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JEROME P. KASSIRER

How drug lobbyists influence doctors

CONGRESS IS in a stew over lobbyists' influence on political decision-making. The Abramoff fallout is likely to strike many who participated in the money-for-favors game, yet all the churning around is unlikely to yield any long-term effect. The reason? There are hundreds of well-heeled businesses and groups with a large and expensive wish list. The predecessor to illegal behavior is the undue influence of financial deals that create tension between the legal and ethical duty of a legislator to his constituents on the one hand and to his own personal interests on the other. When we learned about flagrantly illegal activities by certain lobbyists, many acted with surprise. Why should they have been surprised? Money begets influence, influence corrupts, and corruption can cross the line into crime.

But I write not about politicians (plenty of people are doing that already), but about similar corruptive influences in medicine. While lobbying groups spend about $2 billion to convince politicians to do their bidding, pharmaceutical companies spend nearly 10 times that much to influence the nation's 600,000 to 700,000 physicians to prescribe the newest and most expensive drugs. I imagine that many people who regularly watch television assume that the companies are spending most of their advertising budget to influence consumers, but no. Nearly 85-90 percent is spent on doctors, for free drug samples, speaker's fees, consultation fees, and ''educational" grants.

The settlement of the $185 million class action lawsuit against Bristol-Myers Squibb announced at the end of January is a lesson in how physicians paid by the pharmaceutical companies as speakers and consultants can be hazardous to your health. While most of the attention of this suit focuses on how company officials defrauded investors by overly flamboyant predictions for the sales of the highly touted ''blockbuster" drug Vanlev, documents prepared for the suit show that behind the scenes, Bristol-Myers Squibb-paid physicians in major medical meetings were shamelessly exaggerating the benefits of the drug for patients with high blood pressure and heart failure and failing to report publicly on substantial numbers of life-threatening drug complications which they knew, from their close relationship to the company, to exist.

Fortunately, the FDA saved hypertensive and cardiac patients from ever receiving Vanlev because it knew about the potentially fatal events, determined that they were excessive, and Bristol-Myers Squibb was eventually forced to withdraw its application to market the drug. A real save by the FDA!

The BMS settlement exposed a well-hidden method of influencing doctors. The biased talks were given in ''symposia" at major national medical meetings of major medical organizations such as the American Society of Hypertension and the American College of Cardiology. Symposia, little known to the public, are special events, usually lectures by leaders in the field, sponsored by drug and device companies and typically held in the morning before the official program or in the evening following the day's usual program. Nice snacks and drinks are often served and sometimes dinner also. As hard as they try to be objective, the speakers' financial ties to the industry often create subtle (or even overt) biases that induce them, either consciously or subconsciously, to adhere to the company line. From the experience with Vioxx, we learned that if they stray from the company's message, they may not last long as a paid speaker. (For perspective, the preliminary program of the American Psychiatric Association's June 2006 meeting in Toronto features at least 46 such symposia, sponsored by the major companies that make the drugs that psychiatrists prescribe.) What the APA gets for this collaboration with industry and what industry gets in return is not public knowledge.

The Senate Finance Committee is aware that the industry is using ''educational grants" to prominent physicians to influence the drugs that doctors prescribe. It is difficult enough to get reliable data on drug benefits and risks from industry-supported studies, but when physicians and physicians organizations, who should know better, knowingly exaggerate the efficacy of new drugs and underplay their complications, the consequences for the health of the public and individuals like you and me are too close for comfort. Lobbyists influence how the government spends your money, but financially conflicted physicians can threaten your well-being.

It's about time that pharmaceutical companies cut back on their massive campaign to influence doctors and to use paid ''experts" to influence other doctors. It's about time physicians, academic medical centers, and professional medical organizations wean themselves away from the deep pockets of companies whose principal goal is not education but marketing.

Dr. Jerome P. Kassirer, a distinguished professor at Tufts University School of Medicine, is author of ''On The Take: How Medicine's Complicity With Big Business Can Endanger Your Health."

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