Of Reps, Wraps and Payola


female drug rep I've never been one to hide my disdain for the tendency of mainstream medicine to allow financial incentives to color medical research and decision-making. In fact, what the record industry once called "payola" -- and which rocked that industry to its core in the 1950s -- is accepted practice in the medical industry.

As former Editor-in-Chief of the New England Journal of Medicine Marcia Angell has pointed out in her books and elsewhere, medical research has been virtually overrun by checkbook research -- with Big Pharma paying the Big Money to get the results they need.

It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgment of trusted physicians or authoritative medical guidelines. I take no pleasure in this conclusion, which I reached slowly and reluctantly over my two decades as an editor of The New England Journal of Medicine,” Angell said.

She's not the only one to have seen first-hand the corruption of medical research. Take, for example, this quote from an abstract of a paper on vaccinations. This article was published by a group called the Cochrane Collaboration, an international collection of scientists who have volunteered to review medical research in the effort to develop evidence-based practice guidelines. And this is what the scientists had to say about the research on the influenza vaccine:

"Fifteen of the 36 trials were funded by vaccine companies and four had no funding declaration. Our results may be an optimistic estimate because company-sponsored influenza vaccines trials tend to produce results favorable to their products."

But the real problem of Pharmaceutical Payola occurs much further down the food chain, at the offices of individual doctors. Multiple studies have found that pharmaceutical marketing has dramatic impact on doctor's prescribing habits.  One of the most effective ways of influencing doctors is through providing continuing medical education credits for free through company-sponsored seminars.

I've seen this influence more directly through the eyes of others. I once knew a woman who worked for a specialist group practice; her sole job was to review drug company studies, and advise the practice as to which ones in which they should participate. Her decision algorithm, however, had nothing to do with scientific advancement or patient wellbeing. Rather, her recommendations were entirely based on which studies would prove most lucrative to the practice. Because what the doctor doesn't tell you, dear patient, when he offers you a chance to be cured by this new breakthrough drug that they are testing, is that he is getting paid anywhere from $6,000 to $18,000 for each patient he enrolls -- plus another $20,000 when he hits the 20-patient mark.

Not surprisingly, all of this kind of bothers me. It bothers me mostly because detractors of alternative medicine routinely claim that mainstream medicine is "based on science" and alternative medicine is not. Nothing could be further from the truth.

In fact, the opposite is likely to be more consistent with reality. According to one study, fewer than 20% of mainstream medical procedures are supported by research. Only one-half of medical interventions are therapeutic. And very, very few surgical procedures are subjected to double-blind trials before widespread acceptance.

In contrast, chiropractic care for a variety of musculoskeletal ailments is well documented in the scientific literature. Acupuncture has an exceedingly long trail of research, and nutritional interventions are "alternative" only in the minds of troglodytes.

Whether I am adjusting someone for their headache, using acupuncture to treat a child with Tourette's, or using diet and nutritional supplementation to help a patient eliminate their arthritis pain or control their autoimmune disease, I can in every case point to research supporting my use of those procedures. And, unlike in mainstream medicine, nobody -- but nobody -- makes money from research into nutritional therapy or chiropractic. So it is unlikely to be tainted by money, even if the players in the industry had the finances to do so.

Which, at long last, brings me to the point of this post. (In journalism, this is called "hiding the lead." When I was a newspaper editor, I regularly chastised my reporters for doing this.)

Coupled with my scorn for mainstream medicine for allowing itself to be bought by the highest bidder has always been my admittedly sanctimonious opinion of my own ability to stand above the fray. I have even bragged that the largest gift I have received from any nutritional company was a case of apples (It was from Douglas Laboratories, back in the 90s) and a bottle of honey.

All of that changed yesterday, however, when a rep from one of the nutritional vendors whom I use for patient's supplements stopped by. My relationship with this company is less than a year old, but not for lack of interest. I first encountered them several years ago at a nutritional conference I was attending. Impressed by their products at the time, I have intermittently contacted them for more information, but never received any response. I'm not surprised; in the larger scheme of things, my little practice in Podunk, Connecticut is not going to bring out the big marketing guns.

Purely by serendipity, however, that changed last year. One of their reps stopped by, unannounced, saying that she had seen my sign in passing, and wanted to introduce herself. I'm pretty sure that she was on the way for Someone Else's Office and just got lost, but it was a serendipitous visit nonetheless. In a short introductory meeting, I let it drop, without qualification, that what would sell me was science. And quality. And if their products did not stand up to either, #thankyouverymuchbutbutnothanks.

A few weeks later, she showed up again, armed and ready. She dropped journal after journal in my hands, explaining how it fit into her company's products and the benefits provided. I was impressed. She left, and I did some homework; she wasn't just blowing me smoke.

So I ordered a few products, and began using them. Patient feedback was good, but more importantly, patient improvement, documented objectively, was impressive. I know, there's always the problem of confirmation bias when a clinician reviews his own work, so I can't conclude from a truly objective standpoint that the products worked. But you have to go with what you've got, sometimes.

This company offers a number of conferences, and at her last visit, I asked the rep why they don't include CEU credits for doctors attending them. Her answer was simple, blunt, and honest.

"We won't," she said. "We talk about our products."

Compare that answer to that of the pharmaceutical companies, which routinely spend millions of dollars sponsoring CEUs for medical doctors, and consider it a routine cost of doing business. I have attended some of those lectures, all of which have been extended infomercials for one or another miracle drug. The fact that this nutritional supplement company specifically delineated a difference between education and marketing was impressive.

At this visit, she also plopped another inch of independent research on my desk, and we talked about the scientific backing for some of their new products.  I was so engrossed by the information, that I completely forgot about the wrap she had brought from some deli.

I shouldn't have; this was unique. During her previous visits, she had never provided me with a free sample of anything, except as a quick taste test when I had mentioned that other, similar products had been met with unhappy looks from my patients.

So engrossed was I with the data that I forgot about the sandwich. Sandwiches, by the way, fall well within the guidelines for proper behavior for representatives visiting doctors, so I did not feel any gross or subtle moral violation for accepting the food.

After the rep left, I got around to opening it up, and discovered, perhaps, the Best Wrap I Have Ever Had In My Entire Life. I immediately emailed the rep to get her source; she demurred, however. So I still don't know where The Wrap came from.

So I have to confess. In addition to having been courted by a case of Red Delicious apples, I have now been waylaid by a chicken wrap of unknown provenance but undisputed tasteworthiness. That is the full extent that any company has sought to influence my prescribing behavior.

So the next time I recommend a supplement to you, I want you to have full and transparent knowledge. I'm doing it for the wrap.