A Healthy Dose of Skepticism

With the latest Big Pharma debacle ("Hey, let's shoot ourselves in the other foot") from the Prozacasaurus' overmarketing of Zyprexa (see Grrl's, Jake's, and David's (addendum, 12/21) blog entries on the subject), this recent (and free access) article from PLoS Medicine: Educating Health Professionals about Drug and Device Promotion: Advocates' Recommendations seems particularly relevant.

Nephrology News and Issues provided a good summary of the PLoS article:

A group of physicians and advocacy groups is taking on pharmaceutical promotions, calling in a journal article for an overhaul of the way healthcare professionals are educated on how to handle them. The article, published in the November Public Library of Science Medicine Journal, gives four objectives to improve education on pharmaceutical promotions. The content of the article originated in an email discussion among representatives of the American Medical Students Association, Healthy Skepticism, No Free Lunch and PharmAware. Significant education reforms are necessary because of the risks involved, the group said. It cited serious side effects from Vioxx and hormone replacement therapy as examples of the dangers of misleading promotion. Most medical and pharmacy school students spend only half a day or less learning about pharmaceutical promotion, the article said. The first suggestion in the article is to educate health professionals about the decisionmaking process, including teaching them about persuasion and how to understand statistics. Ethical problems from receiving gifts should also be a focus, the group said. The article also calls for professionals to learn that while all promotion may not be harmful, it is rarely beneficial. Many people believe they are more skeptical than they actually are, the authors noted. The groups cited evidence that exposure to promotional materials correlated to a medically inappropriate use of pharmaceuticals and suggested showing an intentionally deceptive piece of promotional material, having people discuss it and then explaining the misleading techniques used. The groups called their proposals necessary, but insufficient to fully combat the influence of promotional materials.

Now this may seem to be another case of me biting the hand that feeds me, but current sales and marketing practices in pharma are hurting the industry. As Jake noted, lying is not good business. And that giant sucking sound? That's pharma marketing's budget. A bunch of dinners and educational sessions for the docs are one or two less HPLC or LC-MS systems for me. Not that I'm bitter or anything.

One thing I have to wonder...are prescribing MD's that gullible? The vast majority of doctors with whom I interact both personally and professionally are very smart and skeptical people. I have the same expectations for the MDs who treat my family and me as I do myself. I scour the medical literature on clinical studies for any drug that gets prescribed for me or a family member, and I read that literature skeptically. What's the real efficacy? The liabilities? Any drug-drug interactions I should know about? Most docs I know are consersant in these subjects, and are careful to offer a balanced view to me. So how can the pharma sales reps make such inroads with such otherwise skeptical folk?

Marshal Mandelkern, an assistant clinical professor of psychiatry at Yale School of Medicine, wrote the following response to the NYT article on Lilly's marketing strategies for Zyprexa:

To the Editor:

It seems from your article about Eli Lilly's marketing of Zyprexa, and from what I know from my experience as a psychiatrist, that the company has behaved as any for-profit corporation would.

While it may not have suppressed important information, it has certainly tried to present the situation in a way that maximizes sales of its product.

For it to do anything else would be a dereliction of duty, which is to shareholders, not patients.

The main hope for patients, then, lies in an objective physician, whose only duty is the good of his patient.

The physician must remain as free as possible from financial incentives and concerns, whether from drug companies or insurance companies, and exert his efforts to obtain objective information about drugs from as many sources as possible, and use this knowledge solely for his patient's benefit.

It is in the public's interest for physicians to remain objective, and devoted solely to their patients' well-being, free from financial entanglements with drug or insurance companies.

Marshal Mandelkern, M.D.
New Haven, Dec. 17, 2006

The other four Letters to the Editor may be found here

Sales forces are a necessary component of a profitable company (I couldn't get my HPLCs without 'em), and drug discovery scientists self-deprecatingly note that we'd be awful pharma sales reps: "OK, Doc, here's the latest on our greatest, but come to think of it, there were a couple of trials which showed only marginal efficacy between our drug and that ol' standby from SquibbMerlCo. Your patients are better off with their pill." I am less sanguine about the notion that the interest of shareholders should overide honest disclosure of adverse effects. That's the cognitive dissonance which infects many drug discovery research scientists. We're not exactly of the "huge profits at any cost" mindset, and do our work out of a combination of scientific inquiry and, believe it or not, a sense of altruism. However, the rest of what Dr. Mandelkern writes rings true with the recommendations set forth in the PLoS article. Reform in pharma sales practices is necessary, and this may happen as a response to market drivers. Pharma sales forces in one form or other are inevitable, and the objective stalwart between glossy marketing and the patient is the well informed and skeptical physician.