The Insider is intrigued by the decision-making process that leads a doctor to prescribe a particular drug -- say, oxycontin, a potent and addictive pain killer -- as opposed to some other medication for a work-related injury. Oxycontin was orignally developed for the extreme pain of cancer but quickly migrated to an almost routine use among workers with strains and sprains. Who got inside the doctor's head to reach for the more potent and more dangerous medication -- and how did they do it?
According to a fascinating article in today's Wall Street Journal by Scott Hensley and Barbara Martinez (available by subscription only), the path to a doctor's brain is at least in part through his stomach. Drug companies are sponsoring luncheons at fancy restaurants, where a trained doctor leads a discussion on a specific medical condition that requires pharmaceutical intervention, just possibly a drug manufactured by the company picking up the tab for the lunch.
The doctor who leads the luncheon discussion has been trained by the drug company in the efficacy of a given medication for a specific condition. The article cites one luncheon focusing on "sinus headaches." The lead doctor advises his fellow docs to consider the possibility that the condition is really a migraine. While he does not specifically recommend the sponsoring company's product for migraine, he has definitely planted a seed that may sprout the next time a patient complains about sinus headache.
Doctors are paid a fee to attend training sessions sponsored by the drug company. They are also paid for each "educational session" which they run. The fees do not appear to be huge -- in the range of $750 to $1,200, but some doctors were supplementing their income to the tune of $60,000+ per year. It's important to note that the participating doctors insisted that they are not flacks for the drug companies -- they say that they answer questions at these sessions honestly and candidly. In the example of the migraine headaches above, the lead doctor mentioned the availability of generic medications,in addition to those made by the sponsoring company.
In 2004, there were 237,000 meetings involving doctors presenting to their fellow docs. By comparison, in the same year there were 134,000 meetings involving a salesperson presenting to doctors. Which was more effective? The return on investment for the presentations involving a doctor was twice that of the other sessions.
Drawing upon documentation involving pending litigation, the article states that
increased use of Vioxx can be traced directly to doctor seminars. Doctors who attended a lecture on Vioxx on average wrote $624 more in Vioxx prescriptions than those who did not attend. For doctors attending a more intimate group, such as the above luncheons, the increase was $718. By contrast, doctors attending a lecture by a salesperson only wrote $166 more in Vioxx prescriptions. It does not take a lot of imagination to track the rise in Vioxx use, from one lecture hall to another, from one luncheon to another. The road to the proliferation of Vioxx was paved one menu at a time.
To those of us on the outside, medicine appears to be an exact science. As patients, we certainly hope it is. But to the front-line practitioners, it can be far from exact, a world of intense time pressures, full of puzzling symptoms and inordinate urgency. Faced with these pressures, a treating physician may well rely on the advice he heard while consuming grilled salmon with mustard-dill sauce.
For a fascinating summer read, I highly recommend Complications, written by Atul Gawande, a surgeon who is also a fine writer. The book will help you appreciate the uncertainties of medicine and give you a little insight into what goes on inside a doctor's brain.