Sam Uretsky

Influencing Doctors

Physicians are entitled to a great deal of respect. Attainment of an M.D. or D.O. degree represents both a high level of innate ability and years of diligent study. Since physicians typically put in long hours, a 60-hour work week, including time on the midnight shift isn’t unusual, they should be recognized for their dedication, and, since the practice of medicine is usually (but not always) well paying, physicians deserve the same respect we pay to anybody who achieves financial success.

Finally, because physicians make decisions that intimately affect our lives, there is a special place for them in the pantheon. Dentists meet most of the basic criteria of ability, effort and income, but we do pay more homage to someone who treats cerebellar ataxia than someone dealing with an apical abscess. Politicians and medical insurers routinely speak of the importance of having medical decisions made by physicians, not bureaucrats — and that’s when things go too far. We have to recognize that physicians are both fallible and foolable, and their profession is not an exact science. While the government persists in treating physicians as highly educated professionals, drug and device makers treat M.D.s like small children. One method is profitable.

On Sept. 2, the pharmaceutical giant, Pfizer, agree to pay a $2.3 billion fine to settle civil and criminal charges that it had illegally marketed its pain-killer, Bextra. Bextra, the brand name for valdecoxib, was a COX-II inhibitor, one of a group of pain relievers that worked about as well as ibuprofen (Advil, Motrin) and naproxene (Aleve, Naprosyn) but with less risk of causing stomach ulcers. The other drugs in this group were celecoxib (Celebrex) and rofecoxib (Vioxx), and while they did reduce the risk of ulcers, they increased the risk of heart attacks even more. Meanwhile, Eli Lilly agreed to pay $1.4 billion for its mispromotion of olanzapine (Zyprexa). Merck has settled an estimated 44,000 claims over its COX-II inhibitor rofecoxib (Vioxx) for $4.85 billion.

In 2004, Pfizer had paid $430 million for improper marketing of gabapentin (Neurontin). In each case, the physicians had easy access to accurate information about the approved uses and doses of these drugs, and presumably many did check the facts, but a lot didn’t. The current rules provide mechanisms for drug manufacturers to distribute information about unapproved uses and dose schedules for drugs, and in some areas, particularly cancer treatment, research may run ahead of regulatory review and there are valid reasons for using drugs in an unapproved way — but in the cases of Bextra and Zyprexa, it seems the drugs were being mispromoted to increase sales, regardless of the clinical outcome, and the fines, while high, had all the deterrence value of capital punishment. According to a report in the Indianapolis Star, “During a golf game, one doctor agreed to start new patients on Zyprexa for each time a sales representative parred, or put the ball in a hole within a predetermined number of strokes ...” There have been more reports of medical journal articles being ghost written, with a focus on review articles where the putative author expresses an opinion on the value of a test or treatment. In all these things, physicians, probably only a few bad apples, but still physicians, are participants.

There are no solid numbers to tell how much money is wasted in health care, how much is spent on unneeded lab tests as protection against lawsuits, how much is wasted on drugs that are newer, but no more effective than older drugs. Most of the time, inefficient treatments work, the extra expense is small, and everybody is satisfied, but the cumulative cost runs into an unknown number of billions.

We respect physicians — they’re entitled — but the nature of modern practice may not lead to optimal care. We see our family physician, and never get to meet the serious researcher, or the statistician who analyzes the results, or the faceless bureaucrat who imposes science before friendship, and that’s why it seems important to have decisions made by doctors. The decision is a slam dunk — or should that be a three putt?

Sam Uretsky is a writer and pharmacist living on Long Island, N.Y.

From The Progressive Populist, October 15, 2009