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Who gets to decide on what it means to have a disease? I posed this question a while back in reference to Alzheimer’s disease. I’ll save you from reading the article, but the main headline is that corporations are very much the “who” in who gets to define the nature of disease. They do this either through the invention of disease states or, more often, by redrawing the boundaries of what is considered a disease (think pre-diabetes).

On today’s podcast, we invite Adriane Fugh-Berman to discuss the influence of industry, whether it be pharma or device manufacturers, on healthcare. Adriane founded PharmedOut, a Georgetown University Medical Center project that “advances evidence-based prescribing and educates health care professionals and students about pharmaceutical and medical device marketing practices.”

I’ve listened to a lot of Adriane’s talks. It is clear to me that she is not anti-medicine or even anti-pharma but is very much against both the visible and hidden influences that pharma and device manufacturers use to sell their products.  This could be through overt marketing like advertisements or drug rep visits, or more covert measures like unrestricted grants to advocacy organizations, funding of CME, paying “key opinion leaders,” or the development of “disease awareness campaigns.”

So take a listen and don’t worry, while GeriPal podcasts offer CME, we never take money from industry.

By: Eric Widera


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Moderators Drs. Widera and Smith have no relationships to disclose.  Guest Adriane Fugh-Berman has no relationships to disclose.

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Welcome to the GeriPal podcast. This is Eric Widera.


This is Alex Smith.


And Alex, who do we have with us today?


Today we are delighted to welcome Adrian Fugh-Berman who is professor in the department of pharmacology and physiology at Georgetown University Medical center in the department of Family Medicine and also founder of Farmed Out. Adrian, welcome to the GeriPal podcast.


Happy to be here.


We’re also delighted to welcome back Alexis Colley, who is a resident and palliative resident in surgery and a palliative care fellow at UCSF. Welcome back to GeriPal.


Thanks for having me.


So today we got a really, I love this topic, how pharma invents diseases. So we got a lot to talk about with pharma influence on medical providers prescribing ton to talk about. But before we jump into that topic, we always ask for a song request. Adrienne, do you have a song request for Alex?


Yes. I would love to hear 50 ways to, to leave drug companies.


Now I have it. Is that a Beyonce song?


No, it’s a parody of a Paul Simon song. Of course. 50 ways to leave your lover.


So you wrote the parody. Alex usually writes the parodies, but this is a new one where we have a guest writing.


I love it, I love it. This is a guest written parody. This is great. This will be fun. Here we go.


(singing) Overpromoted med. She said to me, you know, you, we’ve got to treat our patients carefully. I’d like to help you to become pharma free. There must be 50 ways to leave drug companies. She said, it isn’t education that the reps provide and what they know about you, they’re unlikely to confide. What they want to do is control what you persist. There must be 50 ways to leave drug companies. 50 ways to leave drug companies. Have the reps take a hike, mike. Buy your own pen, jen don’t need a free meal, neil. Just set yourself free. Throw away your samples k don’t have to use new drugs. Pay your own cm e lee and get yourself free.


We got more of that song at the end of the podcast, so get ready for it.


That was wonderful.


So we got a lot to talk about, again, on the influence of pharma. We’re going to talk about devices too, on physicians, on providers, how they prescribe. Adrian, you’ve had a long research career, a lot of influence in this regard. What’s your origin story? How did this all start for you?


Well, I started off as a women’s health activist. I worked in reproductive health clinics, and I was very involved with the National Women’s Health Network, which is a consumer advocacy organization that does not take money from drug companies or other industry. So we had been working against medicalization of menopause and medicalization of childbirth, medicalization of other normal life states. So I’d been doing that for quite a while before I decided to go to medical school.

And so I was always an activist. And later, so I went to Georgetown, then to the residency program in social medicine at Montefiore, where I did internship, and then eventually went to work for NIH, worked as medical director of several alternative medical clinics, and then came to Georgetown. So in, let’s see. So I guess more than 15 years ago, the attorneys general of the highest lawyers of every state created a grant program, the consumer and prescriber grant program.

It was funded by punishment money from a drug company, Warner Lambert, which was a subsidiary of Pfizer. It was punishment money for off label, illegal promotion of a drug called Neurontin. And just for our listeners, too, if.


You want to learn more about that, we did a gabapentin super special a ways back where we talked a little bit about how gabapentin rose in fame. I think it’s in the top ten drugs as far as prescribing still to this day, likely because the side effects of this off market are off label push by drug companies to physicians.


Very interesting. I’m so glad you covered that. Yeah. So they funded a number of academic medical centers and organizations to create educational modules on pharma influence. And so farmed out, or we weren’t farmed out at that time, but what became pharma out was funded through one of these. And we’ve been going strong ever since. In fact, once the grant ran out, none of the people who were working with us quit. Even our work study student continued to work for free after our grant ran out. And so we started to just ask friends for money. And we’re still mainly supported by individuals and we’ve been doing great work.


What’s the mission of Pharmdout? What’s the current mission?


I think our main mission is to get pharma out of education, out of medical education, out of continuing medical education. We want a complete separation between industry and education of any healthcare providers.




Because pharma doesn’t have objective information to give. And the idea that we’re partners in this, that healthcare providers and pharmaceutical companies are partners, is a false concept or a lie. Of course, pharmaceutical companies are beholden. They are legally obligated to represent the best interests of their shareholders. And we as physicians and healthcare providers are legally required and ethically required to represent the best interests of our patients.

Those are not the same thing. And what we’re particularly interested in is the COVID means of promotion. So not just the drug reps and not just the advertising, but the COVID influence on medical journals, on medical meetings, on patient advocacy groups, on medical societies. All of this use of third parties


to put out marketing messages that they may not even realize are marketing messages.


Yeah, I guess I’m going to start off with the devil’s advocate position because I actually agree with you, but I’m going to be the devil’s advocate here, is it takes well over a decade for something to become the standard of care. I think that was the party line. It takes a very long time for a new beneficial thing to really be changed in clinical practice. And from a drug company’s perspective, if they have a drug that works, isn’t there a role for sharing and educating physician that this drug is out there? It works. It’s going to benefit your patients.


I think the study that you’re thinking of actually showed that after something has been proven to either work or not work, it takes 17 years to change practice. But that’s when it’s been proven to work. The thing with pharmaceutical company promotion is that it’s most active with drugs that don’t work or are harmful or are very expensive. There’s an inverse relationship between how good a drug is and how much promotion is provided. Which makes sense, right?

If you’re a drug company that has the cure for pancreatic cancer, you don’t need to sell that drug. We’re going to be talking about it at medical meetings. There’s going to be all this buzz that clinicians are going to generate about it. But if you’ve got the 6th or 7th ineffective drug for a particular condition on the market, you’re going to have to promote the heck out of that in order to get anyone to use it. And they’re very effective at changing practice quickly.


That’s fascinating. Not a lot of ads I see for Ozempic out there,


I guess. You know, is this a story, a tale as old as time? Has this been something that we’ve seen for decades, century in medicine, or is this a new thing?


That’s an interesting question. Our topic today is invented diseases. And I think that probably the first or one of the first diseases to be invented for was invented by Arthur Sackler.


I’ve heard that name before, of Sackler fame. Sackler opioid. Oh. What’s the drug companies starts with a p. Purdue.


Purdue, yes. So the Sackler family is most connected to OxyContin. But as Arthur Sackler’s widow likes to point out, he wasn’t around during OxyContin. But it can be argued that Arthur Sackler actually had much more of an effect on medicine, because he actually created the idea of using education as advertising. And he started IMS, which is now iQvia, which is a health data mining organization.

They’re the ones that track all of our prescriptions. They buy that information from pharmacies. And by the way, all of your medical records are also sold to pharmaceutical companies. Companies know what diseases you have, your allergies. Last time you saw a physician, when you go to the hospital, how is that legal?


Isn’t there, like, HIPAA, as long as.


You’Re identified by number and not by name? It is anonymized patient level data, and it’s HIPAA compliant. So there are companies that will take this information and combine it with prescribing information in order for companies to be able to tailor their pitches to physicians when drug reps go into their offices. So when a drug rep goes into a physician’s office, that drug rep knows exactly what antihypertensive that physician prefers for their patients over 70 years old, for.

Eric 11:15

Example, and how well their marketing is working for that particular physician, or that free lunch is working for that particular physician.

Adriane 11:25

But back to Arthur Sackler. So he invented some marketing techniques, that. Brilliant marketing. He’s in the medical Advertising hall of Fame. He was a brilliant marketer, and he was hired at some point by Roche, which had a sedative called. That became was Valium. But they previously had a sedative called librium, and they didn’t want sales of Valium to cannibalize sales of librium. And so the idea that Arthur Sackler came up with is to cast live, cast valium for a different indication, if you will.

So he invented the idea of psychic tension, and that way, Librium could be sold for generalized anxiety disorder, garden variety anxiety, but Valium would be sold for psychic tension. And psychic tension was the discomfort that someone might feel on getting married or going to college or moving. So normal kinds of life stresses that anyone might have. And Valium became a block was the first blockbuster drug. Brilliant market.

Eric 12:35

Yeah, it was amazing how many people were actually taking Valium. Looking at the history of Valium over time and who was targeted towards, which was heavily gender based, is that right?

Adriane 12:47

Yeah, absolutely. Very much targeted towards women.

Eric 12:50

Is that still a theme? Because it feels like, aside from, we’ll talk about, like, low T and testosterone, but it feels like there may be a gender influence there, too. Is there one?

Adriane 13:04

Well, there are many things that are targeted mainly towards women. And I’ll say one thing that has really come up lately is there’s been a resurgence of casting menopause as a disease. And so that’s something that we are going to see more of in the coming years. And this is really sort of a tragedy because feminists worked hard during the sixties and seventies.

Eric 13:40

Maybe just start off with feminists again. We’ll have Tim cut this out.

Adriane 13:45

Feminists worked hard during the sixties and seventies to stop the medicalization of menopause and pregnancy and, and to elucidate that the only symptoms that have been proven to be related to menopause, as opposed to aging, are hot flashes and vaginal dryness. And of course, estrogen was promoted very much from between the sixties and really about the two thousands.

Eric 14:20

I remember in med school, I went to med school, 98 to 2002.

Adriane 14:24


Eric 14:26

Fixes everything. Everybody should be on it.

Adriane 14:28

We thought it prevented cardiovascular disease, we thought it prevented dementia, we thought it prevented strokes, we thought it prevented incontinence. And then the hers trial, which was done in women with preexisting heart disease. And then later the very large, definitive trial, the women’s health initiative, which was done in healthy women, showed us that the harms of menopausal hormone therapy outweighed the, the benefits, and that it really should not be used to prevent any disease.

That menopausal hormone therapy increases the risk of cardiovascular disease, stroke, breast cancer, ovarian cancer, deaths from lung cancer, and also dementia. Dementia, mild cognitive impairment. It actually causes some brain shrinkage anyway, and certainly for severe menopausal symptoms, the only two of which are hot flashes and vaginal gynosts, it can be a reasonable choice, although women should be informed of the risks. But currently, just in the last year or two, there has been this resurgence of, oh, there’s a stigma around menopause. Women can’t talk about it.

Workplaces need to be sensitive to it. Bosses need to hire menopause coaches. The women’s Health initiative. This myth, that myth has been perpetuated, that the women’s Health initiative was wrong and that, and really, women shouldn’t be afraid of using menopausal hormone therapy to address the ten or 16 or 32 symptoms of menopause which include everything from brittle nails to weight gain and brain fog and all of these other things that many of us would love to find a pharmaceutical fix for. But why do you think there was.

Eric 16:14

A resurgence in the last couple of years? I’ve definitely seen it. I’ve seen a lot more even talk on social media about the importance of thinking about hormone replacement therapy. I think there was something just published in one of the medical journals this week about it, too.

Adriane 16:31

Amma just this week published a review by some of the women’s health initiative investigators that just pulled together some of the information about the trial, including the fact that there were fewer adverse effects in women in their fifties. Of course, there were fewer adverse effects in women in their fifties. Women in their fifties have a low rate of heart attack and stroke, et cetera, to begin with. There’s going to be less risk of any disease in women in their fifties rather than women in their seventies, for example. So the review itself doesn’t break any new news, but the way it was reported by media was just terrible, which was saying that, oh, this new study has found that, that everything we knew about menopause, menopausal hormone therapy, was wrong, and it’s really fine for everyone to take it. Really terrible coverage. Terrible.

Eric 17:26

So I guess another question is, again, this is kind of like the, it’s not really invention of disease. Right? Like, menopause is menopause, I guess you can argue it’s not a disease. It’s a natural part of life.

Adriane 17:40

It’s a really artificial designation. You know, menopause is, is when you’ve gone a year without having a period. You don’t even, you don’t even know when menopause is. The only thing you could actually celebrate is the one year anniversary of menopause. Right. Because you don’t know with any period whether that’s going to be your last.

Eric 17:57


Adriane 17:58

So there’s no real medical distinction for menopause. And, of course, if you just throw in any condition that has to do with aging or has to do with life in there, people.

Eric 18:10

Low testosterone.

Adriane 18:12

Low T. Low T. And by the way, testosterone is now also being pushed for menopausal women, like, added on to the estrogen. Well, there’s no such thing as a harmless hormone, and low T was pushed a number of years ago. There’s been less of a push recently, perhaps because the FDA, the FDA actually changed the label on low T, which makes it harder. I’m sorry. They changed the label on testosterone, which makes it harder for companies to push it for low T. Or of course, they always have, like the medical name. So low T was what they called it to consumers, but to clinicians, they called it late onset hypogonadism.

Alex 18:56

You gotta.

Eric 18:57

How do we tend to fire that up?

Adriane 19:01

And certainly with low T, it was really exactly like menopause. Like, is your sports performance less than it was five years ago? Do you ever get tired after dinner? Anything with an online questionnaire? A lot of these invented diseases have these online questionnaires that are designed for people to fail. Like, we gave the low T test to anyone who walked into my office over a period of several days, and even the 25 year old women failed it.

Alex 19:38

A lot of what you’re talking about reminds me of Noam Chomsky’s manufactured consent, this idea that these drug companies are creating conditions and then marketing them to consumers in order to sell their products. I wonder if you were influenced by Noam Chomsky in your work.

Adriane 19:58

Oh, you’ve got to love Noam Chom Chomsky. Yeah, that is a really interesting. That’s a really interesting thing to bring up, because manufacturing consent is very much what pharmaceutical companies do with clinicians. They make it seem as though they’re deferring to us and we are making our own decisions, but in fact, they’re really manipulating us. And they also do this with consumers in consumer advocacy groups, which have become extremely important means for pharmaceutical companies to get their messages out.

There are more than 7000 consumer advocacy groups in the US, and there are fewer than two dozen that are not funded by pharma. We actually have a list of the non pharma funded groups on the pharmed out website because it’s a lot easier to keep track of the non pharma funded ones than the pharma funded ones. And the ones that take money from pharma are always up before the FDA or before Congress or before the media backing bad drugs, for example, anyway. And because marketing for drugs starts seven to ten years before a drug comes on the market, it’s very difficult to identify. It’s illegal for a drug company to market a drug before it’s on the market, but it’s not illegal to market the disease.

And I’m sure that there is a company coming out with a low dose estrogen product, maybe a transdermal estrogen product. Cause we’re seeing a lot on, oh, transdermal preparations. Low dose preparations will have all the benefits and none of the risks, which of course has not been established anyway. We’re seeing what we’re seeing now with menopause shows that this is what we call what industry calls a pre launch marketing campaign. And so it’s very difficult to identify the marketing messages when marketing starts up to ten years before a drug comes onto the market.

Eric 22:02

I got a question. So there is a big push right now in the aging space, in particular Alzheimer’s disease, to relabel Alzheimer’s disease as just having a positive amyloid test, whether it be a biomarker, PET scan, so a blood test. And that’s being pushed by the Alzheimer’s association, a workgroup that was heavily dominated by industry. Like a third of the members are directly employed by industry. Another third have significant conflict interests and Alzheimer’s disease. Alzheimer’s association gets a lot of money, too, from industry. Is that part of it, too, where people are now thinking about five to ten years from now, we already have the biomarkers. Maybe we’ll have a drug that they can market. They have a drug right now, they can market towards MCI and Alzheimer’s disease. Do you see this as a similar phenomenon that’s going on, or do you see this as separate?

Adriane 23:08

No, I’m really glad that you brought that up, because what’s happening in the Alzheimer’s disease area is actually really horrifying. There are several of these drugs. A population with Alzheimer’s disease has more amyloid plaque, these sticky plaques in the brain, than population without Alzheimer’s disease. But many, many people, especially over 50, have amyloid plaque in their brains and they have no cognitive deficits at all. So there’s not a clear. There’s not a clear link between amyloid and Alzheimer’s. And, in fact, getting rid of rename.

Eric 23:46

Alzheimer’s as just have or redefine Alzheimer’s as just having amyloid, then there’s 100% accuracy.

Adriane 23:52

Exactly. And what’s really horrifying about what the Alzheimer’s association is doing is they’re saying exactly what you said, that Alzheimer’s disease is if you have amyloid plaque that is assessed now, can be assessed by a blood test, even if you have no cognitive deficits at all, that is.

Eric 24:12

Just and may never have any in the future.

Adriane 24:16

And you may never have any in the future. And, of course, any of us who are over, like, 40 or 50 think that every time we forget our keys, it’s like we’re on this downhill slide. But I have to tell you, this is a wonderful thing about being a professor in the university and dealing with young people because they have the memory of house flies, really because they’re 22 and those of us over 40 just think that anytime we can’t remember a name or whatever, that it’s all starting.

But these drugs are really. They’re really not effective drugs at all. We’ve had bad drugs for Alzheimer’s before. We had some. We had some drugs that we prescribed before, and I used to teach my students that these drugs only caused a small improvement in symptoms. They have adverse effects. We probably shouldn’t use them, but at least they caused a small improvement in symptoms. The drugs that are being promoted and are most widely used now cause no improvement in symptoms. They supposedly cause a small decrease in the rate of decline over years, which will not be apparent to either the patient or the patient’s caregivers. And these drugs cause brain bleeding and shrinkage. Brain bleeding and swelling and shrinkage in a significant number of patients.

Eric 25:39

Yeah. So, because it’s interesting, algae helm came out, there was another one of these surveys, right, about memory problems. And I failed that one.

Adriane 25:51

So did my 22 year old students. It’s okay. Mild cognitive impairment. Of course, not only does it not usually progress, it’s a very squidgy diagnosis. It does not usually progress to Alzheimer’s, and it can change when it’s tested over time, and there’s a great overlap with depression, and a lot of drugs can cause it.

Eric 26:14

But isn’t that true for everything? Everything’s a little squidgy. Right. So I listened to several of your talks. You talked about pseudobulbar affect, right. There are people who have real. Who are suffering from pseudobulbar affect from ALS or a severe stroke. And I’ve had one of those patients, too, who struggled with it, but that’s a very narrow market and probably one you’re not going to make a lot of money on. So there’s a push towards enlarging that market, just like enlarging Alzheimer’s, not just people with MCI, which is incredibly hard to diagnose, but anybody with amyloid in their brain. Isn’t that true for everything? Even, like, low T, low testosterone? There are people who probably fall on that spectrum who have incredibly low testosterone that may benefit from those medications. Isn’t this all about the squidginess?

Adriane 27:15

Well, there are certainly some diagnoses that are more squidgy than others. There’s a lot. The area in which there are the most invented diseases is in psychiatry, because every psychiatric diagnosis is subjective. We have no blood tests for psychiatric diagnoses. There’s a lot of invented diseases in psychiatry, so I’m not sure that every diagnosis is squidgy, but.

Adriane 27:48

Okay, now I’m blanking on what you just. The couple that you just mentioned, pseudobulbar.

Eric 27:52

Affect, we talked about Alzheimer’s disease, low testosterone.

Adriane 28:00


Eric 28:01

Yeah. And then oftentimes, we’re talking about not diseases, but risk factors that have been labeled diseases like prediabetes.

Alex 28:10


Eric 28:11

Prediabetes is a good one out there, where it’s really a risk factor for a risk factor which can cause significance.

Alex 28:21

I have prediabetes. I’ll disclose my health information.

Eric 28:24

You’re gonna name it as a disease.

Alex 28:26

And I have osteopenia. What you think about that?

Adriane 28:31


Adriane 28:35

So with pseudobulbar affect, for example, that is a real condition, but it’s very rare, and so expanding the market makes a lot of sense if you want to make more people eligible for drug treatment. And one of the test questions on a test for pseudobulbar affect was, do you often find things funny that other people don’t think is funny?

Eric 29:01

You laughed, Alex. That’s a positive right there. That is not a funny statement, Alex.

Adriane 29:08

Right. Yeah. So let’s see. But basically, anything that has pre. Before it, you should just ignore pre hypertension, pre diabetes. You know that pharmaceutical companies have had a hand in this. I remember in medical school, we were taught that a blood pressure of 120 over 80 was perfect. That was the goal for blood pressure. And now it’s pre hypertension. And, of course, there are many more healthy people than there are sick people. And anytime you lower the standard, and they have been lowered in all of these cases, you lower the standard for what we call hypertension, what we call diabetes, what we call hypercholesterolemia. Anytime you lower those standards, you’ve made a lot more people eligible for drug treatment.

Eric 29:54

Yeah. And it feels like that more than an invention of diseases. It feels like redefining diseases is a huge marketing focus of pharma.

Adriane 30:06

Yes, absolutely. And, yeah, prediabetes is a good example of that as well. You’re under the limit of what would be considered diabetes. It may never change. Just ignore it.

Speaker 5 30:26

Oh, good.

Alex 30:27

I’ll have the cookie after the podcast.

Eric 30:30

Well, I also think about my own experience as internal medicine doctor, and over the years, pharma’s influence on us. And I’m wondering, from a surgical perspective, Alexis, do you see the same from pharma or any other influences that come to your mind?

Alexis 30:49

Yeah, I mean, I think certainly as a trainee, under different circumstances, sometimes we don’t have our own offices, but we certainly encounter device reps, surgical device reps in our operating rooms every day. And I think it’s an interesting topic because they’re very knowledgeable, of course, about their products, and they’re often practically helpful. Your stapler gets jammed when you’re trying to resect part of the lung. And so they know exactly what to do under a very stressful situation. But I was wondering if you could talk a little bit about sort of devices and that aspect maybe not so much farmed out, but device doubt, I guess.

Adriane 31:42

Well, we do look at devices as well. And while the regulation of, the regulation of, of pharmaceutical drugs really needs improvement, and we actually have a whole report on our site, on 140 page report on improving the FDA that goes into a lot of these issues. Well, there’s a lot of regulation, a lot of problems with drug regulation. There’s even more problems with device regulation. So for surgically implanted medical devices, companies can get a surgically implanted medical device approved without ever testing that device in a human.

Most surgical devices are approved under a 510 or substantial equivalent standard, meaning that the device is substantially equivalent enough to a previously approved device, which may have been approved based on the previously approved device. And down the line, as long as you can show that you’re substantially equivalent, you can be approved without ever being tested in a human. And while the relationships between drug reps and doctors are highly problematic, they’re even more problematic between surgeons and device reps. Device reps are in the operating room.

They are assisting the surgeon. They’re not allowed to actually handle the tools or touch the patients, but they may be using a laser pointer to tell the scrub tech which tool to hand the physician. And they are there to create to help the physician and the team. Hospitals love them because they don’t have to adequately staff their operating rooms with scrub techs who know what they’re doing, but they are there to upsell product. They are there to sell. And of course, they are only selling one company’s products.

They will target the heads of residency programs, because if the head of a residency program only uses one particular company’s hips and knees, that’s what the residents will use. So it’s a great investment. They bring the residents to trainings and get the cadavers for them to practice on, and they provide all kinds of services. So they have much closer relationships with surgeons than even, than drug reps have with physicians. And it is highly problematic.

Alexis 34:00

Yeah, that’s really interesting. I mean, I think as trainees, we’re not always aware of sort of the financial relationships between people who are educating us and who might be receiving reimbursement from these companies. But it’s always been a fascinating tension, I think, because getting to know the reps can be helpful in some ways. Cause they teach you about different devices and you’re a trainee and know very little when you start out. But it’s always seemed like this very interesting tension also. Cause they’re just there in the operating room and they’re like a real person. And so. Yeah, so thank you for bringing nice.

Eric 34:45

They’re not evil. Like, I actually went to Boston to give a talk on about geriatrics and palliative care to ACP audience, to general physicians, and afterwards drug up from Isai. So one of the canamab makers came up to me and talked. Super nice guy. Had a great conversation with them. And it.

Adriane 35:11

Of course they’re nice.

Eric 35:12

Yeah, it’s their job. It’s their job.

Speaker 5 35:16


Eric 35:16

But I think that’s. I think that’s one of the tricks here is that, like, part of this is that we think, like, we’re good and moral people. And, you know, the people who accept these lunches, who go out to dinner probably feel the same. Like they’re. They’re good people. The reps think that they’re doing this for good causes. Like, most of them are not evil people that are trying to get that patient, but they’re doing it to educate surgeons about how to use their devices. So we rationalize a lot of this.

And I also wonder, and part of me feels like I am much more scared of the person who says, oh, that pharma dinner doesn’t influence me at all. I am much more scared of them than the person says. I recognize that this has some influence upon me, and this is how I think about it and I’m doing about it, or I try to avoid it at all cost. And I just wanted to get your thoughts on that. Just like the Alzheimer’s association, made up of great people, great mission, I don’t think any of them are doing this for what they’re thinking is a nefarious reason. They have rationalization.

They have rationalizations just like the people who make up that work group. But, man, I wish they would say, you know what? We are still human beings, and we’re influenced by bias, and we’re influenced by gift giving, we’re influenced by money, and this is what we’re doing to prevent that from influencing how this work group operates.

Adriane 36:50

So it would be great if people were aware of influence, but there have been studies that show that that talks like the ones that farmed out gives. Maybe similar to this kind of talk that we, that these kinds of educational interventions can convince physicians that physicians are affected by industry, and yet it doesn’t change people’s individual minds about whether they themselves are influenced. So you can. Colleagues are susceptible.

Alex 37:19

Not me.

Adriane 37:20

Right. Not me.

Alex 37:21

Those weak willed others, as little as.

Eric 37:23

A, like a two to five dollar gift can influence how people’s prescribing behavior.

Alex 37:28

Yeah, great study from Mike Steinman and Steve McPhee. This is back in 2001 of principles and pens, attitudes and practices of medicine house staff towards pharmaceutical industry promotions. Residents hold generally positive attitudes towards gifts from industry, believe they are not influenced by them, and report behaviors that are often inconsistent with their attitudes.

Adriane 37:51

Yes, absolutely. And we did a study, I did a study with Doctor Susan Wood at George Washington University School of Public Health of Medicare prescribers in Washington, DC, and we found that taking any gifts from pharmaceutical companies, including just a meal, resulted not only in prescribing more branded drugs and more expensive drugs, but more drugs. People who took gifts prescribed 2.3 more prescriptions per patient. And of course, you know, polypharmacy is a huge problem in our patient population, especially among elderly people. So it was horrifying to see that people were actually prescribing more prescriptions when they took one pharma.

Eric 38:32

I also feel like I see less about gifts or like vacations to Hawaii, like these days, nineties, or the two thousands you’d have these big vacations, or. I see a lot more on CME and the influence.

Adriane 38:47

I’m so glad you brought that up because, yeah, in most, most continuing medical education that physician see is funded by pharma, and it always has marketing messages in it. And whenever I say this. So industry will always respond to say, oh, no. There are four or five studies that show that there’s no industry influence on CME. And I love the studies that they refer to, because their studies always refer to. If you ask physicians after an industry funded CME influence, 98% say no. But in fact, every study, including a number we’ve done, most of them, every study that has actually examined whether their marketing messages in CME have all found them. 100% of those studies have marketing messages, and they’re hard to detect. Like, if I look at one continuing medical education module on a drug, or I can’t necessarily tell what the marketing messages are, but if I look at six of them, I can tell you, so this is how we torture our interns.

Eric 39:48

What are some examples?

Adriane 39:50

Oh, well, so for example, we did a paper on marketing messages in establishing the diagnosis of hypoactive sexual desire disorder, or low libido in women, which is really not a medical problem.

Eric 40:09

Was there a survey for that, too?

Adriane 40:12

Oh, yeah. One of the questions that’s asked on the female sexual function index, which is used by physicians to diagnose hypoactive sexual desire disorder, was how often do you feel sexual desire or interest? And in order to score the highest, you had to say that you felt sexual desire, interest, all or almost all of your waking hours.

Eric 40:40

That was totally written by a dude.

Adriane 40:45

So, you know something that people would just fail. But so some of the marketing messages in hypoactive sexual desire in the CME on HSTT was, well, often a very common marketing message for all of these things is it’s a tragic epidemic. It’s what we call a tragic epidemic. It’s like, this is a far more widespread problem than physicians know, and it’s much more serious than. Than it is currently perceived. People might be unaware that they have it. You have to elicit these symptoms with the questionnaires, which we so hopefully, we hopefully provide.

Eric 41:24

I would also add there is, you know, pharmaceutical companies don’t really care about diversity in their trials, but when it comes to marketing their messages, you hear a lot of equity issues come up.

Adriane 41:35

Oh, absolutely.

Eric 41:36

Recently, in the last, like three to five years. It’s always an equity issue, but never an equity issue when they’re actually enrolling patients in their trial, which is mostly like white.

Alex 41:48

I have a question about, and I want to see if Alexis has a question, how do we change this? And I’ll just start by saying, oh, sorry, that’s my pager going off.

Eric 41:59

Alex is getting called by pharma right now.

Alex 42:05

I’m a member. I’m a panelist for CTAF, which is a member of ICer, the Institute for. I think it’s clinical and Economic Review, which evaluates not just the evidence for effectiveness of new drugs and devices, but also the cost impacts and related to what you’re talking about before about the pharmaceutical sponsoring the patient advocacy organizations. We see that at our meetings all the time, where so many of the patient advocacy groups and the patient representatives are appealing. Please approve this.

Please approve this. And so many of them are part of organizations that are heavily conflicted and sponsored by drug and device industries. That said, ISIR and the mechanism of evaluating this is sort of similar to what nice is does in the UK is one lever to address this issue. I’d love it if you could talk more about farmed out and the mission of farmed out and how it will influence or should influence, ought to influence. You hope it will influence this and whether there are other levers that our listeners should be thinking about in order to affect change.

Adriane 43:25

Yeah, so ICER is great. And yeah, doing comparative effectiveness studies of drugs and therapeutics is really important and something that is not required in the US and something that healthcare providers can certainly do is to avoid relationships with pharma and with medical device manufacturers. Not seeing drug reps, not going to industry funded events. And it’s not just physicians, because a quarter of prescriptions these days are written by nurse practitioners and pas, for example, avoiding all industry funded results and depending on unbiased sources of information from ICER and other places as well.

So that’s something that can be done. These patient advocacy groups are not required to disclose their conflicts of interest or their funding. The sunshine act, part of the Affordable Care act, requires pharmaceutical companies to disclose their payments to physicians. And now MP’s and pas as well. They should be required to report their payments to consumer advocacy groups. There should be conflict of interest disclosures at every meeting in which these advocacy groups are. And legislators and regulators and media need to not be swayed by emotional appeals when it’s really evidence that we should be looking for.

There’s a romantic idea that, that new drugs are always better and they don’t need to be adequately tested. And really new drugs and therapies may make life more miserable and kill people faster. You don’t know which one of those it is until you actually do a careful assessment through clinical trials.

Alex 45:12

Yeah, Alexis?

Alexis 45:14

Yeah, I was just curious, from the trainees perspective, would you advocate, or is there any movement for programs or even schools of medicine to be more transparent with their trainees about what is sponsored, what’s not? I was just at a recent Cadaver course actually, and I have no idea who funded that weekend. There were device reps present, but that sort of relationship was never discussed. Any thoughts about medical education and graduate medical education with all of this?

Adriane 45:51

Yeah, I don’t think there’s much of a movement there, and there should be that medical students and residents should be demanding that conflicts of interest be disclosed, but also that their education is free from industry influence. Doctors should be teaching each other. And some of the device reps that we interviewed for some papers that we did, who were medical students at the time and who are now physicians, they wanted to go into surgery and both of them said they would never let a device rep into their operating room.

And one of them said, if you’re not willing to learn the equipment, find another job. So talking to people within industry gives you a really different view. Healthcare providers are being manipulated. I mean, as I said, farmed out is, you know, we’re really interested in these. These. These covert, these hidden methods of marketing, using third parties to convey marketing messages …

Adriane 46:56

and being used to affect regulation, legislation, the approval of drugs and devices, and media perceptions of particular diseases. So we all need to be fighting the medicalization of life. And please subscribe to our newsletter. We’ve got a podcast, Pharmanipulation as well.

Eric 47:15

And I just go to “Farmed Out” to subscribe?

Alex 47:23

Say the name of your podcast again.

Adriane 47:25

And our podcast is Pharmanipulation .

Alex 47:27

Great title.

Eric 47:30

Well, I want to thank you for joining us, podcast. But before we leave, I think we have a little bit more of the song, the parody song, and before.

Alex 47:38

I love this parody song. The first line in the next verse is, she said, it grieves me so that you’re a Kol. Capital Kol. What’s a Kol?

Adriane 47:48

A Kol is a key opinion leader or a nationally known influencer.

Alex 47:53

Okay. And what’s an example of. So that would. Oh, this is talking about you.

Adriane 48:00

Well, no, Kol, it’s an industry term for a nationally known influencer who can shape the perceptions of other healthcare providers. So usually somebody at a well known academic institution who can, you know, go out across the country and tell people that hypoactive sexual desire disorder is a horrible disease. That kind of thing.

Alex 48:18

I see. Okay. All right. Thank you.

Alex 48:26

She said, it grieves me so that you’re a Kol master. Asking marketing as education doesn’t serve us so well. I said, I resent that. But would you please explain about the 50 ways? She said, we owe it to our integrity. Together we can throw industry out of CME. And then she pinched me, and I realized she was probably right. There must be 50 ways to leave drug companies. 50 ways to leave drug companies.

Alex 49:10

Join in. All right, here we go.

Alex 49:14

(singing) Yeah, have the rips. Take a hike, Mike. Buy your own pen, Jen. Don’t eat a free meal deal and get yourself free. Throw out the samples. Hey, you don’t have new drugs. New drugs. They won’t seem easily. And get yourself free.

Eric 49:38

Thank you for joining us on this podcast. That was wonderful. I encourage all of our listeners to check out Farmed Out and listen to the podcast Pharmanipulation. And thank you to our listeners for your continued support.

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