The Drug Pushers

As America turns its health-care system over to the market, pharmaceutical reps are wielding more and more influence—and the line between them and doctors is beginning to blur

The litigation over Neurontin cost Pfizer $430 million in criminal fines and civil damages for the period 1994 to 2002. It was well worth it. The drug’s popularity and profitability soared. In spite of the adverse publicity, Neurontin generated more than $2.7 billion in revenues in 2003, more than 90 percent of which came from off-label prescriptions.

Of course, sometimes speakers discover that the drug they have been paid to lecture about is dangerous. One of the most notorious examples is Fen-Phen, the diet-drug combination that has been linked to primary pulmonary hypertension and valvular heart disease. Wyeth, the manufacturer of Redux, or dexfenfluramine—the “Fen” in Fen-Phen—has put aside $21 billion to cover costs and liabilities from litigation. Similar events played out, on a lesser scale, with Parke-Davis’s diabetes drug Rezulin, and Wyeth’s pain reliever Duract, which were taken off the market after being associated with life-threatening complications.

And what about reps themselves? Do they trust their companies to tell them about potential problems with their drugs? Not exactly. As one veteran rep, voicing a common sentiment, told me, “Reps are the last to know.” Of course, for a rep to be detailing a drug enthusiastically right up to the day it is withdrawn from the market is likely to erode that rep’s credibility with doctors. Yet some reps say they don’t hear about problems until the press gets wind of them and the company launches into damage control. At that point, Slattery-Moschkau explains, “Reps learn verbatim how to handle the concern or objection in a way that spins it back in the drug’s favor.”

Some believe that the marketing landscape changed dramatically for both reps and doctors in 2002, after the Office of the Inspector General in the Department of Health and Human Services announced its intention to crack down on drug companies’ more notorious promotional practices. With the threat of prosecution in the air, the industry began to take the job of self-policing a lot more seriously, and PhRMA issued a set of voluntary marketing guidelines.

Although most reps agree that the PhRMA code has changed things, not all of them agree that it changed things for the better. Some say that as long as reps feel pressure to meet quota, they will find ways to get around the rules. As one former rep pointed out, not all drug companies belong to PhRMA, and those that don’t are, of course, not bound by PhRMA’s guidelines. Jordan Katz says that things actually got worse after 2002. “The companies that tried to follow the guidelines lost a ton of market share, and the ones who didn’t gained it,” he says. “The bottom line is that if you don’t pay off the doctors, you will not succeed in pharmaceuticals. Period.”

A World Without Doctors?

In 1997, John Lantos, a pediatrician and ethicist at the University of Chicago, wrote a book called Do We Still Need Doctors? We will always need health care, of course. But, as Lantos observes, it is not clear that we will always need to get our health care from doctors. Many of us already get it from other providers—nurses, physical therapists, clinical psychologists, nutritionists, respiratory therapists, and so on. The figure of “the doctor” is not cast in stone. It is really just a particular configuration of roles and duties and responsibilities, each of which can be changed.

Many have already been changed. Sometimes I think of my father as one of the last small-town, solo family doctors left in America. His kind of practice has been largely replaced by teams of specialists working in group practices underwritten by insurance companies and for-profit health-care chains. I doubt that any of the doctors my family has ever visited, except for a pediatrician who took care of our children when we lived in Montreal, would recognize us if they passed us in the street. Last year, while driving in Wisconsin, I filled up my car at a combination gas station, pharmacy, and walk-in medical clinic. I don’t mean to complain. As long as our health insurance has been paid up, we have usually gotten good care. We simply live in a country that has decided that the traditional figure of the doctor is not worth preserving in the face of modern economics. Instead, we put our trust in the market.

Perhaps we are right to do so. We can get used to a world without doctors. As Lantos points out, we have gotten used to a world where we have shoes but no cobblers. We can copy documents without scriveners, make tools without blacksmiths, and produce books in the absence of bookbinders. We have left the old world behind, and for the most part, we don’t miss it.

As the figure of the traditional doctor fades away, it is being replaced by a figure akin to the drug rep, one whose responsibilities are to compete as vigorously as possible in the medical marketplace. Patients are being replaced by “health-care consumers,” who shop for the best medical bargains they can find. If it is true that the drug rep does not put my interests first, the same is true of everyone else in the marketplace; and we believe that such problems in the marketplace will be sorted out by the invisible hand. Buyers will stop buying from sellers who provide them with inferior goods. This model of medicine is not unlike that advocated thirty years ago by Robert Sade, a surgeon at my old medical school, the Medical University of South Carolina. Writing in The New England Journal of Medicine, Sade argued, “Medical care is neither a right nor a privilege: it is a service provided by doctors and others to people who wish to purchase it.” He is now the vice chair of the AMA’s Council of Ethical and Judicial Affairs.

Many doctors seem resigned to this shift. They see themselves as a beleaguered group whose lives are made miserable by third-party payers, personal-injury attorneys, and hospital bureaucrats. Whatever idealism they may have had about the practice of medicine is being pushed aside by the concrete realities of hustling in the new medical marketplace. Many academic physicians seem cowed by the power of the drug companies, upon whom some depend for research funding. For some, it’s not so much a question of whether medicine has become a business as what kind of business it has become. When I talked recently to a gastroenterologist at an Ivy League medical school about his work as a thought leader for a variety of drug companies, he shrugged and said, “Better a whore than a concubine.”

Which is not to say that pockets of resistance can’t be found, especially among younger physicians and medical students. The American Medical Student Association may be the only mainstream medical organization with a principled position against taking industry gifts. It stands in striking contrast to the American Academy of Family Practice, which last year refused to grant exhibition space at its annual conference to No Free Lunch, a physician-led advocacy group that advises physicians to “Just say no to drug reps.” The AAFP said that the group’s goals were “not within the character and purpose” of the conference. But it allowed pharmaceutical companies, McDonald’s, and the Distilled Spirits Council of the United States to exhibit. (It reversed its decision about No Free Lunch after protests by a number of AAFP members.)

Whether doctors and reps are all that different from one another is no longer clear. Doctors know a lot more about medicine, and drug reps dress a lot better, but these days both are Organization Men, small cogs in a vast health-care machine. They are just doing their jobs in a market-driven health-care bureaucracy that Americans have designed, and that we defend vigorously to critics elsewhere in the world. Like anyone else, doctors and reps are responding to the pressures and incentives of the system in which they work.

When Michael Oldani and I were having breakfast, he told me a story about a rep he interviewed for his dissertation. The rep had recently spent a day doing a “preceptorship,” a practice in which a drug company pays doctors to let a rep shadow them while they see patients. This rep was shadowing a high-prescribing psychiatrist (she called him “Dr. C”) at a med-check clinic. Med-check clinics are extremely busy sites where psychiatrists see large numbers of patients in quick succession, mainly to make sure that their medications are in proper order. At one point during the day, the rep said, a cheerful man in a wheelchair rolled into the office. Barely looking up from the stack of charts on his desk, Dr. C started quizzing the man about his medications. After a few minutes the man interrupted. “Look at me, Dr. C. Notice anything different?” Dr. C pushed his glasses up on top of his head and looked carefully at the patient for a few seconds before replying, “No, I don’t. What’s up?” The man smiled and said excitedly, “I got my legs cut off!”

After a moment of silence, Dr. C smiled. The man laughed. Neither seemed upset. In a few minutes the session ended, and the next patient came in.

Presented by

Carl Elliott teaches at the Center for Bioethics at the University of Minnesota and is the author of several books, including Better Than Well: American Medicine Meets the American Dream (2003), and the co-editor of The Last Physician: Walker Percy and the Moral Life of Medicine (1999). His article "A New Way to Be Mad" appeared in the December 2000 issue of The Atlantic.

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