Prescription for prestige
Drug firms’ speaking fees flow to Harvard doctors; concerns about influence prompt new restrictions
The Harvard brand, unrivaled in education, is also prized by the pharmaceutical industry as a powerful tool in promoting drugs. Its allure is evident in a new analysis of all publicly reported industry payments to physicians.
Doctors and researchers affiliated with Harvard Medical School collected 45 percent of the $6.3 million given to Massachusetts doctors in 2009 and 2010 by seven pharmaceutical companies that disclosed their payments for parts of those years. The money was mostly for talking to other physicians about the companies’ drugs and the diseases they treat, but also for consulting on research and marketing.
“Companies value the cachet that comes with the name of a prestigious institution,’’ said Dr. Paul Appelbaum, director of the Division of Law, Ethics and Psychiatry at Columbia University College of Physicians and Surgeons. “Even though the institutions themselves are not in any way endorsing the presentations, the aura carries over.’’
The proportion of money going to Harvard doctors underscores why the medical school and its affiliated hospitals, concerned that certain speaking fees can compromise the independence of doctors, are clamping down on such payments.
It is not clear yet whether these restrictions are slowing payments to Harvard doctors, because the data reported publicly are incomplete. But one company,
Many hospitals and medical schools continue to permit doctors to participate in company speakers bureaus, and even at medical centers that largely ban the practice, the analysis — by ProPublica, a nonprofit, online investigative reporting organization, and the Globe — found spotty enforcement.
Consulting with industry to develop new treatments is considered part of an academic physician’s role. But participating in speakers bureaus, while legal, is controversial. Bureau speakers typically show groups of doctors company-created or approved slide presentations about specific drugs or diseases treated by a company’s products. Many of these talks, often held at fancy restaurants, have been moved out of state, doctors said, since last year, when Massachusetts banned doctors from eating the free dinners.
Pharmaceutical companies defend speakers bureaus as an important tool for educating doctors and say industry naturally relies on physicians from top academic medical centers because their peers look up to them.
While some doctors who gave speeches once or twice during 2009 and 2010 earned $2,000 to $3,000, more than two dozen Massachusetts psychiatrists, endocrinologists, and other specialists who gave frequent talks brought in $40,000 to $100,000 and, in a few cases, more. Dr. Lawrence DuBuske, an allergy specialist, earned the most: $219,775. The Globe reported earlier this year that he resigned from Brigham and Women’s Hospital largely because of its new speaking ban.
Partners HealthCare, which includes the Brigham and Massachusetts General and McLean hospitals, halted their doctors’ promotional speaking appearances in January because of concern that they could be perceived as company salespeople and were helping to drive up use of expensive drugs.
Dr. Brent Forester, a geriatric psychiatrist at McLean, was one of the Massachusetts physicians paid the most last year, when he made $73,100 for giving nearly 40 talks for Eli Lilly to colleagues about the antipsychotic Zyprexa and the antidepressant Cymbalta over dinners in restaurants and in doctors offices. He has resigned from speakers bureaus to comply with the new rules, but said he “never felt like a spokesperson for the company at all.’’
“It was an opportunity to educate primary-care doctors about the treatment of psychiatric conditions,’’ Forester said.
Christopher Clark, who oversees compliance for Partners, said his staff searched drug company websites and identified 31 of its physicians who had been hired for speakers bureaus. All but two agreed to resign from the bureaus.
Harvard Medical School itself is also prohibiting participation in speakers bureaus, effective early next year. Consulting payments will still be allowed, with certain restrictions, but will have to be disclosed to Harvard, which has been under pressure from Senator Charles Grassley of Iowa to better monitor its faculty’s relationships with industry.
“We must ensure the integrity and objectivity of all our activities,’’ said Gretchen Brodnicki, the medical school’s dean for faculty research and integrity, who added that the Harvard faculty is huge, about 24 percent of the state’s doctors.
The data on physician payments was compiled from the websites of Eli Lilly,
Companies reported paying about 470 Massachusetts doctors, about 200 of them Harvard faculty, a small percentage of the physicians statewide and of those affiliated with the university.
Most drug companies, however, have not publicly reported payments. The ones that have posted the information report different types of payments for different time periods, so it is not possible to draw definitive conclusions about how many doctors received payments and how much individual doctors earned.
Massachusetts is preparing its own more complete report of payments to the state’s physicians by drug and medical-device companies, as required by a 2008 law, but it is not slated to be released until later this year.
The ProPublica-Globe analysis shows that companies reported paying numerous doctors at Beth Israel Deaconess Medical Center and Boston Medical Center, despite hospital policies saying physicians cannot be paid speakers unless they control the content of the talks.
One of those physicians, Dr. Amjad Almahameed, a cardiologist at Beth Israel Deaconess and a Harvard instructor, was reported to have earned the third most among Massachusetts doctors, taking in $125,600 from GlaxoSmithKline. Almahameed declined to comment. Hospital spokesman Jerry Berger acknowledged that the doctor “may have given talks that were not in compliance,’’ but that he resigned from speakers bureaus in August.
Dr. Thomas Moore, associate provost for the Boston University medical campus, said the school is still reviewing doctors’ speaking engagements. But, he said, at least one doctor who spoke about doctor-patient relationships for Merck made up her own slides, and even though the company reviewed them, the school determined she controlled the material.
Both hospitals said they are improving their oversight.
The growing number of hospitals and medical schools tightening their rules on payments to physicians means that many psychiatrists, neurologists, endocrinologists, cardiologists, and oncologists stand to lose tens of thousands of dollars in income, money they said they used for mortgages and children’s college education and braces.
Dr. Andrew Kowal, director of the pain clinic at Lahey Clinic and a critic of the overuse of opiates, earned $105,115 for giving dozens of talks, mostly about Lilly’s Cymbalta and Pfizer’s Lyrica for fibromyalgia and painful diabetic neuropathy.
“I usually go out to the boonies where doctors wear cowboy hats and cowboy boots and carry guns,’’ said Kowal. “I go out to Arkansas where all this started [opiate addiction], and these doctors come out to hear me speak. It’s a big deal for them. . . . If I can save one kid from getting hooked on opiates, then I’ve done my job.’’
He vowed to continue speaking for free, after Lahey Clinic recently barred its doctors from joining speakers bureaus.
Aside from Almahameed, DuBuske, and Kowal, the other reported top earners in Massachusetts were Dr. Stanley Nasraway, director of the surgical intensive-care unit at Tufts Medical Center, who earned $141,209; and Dr. Tamer Yacoub, an endocrinologist in Fall River, who made $109,658.
Most doctors said they were approached by the companies, usually by sales representatives, to join speakers bureaus. At first, doctors said they created their own presentations. Now, companies generally make them, and they are reviewed by the US Food and Drug Administration.
“We used to be able to change the order of the company’s slides, hide others, and even include some of our own,’’ said Dr. Om Ganda, a Harvard professor who sees patients at the Joslin Diabetes Center and earned $67,887 speaking for AstraZeneca, Merck, and GlaxoSmithKline about diabetes drugs. “Now very little of that is allowed. The FDA did this for one reason: A lot of times the slides did not include enough safety information or information about competing drugs.’’
Even though the evidence is “overwhelming that diet and weight loss and other lifestyle changes far outweigh any drug’’ in preventing and treating diabetes, Ganda said, he speaks for companies about their drugs because “I always like to slip in a few words about lifestyle.’’ Ganda plans to resign from speakers bureaus to comply with the new Harvard rules.
Other physicians said they will not be deterred from what they consider a legitimate form of educating colleagues.
Nasraway, who is a national expert on sepsis, said he resigned from Lilly’s speakers bureau because he felt pressure from a salesperson to imply that Xigris, the company’s sepsis drug, could benefit a wider array of patients than were tested in clinical trials. A Lilly spokesman said that the company was not aware of this particular issue, but that it continues to improve compliance with FDA marketing rules.
Now, Nasraway gives talks, at least 50 a year, for GlaxoSmithKline and Pfizer about medicines to treat drug-resistant staph infections; Tufts’ new policy says doctors do not have to control the content of talks, they just have to agree with it.
“This is not tobacco,’’ Nasraway said. “These are the guys who created penicillin.’’
Columbia’s Appelbaum said that without Harvard doctors in the mix, companies probably will turn to more nonacademic physicians in Massachusetts to talk about their drugs, but will carefully monitor “whether they can still fill the room.’’
DuBuske said he is still packing them in, ever after leaving the Brigham and Harvard. “It’s not like after being there for 30 years, I suddenly got stupid,’’ he said.
Eric Campbell, a researcher at Mass. General who specializes in conflicts of interest in medicine, said restrictions on payments to doctors will work only if hospitals and medical schools enforce them.
Brodnicki, of Harvard, said the medical school plans to rigorously monitor compliance with its new policies, including reviewing all public databases of payments to doctors, and require mandatory online training for all faculty, as will Partners.
“We’ve gotten some pushback from doctors,’’ said Clark, the Partners compliance chief, “but most have said, ‘We know the world has changed.’ ’’
Liz Kowalczyk can be reached at firstname.lastname@example.org.