Well, I’m home.
As I’ve mentioned before, I attended the annual meeting of the American Society of Clinical Oncology (ASCO) in Chicago. Although one of the problems with ASCO, at least for surgeons like me, is that it is a meeting completely dominated by medical oncology. Quite frankly, not that much of what is presented at ASCO has a lot of relevance to my surgical practice. There are exceptions, of course. In fact, Monday morning’s sessions on breast cancer were the best of science-based medicine that will change practice. Perhaps I’ll blog about that tomorrow or later in the week. As I write this I’m just too tired from the meeting and the trip home to lay down any serious science for you. That takes thinking and work, and, besides, so monumental were the studies presented that I haven’t quite decided what I think of them yet. (Perhaps my good buddy at another blog should take this on Monday.) In the meantime, I thought it might be of interest to do a bit of an update on the post about drug rep swag that I wrote about three years ago and reposted yesterday. (Remember to go back and read it if you haven’t already; after all, if you’ve been reading this blog less than three years, it’s almost certainly new to you!)
Three years ago, the swag at ASCO was very impressive indeed. There were laser-engraved pens, lights, bags emblazoned with the names of attendees, and a even Bluetooth mouse that could be had easily. This was in addition to huge quantities of the usual “minor” swag, such as pens, Post-It notes with drug company logos, Tote bags, books, and flash drives. This year, as opposed to three years ago, I noticed a distinct decrease in the amount of swag. True, my observations are not scientific at all, but I did note that, for example, the game at the Genentech booth in 2007 that led its participants to get all sorts of goodies appeared to be gone this year, even though the booth looked identical to the one in 2007. Similarly, other than pens, swag that attendees could take home was much more scarce, other than pens, most of which were not even particularly good pens. There also appeared to be a lot more booths offering free coffee and little snacks, like candies or cookies. I also noticed something I hadn’t seen before anywhere at any meeting. It was so odd that it immediately caught my attention:
So let me get this straight. If you are a physician and happen to be licensed and prescribe in either Vermont, Minnesota, or Massachusetts, Bayer can’t give you a cup of coffee. I wondered about this. Do they actually check? Since I don’t live in any of those states, I decided to find out. No one asked me for my meeting badge, which was emblazoned with my name, institution, and city and state. I just walked up and poured myself a cup of Starbucks coffee, put some half-and-half in it, and drank up, thus forever sealing my fate as a minion hopelessly in the pay and thrall of the evil big pharma. And not just big pharma, but evil German big pharma!
Dr. Len Lichtenfeld of the American Cancer Society apparently had a different experience:
This year tops them all and shows how far we have come in protecting the public and preventing drug companies from unduly influencing the doctors attending ASCO by putting restrictions on which doctors could get a free cup of coffee.
At one drug company booth where they were offering a small cup of espresso to meeting attendees there were signs posted which said that doctors from Minnesota and Vermont were forbidden by state law (yes, that’s right: forbidden) from having a free cup of coffee. There was another sign which said that the drug company could/would report to the federal government and publicly post the name of any other doctor who took advantage of that free cup of coffee.
If you swiped your plastic identification card, and weren’t from Minnesota or Vermont, you got your cup of coffee. No identification card, no coffee. Live in the great states of Vermont or Minnesota? You are just plain out of luck. The coffee bar outside the convention hall is just the place for you.
I wonder which booth Dr. Len managed to hit. The Bayer booth had this sign up, but nothing more. There appeared to be no mechanism to enforce it, because anyone could just walk up to the coffee and pour himself a cup. I also wonder how Bayer apparently interprets the laws from three states as banning even a cup of coffee being provided to physicians while whatever company in whose booth Dr. Len found himself interpreted the law such that it decided that it only applied to two of those states. For example, here is a summary of the Massachusetts law, the relevant portion of which reads thusly:
- Pharmaceutical or medical device manufacturing companies may only provide or pay for meals for physicians that are modest and occasional in nature, and are directly related to an informational presentation;
- No pharmaceutical or medical device manufacturing company may provide physicians with financial support related to the costs of attending CME events, conferences, or professional meetings;
- No pharmaceutical or medical device manufacturing companies may provide inducements or gifts to any physician who is not a salaried employee of the company.
As of July 1, 2010, and annually thereafter, every pharmaceutical or medical device manufacturing company must disclose to the Department of Public Health the value, nature, purpose and particular recipient of any fee, payment, subsidy or other economic benefit with a value of at least $50, which the company provides, directly or through its agents, to any covered recipient, including physicians, in connection with the company’s sales and marketing activities.127 A person who knowingly and willfully violates these rules can be punished by a fine of up to $5,000 for each violation.
I can see how a company might interpret the above statute to ban even a cup of coffee, becaause it may well have not been related to an informational presentation, but Bayer’s does appear to be a very severe interpretation of the law. After all, the company’s booth was plastered with educational materials and helpful representatives more than willing to talk to you about Bayer products. On the other hand, maybe the company’s lawyers insisted on this in order to preclude any possibility of running afoul of these state laws. In any case, it’s very clear that there has been a sea change since I last attended such a large clinical conference. Gifts and free goodies given away by pharmaceutical companies are rapidly going the way of the proverbial dodo. Even getting a cup of coffee from a large pharmaceutical company risks big penalties to the pharmaceutical company (if the physician comes from the wrong state) and the physician’s being branded as hopelessly in the thrall of big pharma, having apparently sold his medical soul for a hit of caffeine.
I’m being a bit sarcastic, but that’s more because I haven’t resolved for myself what should and should be appropriate. Before I try to answer that, let’s check out something else I saw on the exhibit floor at ASCO. Over at the Roche display, there was a rather odd scene:
First off, the guy standing there vigilant was, as he appears to be, functioning as in essence as a guard. His job was to prevent certain people from entering the confines of the Roche booth. But which people? The answer was on this sign:
A closer look at the sign revealed this:
Wow! It’s a no-Americans zone!
Physicians who were not from the U.S. could enter the heaven that awaited them, thanks to Roche. And the people manning the entrances to the booth were checking meeting badges and turning away American physicians. I wanted desperately to know what forbidden rituals of big pharma were going on within the booth. Were Roche and foreign physicians sacrificing goats to the dark gods of big pharma? Were foreign physicians going to get a leg up on their American competition by pledging their souls to Roche in contracts signed by blood? Were there orgies in there, with beautiful incubi and succubi with the word “Roche” tattooed on their nether regions seducing unwitting foreign physicians who had made their way to Chicago?
I don’t know. All I could find was what I could see on the outside looking in:
My lurid fantasies were completely disappointed. It just looked like nothing more than coffee, drinks, and other snacks. One wonders if Roche was subliminally piping in messages telling these doctors to prescribe more Xeloda and Avastin. I also wonder if it worked.
Yes, I know I’m being facetious. Actually, what was almost certainly going on at the Roche booth was that representatives were talking about potential off-label uses of its drugs, as Dr. Lichtenfeld pointed out two years ago. Personally, I don’t agree with Dr. Lichtenfeld’s apparent self-righteous anger that his foreign colleagues can learn all the latest and greatest off-label uses of Roche’s drugs (many of which aren’t necessarily supported by particularly good evidence) and he can’t or his assumption that the off-label use of Avastin would save his patient’s life. However, I do understand just how bizarre this situation is and how frustrating it could be to my medical oncology colleagues. (Personally, I rarely prescribe anything other than pain medicines for postoperative patients or antibiotics for the uncommon postoperative wound infection.)
Let me lay to rest (or attempt to lay to rest) some of the irritation some of you are no doubt feeling towards me right now. Try to hold your wrath at bay for a moment, and try to remember that I’ve made a bit of fun of some of the excesses of pharmaceutical company marketing since the very beginning of this blog. In fact, one of the very earliest posts on the first iteration of this blog was all about weird stuff doctors get from pharmaceutical representatives and have returned to the issue from time to time. The very reason I wrote my post about the outrageous swag at ASCO three years ago was because it disturbed me.
I understand that the relationship between big pharma and physicians has traditionally been far too cozy. I also understand that big pharma has often gone to great lengths to try to influence physician prescribing practices. I even understand that some of my colleagues yield to the temptation of that filthy pharma lucre. What I haven’t managed to figure out for myself yet is where the line should be drawn. It’s obvious to me that accepting trips or lots of money to speak for a pharmaceutical company to hawk its products is going too far, but is accepting a cup of coffee at a large medical meeting in the exhibition hall going to hopelessly taint a physician’s objectivity? I don’t know the answer to that one. Worse, if we accept that, for example, taking a cup of coffee at a trade show is not going to compromise a physician’s ethics, then the questions become even dicier to answer because then you have to decide where between a cup of coffee and accepting expensive trips or dinners the line should be drawn.
No wonder so many physicans, medical societies, and medical schools are deciding that the easy way out of this question is simply to take an absolutist stance that accepting anything of value from a pharmaceutical company is hopelessly corrupting and to be avoided. Quite frankly, it is a lot easier to do that than to ask the hard questions, namely what level of entanglement between big pharma and physicians is innocuous or even promotes better patient care by providing physicians with science-based information about new drugs and what level results in undue influence. It’s hard not to remember that pharmaceutical companies have traditionally contributed a lot of money to continuing medical education. Should such unrestricted grants for CME be viewed as harmful? I don’t know the answer. I do know that, if I were going to write a post making fun of the contention that we should limit the influence of big pharma among doctors, I’d have a hard time coming up with a more ridiculous example to go full mental Orac on than banning cups of coffee from pharmaceutical companies at a medical meeting or promulgating rules that lead drug companies to exclude American physicians from their booths, and I’ve actually been troubled by pharmaceutical company marketing practices for a long time.
Hey, I know! Maybe big pharma should be excluded from medical meetings altogether! Actually, I’m serious. If we as a profession have decided that the taint of influence due to big pharma is so powerful that even a cup of coffee is dangerous, then how on earth can we justify dozens of booths at a major medical meeting, some of which cost on the order of a quarter of a million dollars transport and staff?
I guess in the future it’ll have to be overpriced, cold coffee sold at the convention center for me and hope my name doesn’t end up on a list of pharma thralls for having accepted a couple of cups of coffee this year at ASCO.