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Should you be worried if your doctor is on Big Pharma's payroll?

Pharm League

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The time-honored relationship between the drug rep and the doctor dates back decades. In the old days, a representative of the pharmaceutical industry would simply pay a visit to a doctor's office, bearing gifts: sandwiches, samples of Paxil, brochures, and in the headier days of "doctor detailing" — that's what industry calls these visits — tickets to professional sporting events and all-expense-paid tropical vacations. The drug reps are often young, attractive, scrubbed, well-coiffed and intensely personable, and as long as they don't come right out and ask the doctor to prescribe more of a certain drug so they can meet their quota, they remain welcome guests in most offices.

But over the course of the last decade or so, this awkward, ritualized dance has grown more complex — and for Big Pharma, far more effective.

Armed with literally billions of dollars in its PR war chest, the pharmaceutical industry has had an epiphany: Who's the best person to convey a marketing message to a doctor? The answer's easy: another doctor. After all, a drug rep has a flashing neon sign of a motive, and that is to secure prescriptions. But a doctor? An M.D. is concerned only with the disease and the means to treat the patient. For drug companies with the aforementioned means, that's more than enough.

We've never really known, in a monetary sense, just what the doctor-drug industry relationship entails — except that it includes money and, in some cases, lots of it. But over the course of the past year or so, seven of the world's biggest pharmaceutical companies have begun disclosing what they pay your doctor to consult and speak for them before gatherings of other physicians in hospitals, tony hotels and pricey restaurants. A provision of the health care reform bill (unless it's repealed) will require the entire industry to disclose their financial ties to our doctors by 2013.

ProPublica, a nonprofit organization dedicated to investigative journalism, didn't want to wait that long. Recently, the watchdog group assembled a searchable database combining the disclosures of the companies and linking them to individual doctors. For the first time, patients can search their doctors' names and find out which companies pay them and how much.

Before you pat the drug companies on the back for their laudable transparency, it's worth noting that collectively they've paid out more than $6 billion in settlements over the past few years — or about 20 percent of Tennessee's fiscal year 2011 budget — to avoid federal criminal prosecution. In nearly every case, it was found that the companies were paying doctors to promote non-FDA-approved, off-label uses for their drugs — a surefire way to boost market share and sales.

As part of their settlements, Pfizer, Merck, Eli Lilly, Johnson & Johnson, AstraZeneca, Cephalon and GlaxoSmithKline are now required to disclose payments made to physicians. Only three of the seven — Merck, Glaxo and AstraZeneca — had previous plans to begin disclosing this information. Regardless how it came to light, though, the information assembled by ProPublica makes for an illuminating document.

From the database — which covers 2009 and some of 2010, depending on the company — ProPublica culled 43 doctors who'd made $200,000 or more in the available disclosures. Perhaps it shouldn't be surprising that Tennessee had the most physicians on the list, with five topping the $200K mark.

Nor should it be surprising, perhaps, that three of those came from the Medical Mecca of the South, Nashville — where one in every 12 occupations is a health care job.

Of course, these disclosures represent but a slice of the pharmaceutical pie. And the numbers available depict just a year-and-a half snapshot. With some of the disclosures it's less. Nor does the list include pharmaceutical payments to nurse practitioners and physicians' assistants, or to doctors who speak at continuing medical education events sponsored by medical education companies — which are funded almost entirely by the pharmaceutical industry.

This is merely the tip of the iceberg. A New England Journal of Medicine article estimated that 94 percent of doctors have received some token of Big Pharma's esteem, whether it's a free lunch or payment for enrolling their patients in clinical trials, while nearly 30 percent have regular speaking and consulting gigs. Nevertheless, the very availability of the information is unprecedented.

So the Scene culled eight of the highest-paid Nashville doctors from the database. According to industry disclosures, they made anywhere from just above $40,000 to $240,000 during 2009 and 2010. Out of an abundance of caution, the Scene went to the source documents to double-check ProPublica's numbers. The companies don't make it easy: Sometimes last names are listed first; sometimes first names are listed first. Sometimes the name of the doctor's private practice is listed first.

But if anything, our doctors' ProPublica figures were low. Recently released Eli Lilly disclosures from the second quarter of 2010 available on the company's website hadn't been added to the database, giving a few of the doctors a significant bump.

In terms of credentials, these doctors run the gamut. There's the chairman of a local university's psychiatry department. There's a well-published clinician and former Fulbright scholar. And there are a few private-practice docs with no published work and few academic associations to burnish their curricula vitae. The Scene called all of them to discuss their relationships with pharmaceutical companies and the potential conflicts of interest that industry observers say they pose.

Almost half did not respond to repeated messages left for comment. But most of those who did speak with us were candid and forthcoming. Even if indirectly, they painted a vivid picture of the variability among doctors paid by Big Pharma — and how this $300 billion industry touches each and every one of us.

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