It's twilight over the beach and the blue Pacific. The trade winds carry the
scent of the sea mingled with touches of ginger and barbecue smoke. I'm
seated in the dining room of an elegant restaurant on the windward side of
Kauai, finishing a cocktail and getting ready to spear a crab cake
pupu with my chopsticks. Somewhere between the crab cake and the ahi
carpaccio, the lights dim and a PowerPoint presentation begins. Then I
notice that jaws are beginning to drop all around our table, and that all of
the jaw droppers are nonphysicians.
The speaker -- a physician from a neighbor isle -- is telling us about
therapy for irritable-bowel syndrome. Every few words he utters (or projects) are
"diarrhea," "bloating," "constipation" and, of course, the combination of
"diarrhea and constipation."
Our entrée choices of prime rib or mahi mahi arrive at the table.
"Diarrhea... constipation."
Dessert is chocolate mousse or cheesecake.
"Constipation... diarrhea."
"Coffee, sir? Decaf, or regular?"
"Diarrhea... constipation."
This goes on for another 45 minutes, while jaws continue to drop and
giggling spreads from table to table. Finally, the speaker mentions a new
drug for irritable-bowel syndrome, a product of the very same pharmaceutical
company that is paying for the drinks, the pupus, the wine, the
dinner and the little bag of medical knickknacks each doctor got when he or
she walked in.
What distinguishes this free feast from the others routinely offered to
physicians is the fact that there are so many nonphysicians -- spouses and
teenage children -- in attendance. That's no surprise: When someone in the
family has to go to Hawaii on business, other family members say,
"Take me along!"
Physicians get used to enjoying a meal while listening to descriptions and
looking at pictures of all kinds of pathology. We become a desensitized out
of the necessity to get through the workday and still be able to eat. Our
spouses and children are different.
Tonight's dinner and entertainment are compliments of the pharmaceutical
company whose sales representative invited me. Salespeople in general
are quite likeable folks. You need to be likeable to be successful in sales.
And there's no denying that pharmaceutical reps have been helpful to me.
During the early (and expensive days) of the Internet, pharmaceutical
companies would do computerized literature searches for me gratis, providing
beautiful printouts in neat folders bearing the company logo. Reps or
detailers have also arranged for me to get extra samples of medications I
can distribute to my more needy patients.
The rep who invited me to this dinner is truly a nice guy.
"Thursday night at seven," he said.
"Sure, I said."
"Bring the wife," he said.
And I did. And the price of our meal was added silently to the price of
prescription drugs.
Pharmaceutical companies claim that a big portion of their revenues goes to
fund research. That may be true, though it hardly explains why the same
medications from the same company cost half in Canada what they do in the
United States. Part of that "research" is clearly market research.
Ten years ago, I conducted a small study of the unsolicited mail I received
as a physician. I carefully logged and weighed every piece of this mail -- the
slick magazines, video cassettes, refrigerator magnets, penlights, music
boxes and custom-printed Post-It notes, and more pens than you'd find in a
stationery store's stock room. Reasoning from my own experience (which may
or may not represent the average doctor) of receiving more than 500 pounds
per year of such mail, I concluded that 1.5 percent (by weight) of all the
mail sent in the United States is unsolicited mail to physicians.
That equals several million pounds of mail. Even if my calculations were off
by a factor of ten, it's still millions of pounds. Almost all these mailings
are subsidized by pharmaceutical companies. Imagine how much it must cost to
print and mail a million pounds of anything.
Then there are the tickets to sporting events (the Yankees-A's game was
great) and concerts, plus reference books for my library and all kinds of
nifty packs and carrying bags.
It adds up to lots of money. The consumer pays.
I, of course, consider myself immune to these blatant attempts at
persuasion. Am I? I think so. I read serious medical journals and unbiased
reviews of medications. I always try to prescribe based on hard evidence. I
use effective generics. I want the best for my patients.
I also know that someday I'll have a patient with irritable-bowel syndrome
tell me she's tried everything. I'll ask her if she's tried the
drug-that-paid-for-my-dinner. If she says no, I'll consider saying something
like, "There's this new drug. It's pretty expensive, and I know that your
insurance doesn't cover it, but it might be worth a try."
Ka-ching!
So it's probably time for Doctor E to take the pledge once more. To swear
that he won't take any more of these gifts. To promise to get his
information about drugs only from objective, unbiased sources. "I'm sorry,"
I'll say to the next drug rep, "but I can't accept your invitation. I'm
doing my part to keep drug costs down."
That's what I'll say -- but do you realize how much ahi carpaccio costs when
you have to pay for it out of your own pocket?
