Most US neurologists prescribing MS drugs have received pharma industry cash | Nearly 80% of US neurologists prescribing drugs for multiple sclerosis (MS) received at least one pharma industry payment, with higher volume prescribers more likely to be beneficiaries, 5 year study finds

[u/FunnyGamer97]

https://www.eurekalert.org/news-releases/1095648

[u/NinjaLanternShark]

So how much are these docs getting paid?

The average individual amount received was US$779, but 10% of recipients amassed US$155.7 million between them

Holy snot! The average amount is $779 but among the top 10%, the average amount is $268,448!

US$50 was associated with a 10% greater likelihood of prescribing that company’s drugs

OK, this feels like it could be education. Come to a conference, learn about a drug, have a few drinks on us.

US$5000 with a 50% greater likelihood

And that's a kickback.

[u/Relax_Dude_ → u/NinjaLanternShark]

As a physician I can maybe shed some light on this. I'm a pulmonologist, received maybe about $1500 in my lifetime from pharma. None in cash, just lunch and dinners. They might bring lunch for the entire clinic staff or trainees. They might host a dinner session where an expert will speak on the subject while we attend, ask questions, and get a free dinner. It adds up over the years. Lunch might be $20-30 while dinner might be a bit more. It can add up to a few hundred per year and over several years it can certainly add up to the thousands. The ones that are in the tens of thousands or hundreds of thousands are not because they're getting kickbacks for prescribing, it's usually some combination of consulting fees and/or flying them out to give talks. So it's not hard to imagine if theres some renounced expert who strongly believes in the drug would be willing to give educational talks to other neurologists about it. If they get flown out, their travel, hotel, food, and speaking fee will be paid for. That usually amounts to fees in the tens of thousands range over several years. The ones getting 100k+ are most likely to be in the form of research grants or consulting fees. A research grant can easily be 100k for each individual grant. Thats just the reality of things. And while all this seems sketch to outsiders, I think there is some benefit to us attending these dinners and educational sessions. If theres new medications that actually work well and we're interested in prescribing them, we can pick the brains of these experts who are actually using it as well as the manufacturers themselves can guide us on how to get it through insurances. In my field, I was prescribing biologics for asthma. A new one came out a few years ago that I thought was fantastic on paper, could help alot of people for whom the other biologics weren't working. Theres some benefit in attending a dinner to ask them questions about the logics of administration, teaching, insurance coverage, dosing, certain adverse events to look for, etc. And of course for some of the more basic meds like inhalers they often give free samples which we're constantly giving them away to patients, preferably ones that are really tight on budget. I may give them samples to see if a certain inhaler works well for them before making them pay hundreds every month to maintain it. It's easy to say, "doctors are getting their pockets lined by big pharma" and get clicks but the reality is 99% of docs are just ordinary people who genuinely want to learn about the drug while also having a nice dinner with colleagues and de-stress a bit. Theres certainly bad apples out there, but thats the case with anything.

[u/VrachVlad → u/Relax_Dude_]

I'm a physician as well and I agree with everything you've said here. Especially if the Pharma rep buys lunch for the entire office that's going to be $300 per lunch and typically we'd have a rep in once a week. Seeing someone have >$10,000 per year from this is honestly not unusual. The last rep I had was trying to get me to prescribe Xarelto and I was asking a whole bunch of questions about it since Eliquis is substantially better in every single way except it's twice a day dosing and much more expensive. My drug prescribing habits don't change because of these reps in terms of what I will typically reach for. What I will say is that the rep reminding me of a drug being on the market is probably the more instrumental thing that these reps do. Especially the biologics because now there's becoming quite a lot of them.

[u/treehugger100 → u/VrachVlad]

I work in a professional field where accepting lunches/meals like that is considered highly unethical. I’ve never understood why it isn’t considered unethical in healthcare. Also, I’m not going to disagree with you about what you do but it seems highly unlikely, if not impossible, that those meals and reps don’t create bias in prescribing broadly. The companies wouldn’t do it if it didn’t.

[u/thegooddoktorjones → u/treehugger100]

I work in engineering and manufacturing and sales lunches are extremely common, as are informational meetings that are half new product info we need, half sales pitch.

[u/moradinshammer → u/treehugger100]

It was also the playbook of Purdue to hire Drs that prescribed lots of oxy for lucrative speaking gigs.

[u/treehugger100 → u/moradinshammer]

It’s like these doctors defending these practices learned absolutely nothing from that whole disaster.

[u/sapphirebit0 → u/treehugger100]

I agree. Just because it’s been “normalized” doesn’t mean we should accept it.

[u/DigNitty → u/sapphirebit0]

People here are arguing whether it’s entirely unethical or not.

It’s in the middle. Pharma paying for the CE and food of doctors is the current system. That had the benefit of doctors being able to ask questions directly to experts, and the conflict of that expert likely being at least partially biased toward the use of some drugs over others.

[u/DJanomaly → u/treehugger100]

I’ve never understood why it isn’t considered unethical in healthcare.

Because constant updated training is a crucial part of the job.

What field do you work in that that training with food is considered unethical? I work in tech manufacturing and everyone does it all the time. I’m going to a weeks worth of lunches and dinners next week (CEDIA).

[u/treehugger100 → u/DJanomaly]

In my field my employer pays for my food at work related functions out of town. If it’s in town I pay for it just like I would at work.

[u/hexiron → u/treehugger100]

Generally because we get so many free lunches and no one ever listens to their boring sales pitch. All of it gets logged in conflict of interest statement throughout the year, which is why this paper was easily put together.

[u/andy013 → u/hexiron]

So do you think pharma are losing money on all the free lunches they pay for?

[u/hexiron → u/andy013]

It's such a tiny percentage of their budget I doubt they are super worried about ROI. It's not handled at the higher end, it's typically local reps who have it in their budget and need to "work". I'd say about half the time they don't even do sales pitches, they just wear branded clothing and bring some samples or pamphlets and ask questions about what the practice or dept does most.

[u/andy013 → u/hexiron]

Of course they are worried about ROI. Pharma are not charities. They don't spend money unless it makes good business sense to do so. Studies consistently show that it affects prescribing, so they profit from these lunches: https://pubmed.ncbi.nlm.nih.gov/27322350/

Studies also show that doctors do not believe that promotion affects their own prescribing.

[u/hexiron → u/andy013]

That paper does not conclude that their $12-18 paid lunch results in an increase in prescriptions…

[u/andy013 → u/hexiron]

There are many more studies that looked into this:

https://pmc.ncbi.nlm.nih.gov/articles/PMC8315858/

https://news.cornell.edu/stories/2020/02/after-free-lunch-drug-firms-doctors-increase-prescriptions

https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1000352

https://bmjopen.bmj.com/content/7/9/e016408

Many doctors believe they are not influenced by small gestures like free lunch. But even small gifts can create a sense of reciprocity or obligation, which can subconsciously influence behaviour. See: https://onlinelibrary.wiley.com/doi/abs/10.1111/jlme.12076

[u/hexiron → u/andy013]

The major limitation still remains and is discussed in all of these studies - the lack of causality.

The cross-sectional design of most included studies allows for the possibility that some of the observed payment-prescribing association may be accounted for by manufacturers targeting payments to physicians who are already high prescribers, or potentially by other mechanisms.

This issue came up in the most recent review article you posted which also cited many studies that failed to show causality or correlation.

[u/treehugger100 → u/[deleted]]

Because maybe that patient could benefit equally or more from a generic or lower cost medication (maybe even no medication but another approach) that would treat that persons condition effectively but the bias you admit is happening in this situation is coloring your viewpoint and leading to you not selecting those other options. Not only could that patient have received effective care otherwise but prescribing more expensive medications that are not needed to provide the best care drive up the costs of healthcare.

I’m not going to even go into that newer medications also don’t have the longevity of use to fully understand all the unintended side effects that may occur with potential dire consequences for patients.

The best way to avoid this is just stop this whole situation from being allowed as other countries have done. The vast majority of people like to think they are objective and are doing the best job they can. I expect you and the others in this post defending this practice feel that way but that doesn’t make it true. I believe doctors are humans that are impacted by the same psychological processes we all are including recency bias among others.

Anyway, I doubt I’ve changed your mind and you aren’t going to change mine. Have a good day!

[u/thinkbetterofu → u/treehugger100]

im glad it strikes you as weird that doctors are literally commenting "yeah we take bribes but its totally fine because im asking REPS FROM THE DRUG COMPANIES ABOUT THE DRUGS AS IF THOSE EMPLOYEES ARE NOT BIASED"

like HELLO?

[u/WillSupport4Food → u/thinkbetterofu]

Calling free lunch a bribe seems a bit intellectually dishonest. Doctors are still beholden to their licensing boards and ethical oversight so implying that they'd all compromise their standard of care for a $20 meal from Chipotle is a little insulting. Not saying it doesn't happen, but it's far cry from pharmaceutical companies sliding a doctor a big bag of money with a dollar sign on it like laypeople often portray it. If your employer pays for your lunch during a company meeting would you also consider these a bribe?

Continuing education is a vital part of medicine so that you don't end up with doctors who graduated 30 years ago and never updated their practices in that time. If a new treatment comes out, doctors in the field need to update their knowledge on that treatment. That generally requires taking time off work or traveling to where the lecture is held. All of that costs money and often times either your workplace or the host of the lecture will cover some or all of the associated fees. Otherwise you get into the situation where people don't want to/can't afford to take time off work to travel to these continuing education lectures.

[u/sneakypiiiig → u/WillSupport4Food]

Just because the continuing education of the field is wrapped up in the corruption doesn’t justify the situation. That’s insane. It seems like the perfect situation for a predatory pharma company to snake their way into to justify their bribes. And we’re not just talking about one lunch, obviously.

[u/WillSupport4Food → u/sneakypiiiig]

For continuing education credits to be considered valid they generally need to be approved by an independent third party associated with your licensing board so it's not like these are just random sales reps giving misleading/overly biased lectures.

The fact of the matter is experts in their field don't just take weeks off work to lecture everyone in their field every time there's a new treatment option. Literally no matter how you format the system, unless you force experts to provide their consultation for free, someone will be getting paid for CE.

The entire argument here boils down to people not trusting that doctors can make unbiased conclusions about new research just because someone paid for their lunch or their plane ticket to a lecture they took off work to see. Which at that point if you have so little faith in their scientific integrity or objectivity, no system will fix that because it's the doctors themselves you don't trust.

[u/treehugger100 → u/WillSupport4Food]

It’s like you are ignoring that doctors are people. People are influenced by the activities that you are describing. It’s like you guys were never taught human psychology.

[u/WillSupport4Food → u/treehugger100]

Doctors are people and people are fallible. But being trained to recognize bias and critically evaluate new information is something doctors are explicitly trained to do. As a veterinarian I had multiple courses exclusively about recognizing sources of bias in scientific literature, common flaws in methodology, and how to form your own professional opinion. That doesn't mean doctors are magically absolved of biases, but I'd argue that's a lot more training in recognizing and mitigating bias than non-medical professionals considering their continued licensing and likely sole source of income depends on it.

When the consequence for not doing your due diligence and recognizing conscious or unconscious biases is potentially killing someone and/or destroying your career, schools tend to place great emphasis on teaching you how to mitigate those biases and think critically about new information.

The system isn't perfect as I mentioned in a different comment. In a perfect world, an independent third party would review all new treatments and medications, all research would be funded independently, and experts in the field would present that info to practitioners free of charge and in convenient locations/times. But we don't live in that world and experts and researchers in their fields rarely work for free

[u/treehugger100 → u/WillSupport4Food]

Thank you for your response. Considering the volume of repeated problems with doctors not doing their due diligence when prescribing the training you describe isn’t leading to impact at the level that would happen in a decently well functioning system.

I don’t expect a perfect world but I want a healthcare system not driven by pharmaceutical company profits. Other countries don’t allow this and I think the US should ban it as well.

[u/Rikula → u/sneakypiiiig]

As a social worker, our continuing education that we are allowed to receive in our hospital is usually tied to food as well. We can get education without food, but there is usually less attendance since the CEUs happen during lunch breaks. Local companies will sponsor/provide the lunch while someone separate provides the education.

[u/happyflappypancakes → u/thinkbetterofu]

Well the answers are backed up by whatever studies they have performed. Its up to the listener to determine if the evidence is worth it. These are huge trials produce most of the high quality studies that we use in medicine to drive new standards of practice.

[u/babige → u/happyflappypancakes]

Sure like all those negative cigarette studies and Teflon studies that were buried by the companies, and the favorable ones shown to the world.

[u/happyflappypancakes → u/babige]

Well the quality is there in the study. You just have to look. You can usually tell if one is dubious.

[u/treehugger100 → u/happyflappypancakes]

And yet many in this thread are basically saying they don’t have time to read the studies and get the information they need from the company reps.

[u/son_et_lumiere → u/treehugger100]

What the reps can and cannot say is highly regulated.

[u/treehugger100 → u/son_et_lumiere]

And regulations are always followed I’m sure.

[u/thinkbetterofu → u/VrachVlad]

so, you, as a doctor, would be totally comfortable telling any patient you are prescribing a drug for, a full disclosure that you had previously entertained these outings, dinners, or paid speaking events, or trips, from the pharma companies of the drug you are prescribing?

[u/WillSupport4Food → u/thinkbetterofu]

As a veterinarian, sure. Except since you're intentionally phrasing it in a certain way, I'll give my rephrasing. I'd be totally fine telling a client that I recently went to a lecture hosted by the drug manufacturers where they had an expert in the field explain the studies done with the drug and what the results of that were.

People love to call out the funding for these studies and lectures as some sort of gotcha moment like it's a big red flag that a company is funding the study of their own drug, but the reality is if they didn't it's likely no one would and then no one would find out about or use any new treatments or medications. It would be awesome if we had an independent federal agency that conducted research on new treatments in a timely manner, but we don't and probably won't for the foreseeable future.

[u/andy013 → u/WillSupport4Food]

It is a big red flag. Opioid manufacturers funded studies that downplayed risks of addiction. Then they flew "experts" around to spread their propaganda. The fact that so many people are okay with this just goes to show how ignorant they are of the consequences. People died because they were prescribed these drugs inappropriately after their doctor had been "educated". We must have fully independent research and fully independent dissemination of that research. Allowing these companies to design the testing of their own products and then market them heavily to doctors under the guise of education is a disaster. This is why people don't trust medicine, because it doesn't deserve their trust.

[u/Avoiding_Involvement → u/andy013]

Then what solution do you have to fund the literal billions of dollars it costs to produce new drugs and get it past all the necessary clinical trials to get to producers? Nobody is going to pay out of pocket to fund a study on their own requiring years of regulation navigation, lab tests, patient recruitment, etc.

[u/thinkbetterofu → u/Avoiding_Involvement]

universal pharmaceutical development

no more completely fucked pharma pipeline

no more shell companies and startups doing testing in countries where life can be bought cheaper

shut the whole thing down

[u/Avoiding_Involvement → u/thinkbetterofu]

Let me know when that fantasy becomes a reality

[u/reality_boy → u/Relax_Dude_]

I worked at a medical startup making equipment. Reps use to show up with pizza and an expensive piece of hardware they wanted to sell us. It always amazed me how extremely effective this was. Our engineer would usually have the new part on the machine by the time they left for the day.

I agree completely that lunch is not a bribe, and it is very normal. But I feel it is also very influential. This is a very small part of the whole, but we should limit the influence reps have over the system.

[u/ycaivrp → u/reality_boy]

Honestly, They can ban everything. I don't need their pen or their lunches. The lunches are always greasy anyways.

[u/TeleHo → u/Relax_Dude_]

From what I understand, a ton of DMTs for MS came out in 2019-2020 (though someone can correct me if I'm wrong). Could it also be that neurologists are receiving larger consulting payments/research grants/etc. because the drugs are new enough that there's a lot of new research/information to be shared?

[u/LocoForChocoPuffs → u/Relax_Dude_]

I do hope you rely on renowned experts rather than renounced ones.

[u/MrHobodeluxe → u/Relax_Dude_]

Great reply. I work in pharma development. Skepticism and mistrust are definitely understandable when folks haven't been exposed to the realities certain professions experience. It is difficult for people to understand how much things actually cost and why when they've never had any involvement. And to be fair, there are a lot of bad actors out there exacerbating mistrust.

[u/thinkbetterofu → u/Relax_Dude_]

so, you, as a doctor, would be totally comfortable telling any patient you are prescribing a drug for, a full disclosure that you had previously entertained these outings, dinners, or paid speaking events, or trips, from the pharma companies of the drug you are prescribing?

[u/ycaivrp → u/thinkbetterofu]

I actually have. I said, I recently saw a presentation by the company. The data is impressive, and I had seen many real life patients with impressive results since. It could work for you since none of the other drugs out there is working for you. Do u want to give it a try

[u/thinkbetterofu → u/ycaivrp]

From your wording it sounds like you deliberately chose to not disclose that the company had comped meals?

[u/ycaivrp → u/thinkbetterofu]

There was no meals. No pen. I guess in my entire medical career. I prob ate 50 dollars worth of food from drug reps, but honestly, I don't like their food and don't eat their food.

[u/Relax_Dude_ → u/thinkbetterofu]

I wouldn't mind a but i would need the time to explain all yhe above which would add another 10 min of back and fourth discussion which there isn't time for.  And fyi, all of these "payments' including food or whatever are all publically available information.  You can look up any individual, institution, or company and see who is paying who for what purpose down to the exact date. 

I also want to say there is often a preconceived bias favorable to the drug before a doctor attends the event.  For example I went to a Tezpire dinner because I wanted to prescribe it.  I'm sure neurologists are going to dinners of these new MS drugs because they are already interested in it.  I think this part gets completely missed is these discussions.   

[u/pswissler → u/Relax_Dude_]

I understand what you're saying here but in my job (professor at a public university) we're not even technically allowed to take free swag from suppliers at conferences due to the perceived conflict of interest it would result in. Honeraria for talks given is common but it's the sort of things we need to report to our ethics office.

When I worked in industry these sort of supplier lunches were more common, but the fundamental difference is that any induced bias started and ended internally, rather than propagating outward to the public at large. 

"Everyone does it so it's not a big deal" is a poor argument and can only serve to erode trust in your profession. The fact that you acknowledge that it would require a detailed discussion with patients shows that you recognize this. I understand that entrenched field standards are difficult to change (especially since the status quo results in some nice perks for those in the field), but it's something that your field needs to start recognizing as a problem.

[u/Relax_Dude_ → u/pswissler]

I totally understand but I also don't want to give into popular opinion if I strongly believe it's just wrong. All I really care about is my relationship and trust with my patients which I feel like I have. I know for a fact that I only make decisions with my patient's best interest in mind, and they know I go above and beyond for them. And if we're on the subject of erosion of trust in doctors, I would say a much larger percentage of that has to do with social media misinformation for clicks and it has to do with doctors not explaining their decision making or having the time to do so. Maybe 30 years ago if a doc told you to take this medication for your blood pressure, you'd take it no questions asked. Nowadays you have to explain what hypertension is, the consequences of untreated hypertension, what the drug does, less common side effects, etc. Theres nothing wrong with that but its often a time issue. Example: I had a friend's mom tell me the other day that her pulmonologist put her on an antibiotic to take long term. She feels like she doesn't have an infection and her sisters daughter is a nurse and told her she should never take long term antibiotics because it builds resistance and that that doctor didn't know what he was doing. She felt better when she was taking it but then stopped because of her nurse friend. So now they dont trust their doc and dont know what to do. I saw her med list and it was azithromycin 3x per week, it was for bronchiectasis. I explained to her that this is a perfectly good treatment, I explained why and how it works, and told her I would've done the same. I told her she should also be on certain other breathing treatments. She told me she was already on them. What I advised was exactly the same as what that pulmonologist advised. In one interaction theres mistrust, in the other interaction theres trust and comfort. I think those things factor more into mistrust than this idea that doctors are getting kickbacks, which btw are illegal and can get your medical license taken away.

[u/ycaivrp → u/Relax_Dude_]

Ugh new MS treatments are amazing.

[u/gearpitch → u/thinkbetterofu]

Probably not, because people are too stupid to think critically and see the nuance of medical education. Doctors don't prescribe drugs they don't learn about, and that's almost entirely through company outreach. Patients are emotional and reactive, and would reject most medicine as sounding like a bribe. Aka like this study. 

[u/Ifch317 → u/Relax_Dude_]

Pharma often brings those "prescriber experts" in to talk about off-label uses of a drug because their own marketing teams are not allowed to discuss anything other than what is in the approved labeling for the drug. This another physician can be brought to speak to peers about using the drug for disease states the drug is not labeled for or at doses above what is approved. This can significantly grow the use of a drug that was initially approved for a limited indication and at low/well tolerated doses.

Using this strategy, Pharma can get a drug labeled at a low well tolerated dose, package that drug for that low dose, then sell twice as much drug by encouraging prescribers to use double the max labeled dose (example: Zyprexa initially labeled for 10 mg/d max dose then routinely prescribed at 20 mg/d).

[u/somehugefrigginguy → u/Ifch317]

Pharma often brings those "prescriber experts" in to talk about off-label uses of a drug because their own marketing teams are not allowed to discuss anything other than what is in the approved labeling for the drug.

This isn't true. Whether they're the pharma marketing team, or an independent expert paid by the pharma company, they are legally prohibited from discussing off label use. Some experts may be doing it, but it's not the workaround you're implying it to be.

[u/jnkmail11 → u/Relax_Dude_]

Thanks for the perspective. Is there really not a more cost effective way though? I imagine the same 10 questions get asked most of the time anyway and will doctors really not prescribe a new medicine if it doesn't come with a dinner?

[u/Relax_Dude_ → u/jnkmail11]

We absolutely will but sometimes we just dont know about it because it's so new. I'll give you specific examples if it helps. The biologic I was referring to earlier was Tezpire. Each of the biologics are managed so differently and have different protocols. It's just way easier to ask an expert all of my questions, how do I dose, what criteria do I have to meet for medicare to cover it? medicaid? do I ramp up dose, what labs do I routinely check, risk of anaphylaxis - enough to warrant in-clinic administration, can it be self administered, etc. I'll give you more examples of things I learn from pharm reps. Trelegy was the first triple-therapy single inhaler. Breztri came out a few years later as the second triple therapy inhaler. I actually didn't know about it until a Breztri rep came. I mostly continued to use Trelegy due to familiarity and the fact that alot of my patients had copd and asthma overlap and Trelegy is only approved for asthma, but I will admit I prefer to prescribe the Breztri MDI delivery as opposed to the Trelegy dry powder. Many years ago it was the Xarelto reps that brought to my attention the new data on xarelto in cancer related DVT and dvt prophylaxis. And while I had read about the data on heart and vascular disease, they were able to elaborate on that. I actually still have never prescribed it for heart or vascular disease but it's good to know. I think my most recent educational dinner was Ion bronchoscopy. It's something I had started doing and was already interested in learning, they organized a dinner and connected me to a local guy that does it. I've already seen it in action and read plenty about it. But it's nice to have a review from an experienced guy going through everything top to bottom that I can pick his brain on because reality is not always reflected in studies. But theres still plenty of new inhalers that I have prescribed that I learn on my own - Airsupra might be the most recent example. I honestly dont even pay attention to which company's own which drugs, I get them mixed up all the time. I've also gotten many lunches from the makers of Avycaz, great drug to have in the hospital but I dont think I've ever used it without either an infectious disease doc recommending it or a good discussion with our antimicrobial pharmacist.

[u/peanutneedsexercise → u/jnkmail11]

I just finished residency and we had these lunches a lot in pain clinic. It’s mostly for the office and honestly, I really liked asked hard questions to watch the opioid reps squirm especially after everything that happened after the opioid crisis, and also since we’re a non opioid prescribing clinic but they still try I guess! Free food ftw tho

[u/MerkDoctor → u/jnkmail11]

There is some practical benefit as well. As much as people would like to think their doctors know everything about anything medicine, life just doesn't work that way. So in a lot of cases learning about new diseases or medications come from seemingly random things. An email from administration one day mentioning the rise of X illness so watch out for Y signs, CDC updates (probably worth a lot less as of this year and going forward), these lunches/dinners explaining new medications/updating info about old ones. It in a way helps keep everyone more informed, even if it's not as perfect as just knowing everything out of school.

Personally I went to a dinner a couple weeks ago for wegovy. I've been prescribing it and ozempic and the like prior to that dinner because I understood the mechanism of the drug and the impact it had on patients, but after going to the dinner I have a much better understanding of the risk to benefits, insurance coverages, and state of research on the drug and as a result I'm much more informed going forward, which benefits all of my patients.

[u/TSMO_Triforce → u/Relax_Dude_]

Its corruption. "Thats just the reality of things" is a nonstatement. Recieving any kind of compensation to listen to a sales talk when you deal with peoples health and lives is dangerous. It makes doctors more likely to prescribe a drug from a company that gave them a free meal than one that didnt. Its easy to say that its not much and just adds up over time, but that doesnt change that it is still bribery.

[u/thedukeofwhalez → u/Relax_Dude_]

I appreciate your perspective Doc, and you did bring a lot into perspective for me. But as a pharmacist who then has to deal with the hellscape physicians have caused with their over indulgence in the Pharma industry, you dont need to worry about the special bits that stir you towards prescribing it. Pharmacists can help you. We are part of your team. We are in the same buildings as you and are only a phone call away. We can help. Pharma doesnt need to help you with better understandings. You dont need to be given the value of thousands to trip out and dine fine to learn more about the product. Especially when all of those thousands come from the patients whose copay is $500+ because it wasn't actually fully covered, and continually makes the Pharmaceutical industry a butt load of pure cash profit. A pharmacist can happily help you and our patients will only get better.

[u/sticklebat → u/thedukeofwhalez]

You're speaking as if all (or even most) doctors have in-house pharmacists that they can go to, which is simply not the case. You're also speaking as if all those pharmacists are experts in all pharmaceuticals, even obscure and new and novel ones, which is also not the case. You're also speaking as if all pharmacists have the time to spend educating every doctor around them on all their questions, which is not the case. Sure, there are major clinics and hospitals that might have those resources, but that hardly covers all doctors.

Also, yes, pharmaceuticals definitely market their drugs to doctors to try to get them to prescribe them more, and some of that is definitely not in the best interests of patients. But most major pharmaceutical companies also employ pharmacists whose jobs are to educate doctors on their drugs (and these pharmacists usually specialize in a narrow range of drugs), including when and when not to use them. Yes, the pharmaceuticals are incentivized to do this, because they make money when doctors prescribe their medications and doctors won't prescribe medications they don't know about or understand. But patients also often benefit, because it helps doctors become aware of new treatments and also to understand how and when to use them appropriately.

Maybe some of those pharmacists are dishonest and simply trying to promote sales, I don't know. But a good friend of mine has been doing this for almost twenty years for one of the biggest pharmaceutical companies in the world and that is not the impression I get from how she described her job. Her job is to keep up to date with all the literature on the small handful of drugs to which she is assigned, to run information sessions for doctors around her region – usually by visiting clinics and hospitals, since doctors aren't known for having lots of time to travel, or often remotely after covid; and to be available to help individual doctors with specific questions and cases as they arise. She isn't a salesperson, she's not paid based on how well the drugs sell but on ratings from doctors on how helpful she is. Her job is to be the person who knows what there is to know, so that doctors can easily find the answers or be pointed to them without having to dig through reams of literature themselves or recruit a friendly neighborhood pharmacist to do it for them. And according to her, the result of her interactions with doctors is usually "this drug is not a good fit for your patient."

I guess TL;DR often time the people doctors are interacting with at pharmaceutical companies are pharmacists. Pharmacists who know more about the drugs in question than anyone else...

[u/Constant_Natural3304 → u/sticklebat]

If this is normal, why is are these practices so much more prevalent in the U.S. than in other Western nations?

Is it because the U.S. is superior?

[u/sticklebat → u/Constant_Natural3304]

I don't even know if the premise of your argument is true or not, so I'm not sure what you want from me.

[u/thewooba → u/Constant_Natural3304]

Superior in what way? Bit of an odd question

[u/Relax_Dude_ → u/thedukeofwhalez]

While I have an amazing relationship with our inpatient pharmacy, I have mostly had bad interactions with outpatient pharmacists. I have not found them to be helpful for the most part. I dont know if its a CYA thing or what. Also, no one flies out random physicians for thousands of dollars just to learn about a product like you're implying. I'm surprised you're really that much opposed to a $50 educational dinner talk, which is usually given by a well known physician in the community and not the pharm themselves. We often know each other personally. Implying that a physician is nefariously taking money in exchange for prescribing a med is like saying a retail pharmacist is making decisions for the good of the retail company and not the patient. Is that true too?

[u/jsfuller13 → u/thedukeofwhalez]

I have done cognitive assessments on a good number of people who have been harmed by the prescribing habits of physicians. Certainly not all physicians, but I've seen enough to argue that we should be extremely cautious about particular classes of medications and ready to discuss prescribing practices. The number of potentially problematic prescriptions according to the Beers criteria that I find is concerning. The flagrantly irresponsible prescriptions are frankly upsetting.

Furthermore, we know how programs like this work psychologically (Not my area of expertise, but happy to pull sources). Large payoffs tend to be less effective for long-term behavior change. This sort of seemingly trivial exchange is nefarious and well-targeted to change prescribing behaviors. These practices by pharma should be illegal.

[u/silentbargain → u/jsfuller13]

Thank you for your words- they need to be seen by others. You are absolutely correct about the dangers being fostered by overprescription.

[u/Relax_Dude_ → u/jsfuller13]

In my opinion, Beers list compliance might be the worst criteria to use to judge physicians. Firstly its not an absolutely contraindication to prescribe those drugs, they are to be used with caution. Second, the list is so extensive, there are MANY conditions that are impossible to treat without violating the beers list.

[u/jsfuller13 → u/Relax_Dude_]

The criteria include recommendations along several lines, with varying levels of evidence and strength of recommendation. I feel comfortable with patients being prescribed medications on the list. In my capacity I tend to reach for the list as support when I see clear evidence of bad behavior by prescribers. Last week I wrote up an assessment for a patient prescribed a high dose of an opioid that had been prescribed for 20+ years, a high dose of gabapentin, a benzodiazepine, and several others that were on their own or in combination concerning. We should have room for clinical decision making. Excesses are regular and impactful on patients' health.

[u/Relax_Dude_ → u/jsfuller13]

Yea that sounds bad but I can probably venture to guess that the patient has debilitating neuropathy and or chronic severe back pain, and anxiety. If they never attempted to wean the patient down and try alternatives then yea thats poor management. And if that doc is willy nilly prescribing high dose opiates and benzos to all his patients then yea, investigate. I would be willing to bet those discussions have been had between the doc and the patient, did he not? This is a classic n=1 situation IMO. And back to topic, opiates, benzos, gabapentin are all generics. I have never during my career heard of a pharma sponsered talk of opiates, benzos, or gabapentin taking place. Which beers list violations do you think are actually influenced by pharma?

[u/jsfuller13 → u/Relax_Dude_]

I see similar profiles about once a month. Within that pattern, what I described is fairly moderate. It is often older physicians, particularly psychiatrists, with concerning practices along these lines. With the pattern of referrals I get, I can't confidently say that it's a pervasive practice for any particular physician, but we can certainly start to understand someone's judgment by particular clinical decisions. Edit: to your edited comment, I can only speak to my own areas of knowledge. I would not presume to speak to pulmonary impacts of any intervention. I can and will speak about cognition. To the issue of opioids (the preferred term these days) in particular as being implicated in misconduct by pharmaceutical companies, this is a well-established issue. If you would like some citations, I’m happy to provide. Edit 2; also, benzos are not indicated for chronic anxiety, nor are opioids indicated for chronic pain.

[u/ycaivrp → u/Relax_Dude_]

So, I was a measly resident who went to a thing hosted by Eli Lily during my Endo rotation, about mojaro. I didn't even get lunch! Nor a pen. Then I saw how much the endocrinologists loved it since they were already using it for a little bit. I then prescribed it for some of my patients the next month and it was insane. These people's glucose dropped from 400 all the time to 150/160. Some of them eventually cannot tolerate the side effect etc. Then what I did, I bought a a ton for Eli Lily stock. Okay. That's my story.

[u/Relax_Dude_ → u/ycaivrp]

I think retatrutide is going to be a game changer once it goes through. But thats just my own reading, never attended an Eli Lilly talk nor do I prescribe these drugs.

[u/NinjaLanternShark → u/Relax_Dude_]

The data specific excludes consulting fees and research grants.

And no amount of "trust me, I'm a doctor" condescension will convince me that the best way for physicians to learn about new drugs is to have drug company salespeople wine and dine them.

The system is corrupt to the core.

[u/Relax_Dude_ → u/NinjaLanternShark]

I dont see where they excluded consulting fees, they include the consulting fee data in their tables. They only excluded research grants. Generally "Travel and lodging" for speaking is not categorized under "consulting fee". So thats sorta consistent with what I said that travel and lodging is the highest category, just like the study. I do think this is a 'correlation not causation', just my opinion. In my case I'm more likely to prescribe that biologic having attending the dinner and having gotten comfortable with it. If I didn't have anyone else to talk to about it, I might have referred my patients to someone else to do it, and that someone likely did have some contact with the company. You can believe whatever you want but believing this is a big conspiracy and doctors are somehow paid under the table just makes you sound like the crazy one.

[u/doublenegative-1 → u/Relax_Dude_]

You can't research the best solution to a problem without freebies?

[u/sticklebat → u/doublenegative-1]

Practicing doctors do not have time to comb through all the medical research being done. It's incredibly time consuming, and frankly it's something many doctors would struggle to do even if they had the time. Your typical physician is not the target demographic of most medical literature. They can't possibly keep up with it. The literature is intended for researchers and maybe some specialists. Physicians ultimately get most of that knowledge distilled and passed on to them by others who've done that labor for them.

Honestly I would see it as a problem if these things were presented as "hey, you can have this lunch if you agree to prescribe our medication!" but that's just not how it works. There's no quid pro quo... And providing dinner during evening sessions is just practical; otherwise doctors wouldn't go, because they are hungry at need to eat.

[u/Doct0rStabby → u/sticklebat]

Physicians ultimately get most of that knowledge distilled and passed on to them by others who've done that labor for them.

Right, and if the majority of the time the people who have "done the labor for them" are drug reps working for companies that want to make billions on a treatment they spent millions developing, regardless of whether that is the best choice for a paitent, that is a seriously fucked up system. Really shocking how much effort there is in this thread to normailze this behavior.

[u/thinkbetterofu → u/Doct0rStabby]

im LOVING this thread because its a ton of doctors and pharma reps admitting that they partake in this system of legalized bribery and prescribing drugs from these companies as a result

and they DEFEND it

[u/hal0t → u/Doct0rStabby]

The people who "done the labor" are other qualified clinicians, reseachers, and industry leading clincians. They all have medical affairs and compliance watching them. Whatever they say to the doctors are strictly based off of the approved study data, or actual real world use case they have seen in their clinics which they have document of. Nobody is risking their licensw for some small bucks.

[u/sticklebat → u/Doct0rStabby]

I don't think the system is ideal, but I think it's better than nothing. The "drug reps" are licensed pharmacists and doctors, and their jobs aren't to sell drugs, they don't earn commissions... Their job is to provide information about what drugs do, when they're covered by insurance, the different use cases, how they interact with other common drugs, etc. "Come to this information session with no strings attached, and have a sandwich!" is hardly the kind of "bribery," if you can even call it that, that I'm worried about. Hell, I'm a teacher and the PTA sometimes provides us with lunches, but it isn't liable to get me to boost my students' grades.

In a more perfect world these people would still exist, but they'd be public employees. Since that's not likely to happen any time soon, and I refuse to let perfect be the enemy of the good, having these medical professionals employed by pharmaceutical companies, meeting licensure requirements, and subject to oversight and regulation, is an acceptable circumstance and better than nothing, and simply expecting doctors to magically keep up to date on an overwhelming body of literature, most of which is not relevant to them or they don't have the requisite skill/background to intake, in all that free time doctors are famous for having.

[u/doublenegative-1 → u/sticklebat]

You are saying practicing doctors have no idea what's going on in their field and need it spoon fed to them by companies? If true that is truly grim.

[u/sticklebat → u/doublenegative-1]

No, that isn't what I said. Being unable to keep up with all the medical advances in the world is a far cry from "have no idea what's going," but feel free to keep building straw men if you like the feeling you get by tearing them down...

[u/doublenegative-1 → u/sticklebat]

You just make it so easy...

[u/thinkbetterofu → u/sticklebat]

so, you, as a doctor, would be totally comfortable telling any patient you are prescribing a drug for, a full disclosure that you had previously entertained these outings, dinners, or paid speaking events, or trips, from the pharma companies of the drug you are prescribing?

[u/gmerkron → u/doublenegative-1]

Have you tried doing research outside of free dinners? It's nearly impossible.

[u/NinjaLanternShark → u/Relax_Dude_]

I make purchasing deciding all the time without anyone buying me dinner. I attend conferences on my own dime, and I don't get paid when I present. I talk to people who use products I'm considering, and get unbiased opinions because they're not trying to sell me the thing we're considering.

I get that it's a cushy arrangement and you have absolutely no reason for wanting it to end. Again, you'll forgive me if I don't accept your justification for why healthcare has to be so rampantly corrupt.

[u/Relax_Dude_ → u/NinjaLanternShark]

You're convinced that it's a corrupt system. You do realize this is all transparent. You can look up any company and any physicians name and see exactly who is giving how much to who, down to the exact dates?

[u/NinjaLanternShark → u/Relax_Dude_]

Wow. Just.... wow.

You're so indoctrinated that you think because it's legal, it's right.

The drug companies pay lobbyists (also public information) to influence Congress to pass laws that allow them to keep money flowing to doctors, to make sure they keep prescribing.

I never said anything about coverups or conspiracies. This is business as usual. Drug companies funnel money to doctors to boost their sales. It's so public they do studies on how effective it is.

That doesn't make it not corrupt.

[u/treehugger100 → u/NinjaLanternShark]

Its Human Behavior 101 that the free meals and perks would influence their prescribing activities. I will never stop being shocked how the medical profession and practitioners defend this obviously corrupt behavior.

[u/PsychologicalLuck343 → u/NinjaLanternShark]

I took my 12 yesterday old to a dermatologist who had a pharmacy guy shadowing him. I asked about some of the things we could do at home for his skin and he wrote one or two new prescriptions with each question I asked. I tore the scripts in half and left them in the office and got him on ProActiv, which cleared him up. What an asshole.

[u/Inevitable_Nerve_638 → u/PsychologicalLuck343]

So, to recap: you asked a doctor numerous questions, and based on all the info you continued to provide, the doctor updated his treatment plan to address your multiple questions. What a monster. He also had a "Pharmacy guy" (whatever that means) shadowing him.

1) It would be illegal for a doctor to allow an employee of a private pharma company to sit in on a private appointment without the patient's consent. He or she would've had to introduce him in his official capacity, and ask if you were ok with him being present. If this were the case (it's not), it means that you consented to that.

2) Why would a pharmacy company want to sit in on such an appointment? That makes no sense. Take a moment to really think about it. There are patient advocacy groups that a pharma rep could contact to get patient feedback on their drug. It's completely inefficient to have a single person sit in on 1-on-1 doctor-patient appointments, when they can get feedback from hundreds of patients at once using a laptop or Zoom call.

I think this is more of a case of you not having a clue about what the doctor's process was in response to you, and assuming it meant he was corrupt. You, like the majority of people on planet Earth, are not nearly as smart as you think you are, and it would be good to keep that in mind. There was certainly an asshole in your story, but it wasn't the doctor.

Just because your son's skin issue was cleared up with ProActive doesnt mean the medication wouldn't have worked. The difference is that the medicine went through FDA review, and demonstrated empirical efficacy and safety. To my knowledge, OTC Proactive is not FDA-approved, and doctors have to prescribe approved drugs by law.

[u/NinjaLanternShark → u/PsychologicalLuck343]

When I was 22 I hurt my back rollerblading. Doc asked me what insurance I had then said "Ooo!" and wrote me a script for the then-brand-new Celebrex. No more effective than OTC ibuprofen, but easier on the stomach.

22-year-old me had a cast iron stomach. Everything I ate came from food trucks, dive bars and all-night diners. Doc never asked if I had stomach issues.

My pharmacist sister had to tell me I didn't have to fill the script and I could just take ibuprofen. That was the beginning of the end of my naive belief that doctors always knew what they were doing and were somehow "above" being manipulated by drug companies.

[u/PsychologicalLuck343 → u/NinjaLanternShark]

Not only are they self-interested, they are fine raki g money from sick women, telling them they are merely suffering from health anxiety while your autoimmune disease causes more and more damage. You aren't going to get them to tests for autoimmune disease unless you are fortunate to get referred to a rheumatologist, or have the nerve to ask for a referral, your autoimmune disease won't be found and treated.

[u/TheUnicornCowboy → u/Relax_Dude_]

Your entire industry seems so far beyond corrupt it’s ridiculous, the fact that you think it’s ok to accept hundreds of thousands of dollars in kickbacks for prescribing particular drugs and that’s just an ok part of the job. THATS A BRIBE. Full stop. It’s insane reading that you think that’s normal and ok. I would have my license revoked in a heartbeat if I accepted a bribe in my field. Insane.

[u/Nyrin → u/TheUnicornCowboy]

You either didn't actually read what you're replying to or didn't understand it.

The parent commenter made it explicitly clear that, even in the nominally large cases, it's not a kickback system. But you're peddling that to yourself anyway because hey, manufactured outrage.

[u/thinkbetterofu → u/Nyrin]

its an actual concern. and its absolutely a kickback. but reddit leans neoliberal and is okay with things as long as the system manufactures enough consent. and guess what, most of the people in this thread have a financial interest in keeping this system going, either working for the pharma companies or are doctors admitting to receiving the benefits reported on in the study. but please keep attacking the person who has a reasonable response of justified outrage at this system which does not benefit patients.

[u/FeelsGoodMan2 → u/TheUnicornCowboy]

This is why I think it's funny that people think there's a silver bullet to fixing the US healthcare system. Yeah there's certain things we need to fix, but there's a whole lots of parts of the system that will need to change and sacrifice for it all to get into a good place.

[u/MenWhoStareAtBoats → u/TheUnicornCowboy]

What that physician described are not kickbacks. Accepting a kickback for medications prescribed is a felony and would definitely put the doctor’s license in jeopardy.