My drug-company habit started innocently enough—a pen here, a lunch there. But soon I hit the harder stuff: a trip to Italy in exchange for attending a symposium, tickets to a Mets game for my sons and me (and a chatty drug rep). Et cetera. There's a moment when each of us knows we have gone over the edge. For me, it was a trip to California where I met with a pharmacist for 30 minutes to talk about antifungal medication.
And so now I am in recovery. I have not taken money or meals or pens or trips or any of it for about a year. It is hard, but every day I wake up and tell myself, today I will not take money from a drug company. Today I will stay clean.
There remains one problem—I don't feel that much shame for my former behavior, at least the money-grubbing part. I just don't think that the financial hanky-panky between drug companies and doctors constitutes the central crisis in American medicine or, for that matter, the most corrosive aspect of the entire messy doctor-drug relationship. They need us; we need them. We do the studies they can't do because they aren't doctors. They invent the drugs that we can't invent because we aren't chemists. It's pretty straightforward, really. A symbiosis.
Which isn't to say either side is particularly admirable. Estimates are that pharma spends $8,000 to $13,000 per doctor marketing its various products. Most of the promoting is done in the name of physician education. Yet, like the trip to Italy, it is generally a faintly camouflaged bribe, offered with a wink and a promise of more to come. In exchange for the business-class tickets, the doctor indicates (unofficially, of course) that he will prescribe more of product A, which is made by the crowd that paid for the Italian adventure, than drug B, which is made by a company that hasn't ponied up (yet).
It's a sleazy proposition all the way around. But as Calvin Coolidge once said, the business of America is business. Successful businesses want to sell as much as they can, as fast as they can. So doctors end up with meals and pens and trips and bogus advisory-board positions and, of course, the hordes of fine-looking well-perfumed young men and women—some literally cheerleaders—who hustle their way through physicians' offices.
Despite its successes, the pharma business model does have a problem. The drug reps, foot soldiers in the mercantile crusade, don't know what they are talking about. Unlike a shoe salesman or the guy who sold you your laptop, the drug rep is 100 percent lost. Imagine buying a car from someone who's never had a driver's license—that's how the doctor-drug relationship plays out. None of the people trying to convince me to prescribe product A ever has prescribed product A—or product B or product C for that matter. None has ever experienced the elaborate mess that is routine patient care. The freebies seek to redress this imbalance by making the exchange seem worthwhile.
And so does the drug-company tactic that, unlike meals and frequent-flier miles, poses a real if subtle danger. In place of expertise, the drug reps offer flattery—and with it, a revival of the old cosmology that puts the doctor at the center of the universe, as infallible as he was in the good old days.
Alas, we doctors are easy targets. We feel unappreciated by our patients and by the public. The way we see it, we're just a bunch of blue-collar Joes with a degree, traveling through rain and sleet and snow trying to keep people healthy. Like the president, we think it's hard work and, also like Mr. Bush, we are genuinely shocked that everyone doesn't love us.
Enter the drug reps. Those guys love me; they really love me. I have my own personal troupe of professional grovelers who are paid to laugh at my jokes. You should join me when a few are in my office. It is a laugh riot. And you should hear the compliments I get after giving a paid lecture. My back is patted. I receive countless business cards and compliments.
All of this upsets the physician's internal balance. Doctors make countless decisions every day, and lots of them are wrong. Rethinking the errant judgment is a crucial private exercise. But once the tune of the drug-rep marching band gets going, it drums out reflection. The lonely, monotonous routine of doctoring gives way to the cheap thrill of low-grade celebrity.
So don't bother attacking the freebies. Instead, take aim at the root of the problem—your doctor's insatiable quivering ego. It's not our fault, really. We've been working in a drug-company haze for far too long.
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