Legal Bribery
Episode Description: Every year, the pharmaceutical industry spends over 20 billion dollars on charming doctors. They do so with seemingly innocuous gifts — free food and beverages, drug samples, offering payments for speeches and hosting disease “education” sessions. How much are doctors really affected by this legal bribery? Today, I am joined by Dr. Paul Lichter, who studies ethics and medical professionalism surrounding the physician-industry relationship.
“The fact that the [pharmaceutical representative] could not curry my favor and reciprocity for a gift he would have given me made him not interested in dealing with me. ”
Yibing Zhang: Hi everybody. This is Yibing, and you are listening to Limboland. Every year, the pharmaceutical industry spends over 20 billion dollars on charming doctors. They do so with seemingly innocuous gifts — free food and beverages, drug samples, offering payments for speeches and hosting disease “education” sessions. Today, I am joined by Dr. Paul Lichter, who studies ethics and medical professionalism surrounding the physician-industry relationship.
How did you become interested in tackling this topic in the first place? Because it seems to me that a lot of physicians are either unaware of the consequences of physician-industry relationships or they think they are immune to it, and thus don’t think much about it at all. I’m in medical school right now, and I don’t clearly remember a single lecture on this topic.
Dr. Paul Lichter: I became interested in this subject when I was a young faculty member. I had been invited to go to Cancun to a meeting run by a company. I went to the meeting naively with several of my colleagues and it was to give a company advice on a drug that they were dealing with. But the setting was quite extravagant. I began to think afterwards, you know, does this seem right? This is back in the 1970s. Does this seem really right? And I came to the conclusion that no, it was not right. The company was trying to buy my favor with this type of a thing. The meeting actually was pretty good. I learned something from the meeting and contributed something to the meeting. But, the meeting could have been held in a less extravagant setting. Anyway, not long after that as I recall, a pharmaceutical representative who was dealing with our department learned that I was a golfer. And he was a very fine golfer. He wanted to play golf with me. We went out to play golf at one of the University courses and went into the pro-shop to register. He was preparing to pay for me and I said, “No.” I said, “I’ll pay my own, and you can pay your own.” We played golf, we had a good time, and I never heard from him again. I realized that the money in all of this is very, very important. The fact that he couldn’t curry my favor and reciprocity for a gift he would give me made him not interested in dealing with me. That helped confirm in my mind that it was not good, and that the companies are simply trying to use money to influence the way doctors behave towards them and their products.
Yibing Zhang: You went on the Cancun trip with a few of your colleagues right? Did any of them leave that trip thinking, “oh my goodness, the industry is influencing me. This is such an extravagant trip. They must want something from me.”
Dr. Paul Lichter: No, I don’t think so. In fact, some of the colleagues that went on that trip are still very much involved with industry.
Yibing Zhang: In your paper, you mention that physicians believe that they are not at all influenced by industry. That they’ll go to these lunches and they might even speak at some events. They may get free gifts but they themselves are “above” being influenced by these marketing strategies.
“Industry is trying to influence physicians and physicians are allowing themselves to be influenced.”
Dr. Paul Lichter. Right, that’s absolutely true. I’ve asked at meetings where I’ve spoken to a big crowd. I start by saying, “How many of you feel that you are influenced by industry’s gifts albeit a pen, a pad of paper, a lunch, whatever.” Hardly anyone raises their hand. My next question is, “How many of you feel that your colleagues are influenced by these relations with industry?” And nearly everybody raises their hand. And of course, those two things are not compatible. The fact is that physicians do think they are influenced. They just don’t want to admit it.
The way I answer a question like that from doctors is . . . when doctors say, “I’m not influenced,” is to say . . . “Well, you know, it’s interesting that industry spends perhaps 25 billion dollars a year, including free samples, to influence us and they continue to spend this amount of money.” They’re a publicly held company whose goal is to increase shareholder’s value as well as the executive’s pay and they wouldn't continue to spend this enormous amount of money if they didn't know that it works. It’s not that they think it works. They know that it works. We, in our individual practices and our little individual offices, in our little individual minds, think that industry is not influencing us when these smart people, whose job it is to make money, know that they are, is a disconnect. My guess is that physicians aren’t totally kidding themselves. It’s just that the money talks so loudly. And it’s the “follow the money” saying. Follow the money and you’ll see what’s going on. Following the money here tells you: Industry is trying to influence physicians and physicians are allowing themselves to be influenced. The money is important though to some of these people. Some people, relating to industry, are getting hundreds of thousands of dollars a year from industry to be a speaker, a consultant, to be whatever. That’s not trivial money.
Yibing Zhang: No, that’s not trivial money at all. There was one quote in your paper that I was amazed by. It says “others seem to think that the more gifts physicians take, the greater their certainty of strength of moral character.” I read that line and remember thinking, this is such an oxymoron. This entire sentence does not make sense. How can it be that the more money that you take from the industry, the more that you’re sure, “yes, my advice is not corrupted by anything.”
Dr. Paul Lichter: Well, one thing is that people who take money, physicians who take money from a lot of different companies believe in their hearts that, “Hey, I’m accepting money from competitors. How can I be biased? The more money that I get from different people, different companies, the more likely that I am to be unbiased.” Well, interesting again. Industry is giving them a lot of money and these companies know that those physicians are working for other competitors. Why would a company be so foolish to give a physician thousands and thousands of dollars when they know that the physician is speaking for other companies as well. So the reason for this is. . . and the phrase is not mine (but it has been used by others), who call those kinds of physicians, drug whores. They accept all of this money from all these different companies thinking that it makes them less biased, but in fact, the companies know that all they’re interested in is a physician who will promote expensive prescribing, meaning brand name drugs on patent and the same thing with expensive devices. That’s all the industry cares about. They don't care if it's this drug or that drug. The global attitude of that particular physician to only talk about on-patent medicines and expensive medicines, that’s enough for the companies to continue to give them a lot of money -- whether their competitors do or not. In fact, I think they feel that the people who have the most money given to them from the most companies are the best advocates because it makes the audience think that they are not conflicted. And those speakers, and I’ve heard them as well. When they are showing their conflict-of-interest slide, they often add a little quip to say, “Well, you see all these different competitors that I’m involved with. How can I possibly be biased? I’m telling you the truth.”
Yibing Zhang: That’s so interesting. I feel like if I was in the audience and if I saw that, without having our conversation right now, I would probably believe them. And think, yeah, you are getting all these competitors. Of course you’re not being biased because you are pulled in all these different directions.
Dr. Paul Lichter: Yeah, that’s what they want you to believe.
Yibing Zhang: But that’s a false belief.
Dr. Paul Lichter: That’s an absolutely false belief. They are the worst ones.
Yibing Zhang: Next, I wanted to talk about if all physicians had this insight on physician-industry relationships. Why would they still want to continue this relationship? Why would they still want to receive these gifts?
Dr. Paul Lichter: MONEY. Pure and simple. What the companies are doing is giving legal bribes to the physicians. And physicians accept legal bribes. You know, it’s interesting to think that all of us start into medicine . . . and we get something free. We see our mentors and our supervisors get things free, like a lunch. Industry brings in lunch or provides an “unrestricted grant” that can be used to provide lunch for grand rounds or whatever. We get this free. And we get accustomed to having free things. Now you, as an early medical student, haven’t gotten the kinds of free things that I got as a medical student because now, things are looked at more closely and there are rules in the institution against accepting certain kinds of gifts. But industry will work in any way they can to get around those rules. And as long as they mention the unrestricted grant. That’s one of the most clever ways that industry uses to get around these problems. As best I can tell, it was an invention of industry. It has that feeling of, “What could be wrong with this? We’re giving you money, just use it any way you want.” Maybe for something related to an educational activity. Like the lunch that people eat when sitting or listening to a talk, or to use to bring a speaker in. And the money is given to the speaker from the institution.
You and I, if we ran these companies would do the same things. Your ticket to big profits is through prescribers and purchasers. And if you can get those people on your side to do what you want them to do, what better thing is there you could do? So if physicians really did understand all of this and did back off from taking these kinds of things, industry would have problems. But it would improve the healthcare cost equation. Because, this whole process between industry and physicians drives up the cost of healthcare. Patients receive prescriptions for medicines that are 1) very expensive, and 2) as studies have shown, drugs that they may not need where a generic drug or even no drug might work just fine, and 3) this gets ingrained. It just gets ingrained. And once you have it going, as industry does, it’s just easier for physicians to accept the next lunch or the next invitation to speak somewhere and be touted as an expert somewhere. So it’s a snowball effect and it works beautifully. You get your plans executed by the physicians. They begin to do it for you.
Yibing Zhang: Wow, wow. You mention in here that physicians think that they’re too smart to be influenced by the industry and. . .
Dr. Paul Lichter: But they don’t think that their colleagues are too smart.
Yibing Zhang: Exactly.
Dr. Paul Lichter: Isn’t it funny?
Yibing Zhang: Yeah, it is very funny.
Dr. Paul Lichter: It’s rationalization.
Yibing Zhang: I’m smarter than the people around me, and I can’t be influenced by the industry like the people around me.
Dr. Paul Lichter: But the people around me think that I’m being influenced.
Yibing Zhang: The idea of gratitude comes up a lot in your paper. Even if it’s a small gift, . . . even the gift that you mentioned can go to anything. How does gratitude play a role in the physician-industry relationship?
Dr. Paul Lichter: We live in a culture of reciprocity. When someone gives one a gift, the person who receives the gift feels a sense of having to reciprocate or wanting to reciprocate. So when industry gives something, it’s preying on our sense of reciprocity. I found myself even caught up on this kind of thing. When you meet with industry people, “well, wouldn’t you just try this new drug? This new expensive drug?” You have a feeling of, “Oh, that person was really nice.” And you want to do it. It takes me to think through the whole thing to say, “No, I don’t want to do that.” But I don’t take things from industry at all now, of any kind. That’s not a favored position physician with industry nor is it when I talk about these things to my colleagues or write about them, which I do. It’s not favored by those colleagues.
You know, industry uses what are called Key Opinion Leaders or KOLs to do their business. And how does that work? Industry . . . pharmaceutical representatives or devise representative visits with their physician assignees. They are assigned to certain physician offices. They cover an area. And they go and talk to these physicians, and they may bring in lunch for the physician or physicians if it’s a group and their staff. And the staff begins to expect that everyday they will have a free lunch brought to them. So once it gets ingrained in that particular practice, the industry people can’t stop. They just have to keep bringing in the lunches.
If a physician is really personal, is very engaged with them, is amenable to trying these expensive drugs, or even purchasing an expensive instrument, they will talk to their own regional supervisor and say, “You know, Dr. X might be a good person for us as a speaker.” And they’ll invite Dr. X to speak in a local steakhouse, where maybe 10-15 physicians show up for dinner. And if the talk has engaged those 15 physicians attending, they might try him again a time or two, but then they decide this person can be a Key Opinion Leader, a KOL. A KOL is the creme-de-la-creme for industry. So they take these KOLs and school them in presenting things to physicians that are in favor of industry. Key Opinion Leaders are often paid significant sums of money by industry to do this. They are the sales people for industry.
Yibing Zhang: What I’m wondering is why wouldn't industry just use their own representatives to give these talks?
Dr. Paul Lichter: They could give the dinner talk but nobody would come. They could give the talk to a thousand people assembled at a meeting, but nobody would listen. Nobody would care. It’s too obvious. But when they can get a physician to do it, and particularly a physician with a lot of credibility. Perhaps someone who’s published a lot, someone who’s well thought of in their field to do their bidding. It’s much more credible with other physicians. So, the Key Opinion Leader has the opportunity to influence a broad array of their colleagues and it’s done in a way that appears biased. No one is saying that you receive money from industry that you are biased but how does the audience know. The only people that know that this works for sure is industry. They put tabs on prescribing activities by physicians. They know so much about each of us as physicians, we wouldn’t believe how much they know -- about your personal life, about your interests, about what you read, what you like, where you travel, your family. They know everything because the representatives who visit offices find out all those things that they put into a database. So they know everything about us and how they can get at us, and if it’s a golf game, they’ll take you to play golf. It’s not random in any way and it’s orchestrated in a big big big way -- orchestrated to make it look innocent but it’s far from that and again, it drives up the cost of healthcare by a large factor.