galveston, said it is entirely appropriate for him to report what he makes to tax agencies, to his employer and to regulatory bodies. But he questioned how physicians can be asked to disclose to other parties information about financial ties to industry "without at the same time giving up personal rights and freedoms that are unreasonable to surrender."
In Coukell's opinion, transparency is the answer.
"We are always balancing between privacy and public good," Coukell said. "I think there is an emerging consensus . . . that transparency is for the greater public good."