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Book Review Spring 2005
On The Take President Eisenhower warned about the military-industrial complex having a negative effect on the common good. These days medicine and big business appear to be combining to exert a similar deleterious influence on the health and pocket book of the nation. This volume is one of the latest in a rash (pun intended) of books about the untoward nature of corporate influence on medicine. The author has been an academic researcher, practitioner and most famously, the former editor of The New England Journal of Medicine, arguably medicine's most prestigious and influential journal. Here he explores in detail corporate greed and that of the physicians they try (and largely succeed) to manipulate. Dr. Kassirer describes in some detail the tricks of the pharmaceutical trade in marketing drugs to the physicians who prescribe them and to the general public who increasingly demand them. These are nearly always the newer and more expensive brand names, whether they represent an actual improvement in therapy or are just "me-too" drugs, or in some cases, dangerous. How to subvert the FDA, how to take advantage of doctors' greed and desire for prestige, how to develop brand loyalty without independent evaluation of a drug are just some of the topics covered. Literally, this is a marketing primer by Big Pharma. In the initial chapter, Dr. Kassirer gives us an overview of the special deals, questionable educational opportunities and downright bribes that are offered physicians for post-marketing research on the company drugs. Opportunities to present the marketing message to colleagues at company-arranged so-called drug education meetings or to serve on the company consultant panel are other devices to seduce the all-too-willing MDs. Many of the meetings are held at upscale restaurants or resort weekends with families invited. Continuing physician education (CME), a requirement by most state medical boards for re-licensing, has been taken over in large part by commercial groups and drug company sponsors. The academic medical-industrial complex has grown out of control. After years of tolerance, the prestigious NIH has finally had to ban the practice of their researchers taking multi-thousands of dollars in consulting fees. Chapter 2 deals with some of the more egregious practices of the pharmaceutical companies and their all-too-willing doctor shills. Honorariums for joining the speaker's bureaus; promotion of off-label drugs; ghost written articles, usually by company selected science writers; widening the "vigorish" on the administration of chemotherapeutic drugs; helping companies market their wares and avoid lawsuits are just a few of the nefarious tools that have been employed. As one journalist puts it, it is marketing disguised as science. Dr. Kassirer then goes on to describe conflicts of interest and perhaps even more importantly, the nature and role of apparent conflicts of interest. He even cites a 5 point checklist progressing from mild to severe conflicts ranging from taking cups and pens from the pharmaceutical to taking large amounts of money for the express purpose of promoting a particular company's drug. He explores the nature of self-deception and the "rule-of-reciprocity" that contribute to the problem. Physicians' vehement protests that they cannot be bought for a pocket protector or a dinner are rejected. One doctor states that he gets so many gifts that he cannot recall who gave him what. The availability of generic drugs (and the check-off blanks on the prescription pad that allow their use) also mitigates somewhat the influence of the manufacturers to prescribe its drug exclusively. Still, the corrupting influence of money in any of its forms has a tendency to work its will, especially in a profession that has seen its practice income decline and its malpractice premiums, office overhead and patient load all increase. The author is in a unique position, as a former journal editor to critique his fellow editors and their conflicts. Except for a handful of the most prestigious, and even occasionally them, journals are subject to pharmaceutical advertising for their continued publication. Often this may influence editorial policy on what articles get published. Although authors are usually asked to identify possible sources of conflict, for example pharmaceutical company support for the study they are reporting, it is often incomplete or in the finest print at the end of the article. The book goes on to criticize the major medical institutions that comprise the profession. In addition to medical journals, professional organizations, academic researchers, and clinicians are all subjected to the author's searchlight. After a penultimate chapter on how we got from the $5-$10 a visit practitioner of the 1950s to the corporate executive physician of today, Dr. Kassirer offers some sound medical advice and a few bitter pills to fix things somewhat. Chief among these are ways to diminish, if not eliminate, the corrupting power of money: a tall and perhaps naive order in today's world. Many of his suggestions for improving the ethical climate in modern medicine are unlikely to be adopted in the current climate but we can admire and forgive Dr. Kassirer for his proposed remedies. |
