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Drug firms have to stop paying doctors

By Carl Elliott, Special to CNN
  • Carl Elliott: Disclosure of drug company payments to doctors may worsen the problem
  • In 2013, a national sunshine law will require all drug companies to report payments to physicians
  • Sunshine laws may encourage more doctors to accept gifts from drug companies, he says
  • He says the real problem of pharmaceutical industry gifts is not secrecy, but influence

Editor's note: Carl Elliott, MD, PhD, teaches bioethics at the University of Minnesota and is the author of "White Coat, Black Hat: Adventures on the Dark Side of Medicine" (Beacon Press, 2010.)

(CNN) -- Drug industry critics celebrated last month when Pro Publica announced a new searchable database called "Dollars for Docs."

No longer will worried patients have to rely on reporters to expose doctors on the payroll of the drug industry. Now patients can do it themselves. With a few simple keystrokes, anyone with a computer can search the "Dollars for Docs" database to see how much money their doctor is getting from pharma.

For decades pharmaceutical companies have given doctors gifts and money as ways of getting them to prescribe their drugs. During the flush 1990s, companies began ramping up these gifts dramatically -- entertaining doctors at expensive restaurants, sending them to conferences in exotic locations, even writing checks disguised as "unrestricted educational grants."

When PhRMA, the pharmaceutical industry trade group, began cracking down on these gifts in 2002 in response to public criticism, the influence game began to take another shape. Today, pharmaceutical companies influence doctors by inviting them to be paid speakers or consultants -- or as the companies call them, "thought leaders."

The amount of money paid to a thought leader can be considerable. For example, Dr. Charles Nemeroff, the former chairman of the Department of Psychiatry at Emory University, earned $2.8 million as a speaker and consultant for drug companies from 2000 to 2007. Dr. Joseph Biederman of Harvard University earned $1.6 million during the same period, and failed to disclose most of it to Harvard officials.

Drug companies corrupting physicians?

"Sunlight is the best disinfectant," the pharma critics say, arguing that everyone has a right to know if a drug company is paying a doctor. For once, everyone seems to agree. Doctors, legislators, medical schools, even pharmaceutical industry executives are lining up behind "transparency" and "disclosure" as the preferred solution for conflicts of interest. In 2013, a national sunshine law will require all drug companies to report all their payments to physicians.

There is just one problem. Here in Minnesota, we have had a sunshine law on the books since 1993, and it hasn't exactly been the win-win solution that everybody assumes. In fact, Minnesota has emerged as a national hot spot for conflict-of-interest scandals, and it is not just because the scandals are easier to dig up. Disclosure may actually make the problem worse.

First, while accepting drug industry money might seem shameful to outsiders, within the world of academic medicine it is often just the opposite. Paid consulting for the drug industry is a mark of status. "You're thinking, you're in with the big guys now," one physician told me for my book, "White Coat, Black Hat." "You're in with the senior figures in the field."

Money is not the only incentive here. The drug industry can transform doctors into academic stars. Drug companies may offer physicians authorship on journal articles, make them investigators on clinical trials, promote them in the media and fly them around the country to give lectures and conference presentations.

"At meetings they get big fancy badges, like generals with their medals," a medical writer told me. Asking these doctors to disclose their corporate perks and payments is like asking a decorated officer to display his honors and awards.

Second, sunshine laws may actually encourage doctors to enter into financial relationships with the drug industry by revealing how commonplace these relationships are. Psychologists call this the "principle of social proof." When we're unsure of what to do in ambiguous situations, we look around to see what other people are doing.

This is why theaters plant employees in the audience to laugh and clap; it is also why coffee shop barristas add large bills to the tip jars on the counter. If people believe that others are doing something, they are more likely to do it themselves. For this reason, disclosure requirements may backfire. Once doctors see how many other doctors are taking drug company money, they may simply assume it is the accepted practice.

Third, many people wrongly assume that disclosure is a remedy for the bias that money can produce. They believe that once we know how much money a doctor is getting from pharma, we can simply make up our own minds about whether that doctor is giving us biased advice. But in fact, research produced by a team of behavioral economists led by Daylian Cain at Yale University suggests just the opposite: Disclosure actually worsens the problem of bias. This appears to happen in a couple of ways.

First, when people listen to experts who disclose their payments, they are -- paradoxically -- more likely to believe what the experts say. (Perhaps they think, "He has been open with me, so he must be trustworthy.")

Second, according to the research by Cain and his colleagues, experts who disclose their payments appear to be more likely to give biased advice than those who keep them secret. As they write, "Disclosure leads advisers to feel morally licensed and strategically encouraged to exaggerate their advice even further." (It is as if the expert thinks, "Well, I've revealed my biases, so all bets are off now.") The disturbing upshot is that disclosure leads to more biased advice, and as Cain and his colleagues write, can "hurt exactly the people it is intended to protect."

Does all this mean we should abandon sunshine laws and "Dollars for Doc" databases? No, not exactly.

Disclosure serves a valuable purpose, especially for investigative reporters and attorneys. But the real problem of pharmaceutical industry gifts and payment to doctors is not secrecy, but influence. Doctors who take money or gifts from a pharmaceutical company are more likely to prescribe that company's drugs, write favorable journal articles about the drugs, give lectures recommending the drugs and suggest adding the drugs to a hospital formulary. That influence does not disappear when the payments are disclosed. To fix that problem, the payments must be eliminated.

The opinions expressed in this commentary are solely those of Carl Elliott.