Dollars for Docs

I apologize to my loyal readers for not posting in a long while.  Fortunately, I was awakened from my torpor by an eye-opening new database that lists some of the money paid to specific doctors by pharmaceutical companies.  The Pulitzer Prize winning investigative journalists at ProPublica tapped the public disclosures of seven companies that have begun posting names and compensation on the internet, some as the result of legal settlements.  ProPublica’s “Dollars for Docs” provides both an overview of the issue, as well as a handy database search function.  It is easy to look up specific doctors, or (as I did)  to scan through a whole city or town to see who received money from these seven companies in the past two years.

Some caveats are important.  First, the seven companies represent just over a third of all pharmaceutical sales in the U.S.  The health care reform law, signed in March, mandates that all drug companies report such data to the federal government beginning in 2013. That information will be posted on a government website.  So, this is a preview of the data to come.  Research funding is not included here, only speaking, consulting, and related activities.  It is also important to keep in mind that listed payments are not automatically unethical or illegitimate.  For example, honest consulting relationships between doctors and drug companies reasonably include travel expenses and a consulting fee.

Nonetheless, most of the listed activity is pretty suspect.  I first learned about “Dollars for Docs” from Dan Carlat’s blog.  As Carlat points out: “The vast majority of payments are for doctors who give ‘educational’ talks to other doctors, presumably focusing on one of the drugs made by the funding company.”  And as he notes, the sheer enormity of the database is probably its most striking aspect — published surveys show that well over 100,000 doctors receive cash from drug companies.  Most of the amounts in the database are small, up to a few thousand dollars, not much compared to the income of most doctors.  But some are considerably higher.  My eye-opening experience was to scan the list of San Francisco doctors, where I found a few colleagues I know who added tens of thousands to their income in 2009 and 2010 speaking for drug companies.  It makes me think differently about those doctors — which is the point, right?

Supporters of the status quo argue that there are many other potential conflicts of interest, and that not all recipients of industry money are necessarily biased.  Both of these points are true, but irrelevant.  Money is universally recognized as motivating; that’s why people are paid to work.  A universally recognized motivation, voluntarily chosen and standing here in plausible conflict with unbiased patient care, should be unacceptable from the perspective of medical ethics.  Medical ethics does not stop with financial conflicts of interest.  Physicians are prohibited from sexual relations with patients for similar reasons: A sexual motivation is very likely (although not absolutely guaranteed) to conflict with clinical care.  Other systematic sources of bias will be addressed when they can be identified and controlled.  The fact that we can’t minimize all sources of bias is not a compelling reason to ignore obvious financial ones.

When comprehensive numbers are available online in 2013, we will finally have meaningful disclosure about this potential conflict of interest.  What we as a profession, or as the public, do with these disclosures is another matter.  As I’ve noted before, the public seems more concerned than the medical profession itself about industry-fueled bias.  To that end, patients may begin to use such public databases as a means to choose doctors.  The website of the newly formed Association for Medical Ethics features a searchable database similar to “Dollars for Docs” but with a more explicit message: that accepting industry support is unethical in clinical practice.  If this idea catches on — and I suspect it will, at least in some areas — speaking and consulting fees will not be the only financial motivation at play here.