TheYoung Physician Encounters Big Pharma
(meanwhile growing old)
Eli Lilly Co. is a major employer in Indianapolis, Indiana where I was raised. Executives and employees were friends of my family and members of our church. My father was the minister. After I got into practicing medicine, I found out that Eli Lilly has provided quite a unique service throughout the years—that of processing opium into morphine and codeine, a not so profitable task with the large associated hassle because of narcotic regulations. So, their reputation as a good community player included the larger community, not just Indianapolis.
My next encounter with Big Pharma (slang for multinational pharmaceutical manufacturers) was Mead Johnson of Evansville, Indiana, who gave new medical graduates a black doctor bag and baby formula for the doctor’s family which was much appreciated because we were trying to get Mary through medical school without incurring debt—a major accomplishment even at that time. And, if the infant was breastfed, it was simple enough to make cocoa out of the formula and feed it to mom for reprocessing.
Now, back to Eli Lilly. When, after hanging out our shingles, we ordered a supply of narcotics for our black bags, it was amazing to find that morphine cost only 6/10 of a cent per dose. Other generic drugs were even cheaper. In school, we had been taught to prescribe by generic names and that ethically physicians should profit only from their professional services and not from the sale of drugs and supplies. In our small town, the other physicians all dispensed drugs. The solution for my wife, Mary, and me was to give away medications that cost less than about 50 cents for a month’s supply. We euphemistically called them “samples”. The pharmacists really appreciated us because we wrote prescriptions for everything else; but they straightened us out about the generic names by calling and asking, “What is this stuff?” So, indirectly, Big Pharma got their way with us by inducing us to use trade names.
At that time, the drug salesmen aggressively asked the doctors, “Do you need any of our medications for your own use?” Drug companies were not yet permitted to advertise to the general public. Apparently inducing the doctors’ “personal” use of their product was the next best thing. We were young and healthy and didn’t need much in the way of medicines; but it was nice that someone would take care of us in this regard (compare with a family member with a truck garden). They would have been only too willing to provide us with a daily multivitamin; but since we believed a healthy diet doesn’t need supplementation (we still believe that), it would compromise our attitude in dealing with the public to take a free multivitamin ourselves.
For several years we have been volunteers in the Physicians’ Health Study organized in Boston. They provide us with coded pills—either various vitamins or dummy pills. Even the investigators cannot break the code until the results are ready for analysis. This is called a double blind experiment because neither the volunteers nor the investigators can be biased by premature knowledge of the activity of the pills. The bottom line is: do doctors who take real supplements live longer than doctors taking the dummy pills? The truth might even be the other way around. Doctors are preferred subjects because they leave changes of address (easier not to lose track of them) and they understand how to co-operate with a controlled experiment. Some of us almost hope we are on the dummy pills; but we agreed up front not to have our pills analyzed.
The above described experiment would not ordinarily be funded by a manufacturer because the downside of publicity about an unfavorable result would be greater than the upside of proving that vitamin supplements prolong life. This illustrates a current problem. Almost all drug research is funded by commercial interests. It is true that the drug companies do a good thing by proving that new drugs are safe and effective. But, when 2 or 3 members of an innovative new category of drugs are already marketed, is it beneficial to the public to fund the high development costs of still another member of the same category of drug? This is indeed what happens when market share and not innovation has become the driving force behind the research.
So drug prices rightly reflect the development costs of innovative new drugs. Some of us feel that too much is spent developing and promoting “me-too” drugs. I have mentioned that formerly prescription drugs were not advertised to the general public. The current advertising for prescription drugs is worse than an unnecessary expense because the time a physician spends talking about an advertisement the patient has just seen could have been better spent talking about the more vital details of the patient’s situation. This language of promotion has caused me to talk to sales representatives only about friendly neutral topics such as trout fishing, not about drugs. I don’t trust myself to keep track of every detail about where I learned something so I read the Lancet, the New England Journal of Medicine, etc. A free (throwaway) journal from some foundation is also suspect. The recent new information about hormone replacement after menopause actually being harmful to women in some instances is an example of the benefit of shielding oneself from potentially biased sources. None of my public who take these hormones called me as a result of the “new information” because they had all made their own choices after a balanced discussion of benefits and possible problems with hormone replacement therapy. Thus I was spared an encounter with “Big Pharma” on this topic. I recommend that individual physicians reduce the promotion costs of drugs by limiting or even eliminating time spent with drug salesmen. After all, if these costs are not incurred, they cannot be used to justify high prices.
Attempts to regulate the drug industry have been largely confined to national governments. Recently the European Union has been unifying national drug regulation with some success. WHO (The World Health Organization) has the potential to help in this regard; but their funding is fragile, which weighs more heavily than courage or principle. Unlike WHO, I have been fortunate to have considered my personal funding adequate throughout my life. During my period teaching in Afghanistan from 1968 to 1970 I did talk to drug salesmen at every opportunity as part of my orientation about the local medical scene. Prestigious European companies did not shine brightly in the quality of their promotions--no doubt because of the absence of regulation, another encounter of the middle aged physician with Big Pharma.
There are some bright spots. As a result of outcries from the underdeveloped world about the prices of drugs for AIDS, enormous price concessions have occurred--so far without evidence that the manufacturers are taking a loss. And, even before the outcry about AIDS drugs, several companies have supplied free drugs on a scale permitting possible eradication of entire diseases. For example, river blindness, a parasitic disease in Africa, is well on the way to total control.
I forgive myself for some lapses in logic and consistency in the past. This attitude increases my tolerance for human foibles in others, a blessing at any age.
John A. Frantz M.D.
Chairman Monroe City Council Board of Health
December 27, 2002
In medical school our teachers insisted that we record our patients’ chief complaints in their own words. In my mid-career a “three time loser” replied to the question, ”What seems to be the main trouble?” with “Doc, everything I touches(sic) turns to excrement.” Actually he used a more expressive word for excrement. I wrote his complaint verbatim and the diagnosis: reverse Midas syndrome.
Within a year or so I attended a class reunion where my classmates were talking about important and otherwise noteworthy patients. My entry was King Sadim (sounds oriental enough). The punch line “….this is Midas spelled backward and everything he touched turned to !!!!”. Reverse Midas syndrome has become standard medical slang for a three time loser, even making it to ”Letters to Editor” columns of the New England Journal of Medicine (and without my fingerprints on it).