Your Doctor's Drug Problem

GUEST: Dr. Robert Michels
VTR: 1/29/2004

I’m Richard Heffner, your host on The Open Mind. And I took the title for today’s program, “Your Doctor’s Drug Problem”, right from a recent OpEd piece in the New York Times. Written by Arthur S. Relman, former Editor of the distinguished New England Journal of Medicine, it’s not, I hasten to assure you about doctor’s addiction to anything other than the gifts and entertainments and other blandishments with which pharmaceutical companies so frequently treat doctors, who may then use their products … too often the new and ever more expensive, though not necessarily more effective ones at that.

Well, one scholar estimates that the drug industry spends over $15 billion dollars annually, marketing medications, with almost $5 billion dollars dedicated to detailing individual physicians. Figure that at from $6,000 to $11, 000 a doctor, a year. And you may relate those numbers to this paragraph from Dr. Relman’s comments in the Times:

“Despite the increase in direct to consumer advertising patients still rely on their doctors to choose which prescription drugs, if any, they should take. But what few of them know is that often their doctors’ judgment is influenced by the companies that sell the drugs. Most medical practitioners nowadays”, he points out, “learn which drugs to use and how to use them, mainly from teachers and educational programs paid for by the pharmaceutical industry. Moreover,” he writes, “to its shame, the medical educational establishment tolerates this state of affairs”.

All of which leads me to my guest today, to whom I turn most frequently when there’s a medical issue that really has to be parsed to a fare-thee-well, looked at rationally, even open mindedly, from all points of view.

Dr. Robert Michels was Psychiatrist-in-Chief at New York Hospital, Professor and Chairman of the Department of Psychiatry and then Dean at Cornell University’s Medical College. Now he is University Professor of Psychiatry there and practices in New York City.

And I want to ask what his own approach is to this charge that pharmaceutical firms are somewhat corrupting medical education. Too strong a charge, Dr. Michels?

MICHELS: I’m not sure I should have come today, Dick, I thought I was a good guy on my way over here. And you’re talking about my drug problem and asking me how much I’m corrupted. And starting out with the indictment.

HEFFNER: I’m not going to apologize.

MICHELS: [Laughter] I know that. I know that. It’s a, it’s a fascinating major problem. Bud Relman is clearly right, but that isn’t the entire story. In some ways the doctor’s drug problem is a good metaphor because like other drug problems you don’t necessarily trace the root of the problem to the addict’s craving for the substance. You have to talk about what in the system leaves the empty space that the substance fills.

How do we create doctors who turn to drug companies for this information? And how do we reward them and incentivize them so that the advertising and education of the drug companies is what they seek out and what they get, when they’re looking for guidance.

It’s an issue of medical education. It’s an issue about the distribution of our resources when it comes to the various components of healthcare, clinical care, education and research and in some ways; it’s the nation’s drug problem, not the doctors’ drug problem.

The facts are compelling. It’s clear that the pharmaceutical industry spends a huge amount of money on “educating” … and that word is in quotation marks … physicians. That their motive, they are for-profit organizations, is to increase their sales and their profits in doing that education. It’s clear that doctors consume that advertising/education and it’s clear that it influences their practice.

So far, though, that could be either good or bad. It’s good in that it keeps them up to date; it acquaints them with what’s at the cutting edge of current health care and even more important that it’s part of a large, for-profit industry which has made the growth and the quality of our health care, the envy of the world.

But it’s disturbing because it isn’t aimed at best medical practice, it’s aimed at most profitable medical practice. It oversells recent drugs, or expensive drugs compared to old or familiar or traditional drugs. And it oversells drugs as opposed to other kinds of health care intervention. So the public, and to some extent the profession over-values medication when there are non-medication interventions that are equally effective or preferable because nobody makes money on the non-medical interventions, except perhaps the practitioner … where there are huge industries that make money on drugs.

So we have a complicated system and then put it … I’m talking a lot … but put it in the context of the educational system. There are 65,000 medical students in the United States at any given time. And medical education is under funded. And you have these hugely affluent pharmaceutical industry organizations that have lots of resources and are happy to participate in reaching students or young physicians, taking them out for dinner, maybe taking them to a resort or retreat somewhere for a few days and bringing in the finest lecturers in the field to talk about recent advances. Lecturers who are superb teachers, who are top notch physicians, but who are selected with an eye of how their teaching might lead an innocent, competent doctor to think about prescribing that company’s favorite drug that year.

We don’t have similar organizations that teach for-profit, how to talk to your patient or listen to your patient, or use a treatment that doesn’t involve a drug that makes a profit.

HEFFNER: Is that a suggestion?

MICHELS: Absolutely. But who’s going to pay for that second thing? So that we do what we do with drug problems in general. We scold the abuser and say, you shouldn’t be doing that … you shouldn’t go to, talk to those pharmaceutical agents, you shouldn’t go to those continuing medical education courses that are sponsored by the pharmaceutical firms and push their products. But we don’t deal with the need for high quality, comfortable educational experiences that the doctors are filling by doing these things.

We have to fund medical education at a level where the pharmaceutical industry isn’t competitive with the quality of education you get outside the pharmaceutical industry and we haven’t done that.

HEFFNER: Are you suggesting that without what it is that the drug companies do now, our physicians would be much less well educated?

MICHELS: They would be much less comfortably educated.

HEFFNER: What do you mean “comfortably”?

MICHELS: I mean that medical students and residents and house staff at our hospitals work very hard and they’re poor. And they have very little time. And if someone says, “I’ll take you out for dinner at one of the better restaurants in town and buy you a drink before dinner and all you have to do is listen to a lecture by a top-notch teacher who’s going to talk about what’s new in a certain area of pharmaceutical agents”, that sounds very attractive to someone who doesn’t have money to go to that restaurant and doesn’t have time for that kind of leisure or the resources to pursue it that way. It’s sound like a good deal.

HEFFNER: It sounds comfortable. I wondered if that were your definition of comfortable?

MICHELS: Yes. It’s comfortable.

HEFFNER: But … are you satisfied with that definition? It’s comfortable … the doctor … the doctor in training … the student feels better. He’s better fed that night; he’s had a better time. But is that really the nature of medical education?

MICHELS: Certainly not. It shouldn’t be. But if we make the educational experience sufficiently uncomfortable, we’re inviting comfort becoming more important to the person who’s consuming it.

I’m sure you know there’s been, simultaneous with this concern, another concern, which is the new regulations say that house staff in our hospitals …doctors in training shouldn’t work more than 80 hours a week. And parts of the medical establishment are fighting that, saying they should make more than 80 hours a week. If the system that’s educating you is arguing that you should be working more than 80 hours a week in order to get that education, and working at difficult and burdensome roles, caring for the sick and doing a lot of direct, personal physical care, it’s hardly surprising that when somebody from a drug company says, “I’ll buy you a nice dinner”, that is attractive to you.

HEFFNER: Well now let me ask, as Dean, as a former Dean … would you not be able to make up for, not in terms of creature comforts, but in terms of the presentation of information, not presented at a fine restaurant, but presented in your fine classroom … couldn’t you, couldn’t other Deans, couldn’t other administrators provide that education?

MICHELS: Absolutely. And we do. I would even argue, we don’t make up for it, we do much better. Don’t forget the people the drug companies engage to give these lectures are our faculty, the same ones that teach our medical students in our quite comfortable classroom, frankly.

But we don’t make up for certain other things. The drug companies are very good at what they do or they wouldn’t survive in this climate. So they not only provide you with a lecture, they provide you with a palm pilot, which has been pre-loaded with an information bank which has advertisements built into it.

HEFFNER: Surprise. Surprise.

MICHELS: Surprise. Surprise. They provide you with a fountain pen that glows in the dark and happens to have their name written on it. They provide you with free textbooks which have information in them. They provide you with all kinds of “assists” in addition to that dinner. They also, as I said, take you to nice places. And in doing it, their influence is often extremely subtle.

There was a study a number of years ago of one of our major drug companies that had a drug that was causing some trouble with some patients … the company was struggling with how to deal with this. And they had some of the finest scientists/physicians in the country speaking about this drug and somebody analyzed what they did and they found out something very interesting.

Every time they mentioned the benefits of the drug, they used the trade name that the company sold it under. But every time they mentioned the side effects and the complications they used the generic name. Now, nothing was untrue. But there’s a very powerful, subtle impact on the listener to that kind of thing that influences their pattern of practice.

HEFFNER: Okay. Bob you’re a very wise man. You see things that most of the rest of us don’t. And in all the years that we’ve been talking at this table I’ve understood that. I want to ask you this question. You see this as a system, the drug companies in return for what they get … hundreds and hundreds and hundreds of millions of dollars, provide us with something that has been very important. Are you satisfied with that? And I don’t mean in the most ideal sense I mean, will you stand pat with that system?

MICHELS: I’m not satisfied with it and I think we can do things to improve it. But I think it’s naïve to think that it’s a problem of good versus evil, or that simply stamping it out will make it better.

For example, the drug companies are now the major source of resources for clinical research in American medicine. And that clinical research resource comes out of their profits. We have to attend to the need for that and look at the possible sources for it and alternative sources before killing that source and reducing the value that it’s created for us as a society.

So I guess I’m saying we have to pay attention to the whole system. I think our medical education system has to make sure that the students are protected from this kind of information. The good hospitals I know won’t let drug representatives talk to the students or the house staff. They frequently are eager to provide resources for lectures or conferences. My rule, when I was running a training program, was I was very happy to accept their resources and I would accept them publicly and thank them for them. But I would never let them select the speaker or the topic that was to be used when those resources were expended.

In effect I was saying, “We’re in charge of medical education. You can support it, but you can’t dictate what it consists of.” And that wasn’t a complaint about the quality of the speakers, they got the best. But there’s a subtle and I think highly dangerous effect when you let them pick what’s to be talked about.

For example, in my field, psychiatry … there’s a huge spurt of development and knowledge about the drug treatment for bipolar disease, manic/depressive disease. And many companies have agents that they’re experimenting with and putting on the market in that area. If you let the drug companies decide what our Grand Rounds would consist of around the country, you’d think the most prevalent disease in America was bipolar disease. It isn’t. And it’s important that students learn how to treat diseases for which there isn’t a new drug this year, and isn’t a company that’s about to make money.

Furthermore, one of the older drugs for bipolar disease … lithium, one of the first … isn’t under patent. Nobody makes a huge profit by selling lithium. It is still the best drug for that disease. But a lot of medical students and doctors don’t know that because they’ve been exposed to the pressured education/advertising for other drugs. So you want to be able to correct that system.

But at the same time you want to give the students a nice experience, a high quality experience, a pedagogically sophisticated experience, and I’m ashamed to say that at the moment, some of the pharmaceutical companies have more pedagogic sophistication than some of the medical education institutions.

HEFFNER: Well now that’s, I think, a more important question. I’m not talking about creature comforts …

MICHELS: MmmHmm.

HEFFNER: … I’m talking about more sophisticated … better … maybe I shouldn’t use the term “more sophisticated”, it has implications … but better pedagogic approaches. And you’re saying that’s true of the drug companies.

MICHELS: I’m saying that they are … just as Madison Avenue in some areas knows more about education than our educational establishment, they call it advertising, but they influence people’s behavior and often in a very sophisticated way … educators have something to learn from the advertising industry. I’m saying that medical educators have something to learn, too. But to do that they need resources and they need the time and capacity to attend to that task.

One of the problems and you keep getting into bigger and bigger concentric circles here, our current health care system is in terrible trouble as everyone knows. And a lot of the pressure of that trouble is on academic medicine. And so our great academic institutions, the centers of medical education and medical research are very pressured for resources and they tend to distort their programs to make sure that everything they do doesn’t drain their resources.

Therefore they put more resources into providing reimbursed clinical care or getting research grants and less resources into the nuts and bolts of medical education, which doesn’t generate an immediate return for the institution.

Medical education is under-funded in this country. In the past it borrowed heavily from the earnings of clinicians’ donated time to teach students. We’ve clamped down on those earnings through different reimbursement policies. We’ve clamped down on the institutions’ profit margins through sophisticated reimbursement programs …and what they used to subsidize … medical education is going a little hungry. The pharmaceutical industry has stepped into that gap and provided unhealthy tidbits to gratify that hunger. What Bud Relman calls “a drug problem” and that’s a symptom as well as a problem.

HEFFNER: If the marketplace ideal weren’t prevalent in any part of our medical establishment … pharmaceutical establishment, do you think we’d be better off? Worse off?

MICHELS: Well, we’d be more tranquil and serene. And this is what many people are thinking of these days. If we had a system that was not market driven, we’d probably have fewer uninsured patients … right now 15% of our citizens have no health insurance. So we’d have more universal care; we’d probably have very good basic care. We’d probably have quite solid medical education. We’d probably have less money going into the system, and therefore we’d save money in the gross national product expenditures because it wouldn’t be driven by these giant, immensely profitable industrial organizations.

But we’d also have slower advance. It would take many more years for an MRI to reach clinical usefulness. It would take many more years for new drugs to be developed and to reach the marketplace because there wouldn’t be the passion of the profit motive driving them. So we’d have happier, calmer, gentler and probably less scientifically effective health care system.

HEFFNER: Well, it’s that last point, tell me why “less scientifically effective”, unless you’re talking about time.

MICHELS: Well, I’m talking about the time it takes. The average life expectancy of a citizen in our country has increased by about four months every year for the last century. That’s incredible.

HEFFNER: It is indeed.

MICHELS: That’s incredible. That’s been driven by advances in health care and in our biologic knowledge that goes into that health care. Those advances have not all been made in pharmaceutical industries, but a significant number of them have. And the pharmaceutical advances in our country are driven importantly by profit. We have better antibiotics, we have better anti-convulsives, we have better drugs to control hypertension or hypercholesterolymia or all of the major diseases that affect mankind because for-profit organizations are driven to develop them and market them.

There is no way we can be confident if we took away that motivational system that what we were left with would move with the same rapidity or efficacy. The current system has been immensely effective in generating new knowledge about how to treat people. I’d much rather be treated by a doctor who was trained and uses the drugs that are available in 2004 than in … 40 years ago.

HEFFNER: All right. Then that leads me to the basic question. Given the good and the bad, as you describe them, would you choose to eliminate that profit motive?

MICHELS: I would not eliminate it now. I would try to see how we can develop alternative systems that could offer us options that might compete with it or supplant it. I think there are ways in which we can see … and it’s our country’s usual way of doing it … a mixed system, where some is for-profit and some is run outside of the profit system, as a public benefit system, and they literally can compete with each other and also the public system can serve as a governor on the excess expansion of the profit component of the for-profit system.

Right now too much of our health care dollar doesn’t help anyone’s health. Too much is spent in competitive rivalry amongst alternative, equally effective treatments, not enough in caring for the uninsured. Not enough in educating physicians about treatments that don’t lead to profit for anyone except for the patient, who should be the one who profits. And we have to fix that current imbalance.

HEFFNER: Well, since you’re willing to talk about too much and not enough … what would you do?

MICHELS: Oh, you’re putting me on the spot.

HEFFNER: Absolutely. Because only two minutes left … or something like that.

MICHELS: Okay. The first thing we have to do is what you’re doing. These problems are not widely discussed or understood. The pharmaceutical industry doesn’t sponsor such discussions and the medical profession who looks like the villain in Bud Relman’s OpEd piece hasn’t led in that discussion.

We need a public dialogue about the costs as well as the benefits of our immensely productive scientific pharmaceutical industry. So I want to have that dialogue. I want to educate the medical profession about the evils of the current system. The research that shows that doctors are swayed toward less than optimal prescribing practices by attending these conferences or going to these lectures which have information designed to lead to a particular result.

I want that knowledge to permeate the decision makers and I want to see more effort on the side of the governmental research institutions, the NIH, for example, to make sure that the results of their basic research reached the public uncontaminated by the burdens of the for-profit industry’s additions and elaborations of them.

I’ll give you a very specific, narrow example. When someone has a new drug and they’re trying to see if it works or not, it’s usually tested against a placebo. If it’s better than a placebo, the FDA is interested. I would say the public good would better be served if every new drug was not only tested against a placebo, but also tested against the best available current drug so we’d not only know whether it works, but whether it’s better or worse than the drugs we already have. The absence of that information leads to excessive “me-too-ism” competition amongst for-profit organizations without public gain.

HEFFNER: And I gather it’s not accidental.

MICHELS: Ahmmm … I would say there are certainly powerful forces that would rather not see that happen.

HEFFNER: Bob Michels, too infrequently you come and add this touch of realism and rational thinking. Are you pessimistic or optimistic in the five seconds we have left?

MICHELS: I’m immensely optimistic over the long run, but right now, we’re not in the ideal place for the nation’s health care, health education or health research system.

HEFFNER: Robert Michels, M.D., thank you very much for joining me again today on The Open Mind. And thanks, too, to you in the audience. I hope you join us again next time, and if you would like a transcript of today’s program, please send $4.00 in check or money order to The Open Mind, P. O. Box 7977, FDR Station, New York, New York 10150.

Meanwhile, as an old friend used to say, “Good night and good luck.”

N.B. Every effort has been made to ensure the accuracy of this transcript. It may not, however, be a verbatim copy of the program.

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