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PRI-MED FOR COMPLETE TAKEOVER (or, PROFIT OF DOOM)

Clinical research and education have become marketing tools
completely controlled by drug manufacturers.

I see and hear him every day for a time, sometimes like today for a longer more vivid visit, sometimes so subtle I go about my business as if he did not matter.  I usually see and hear him through myself, not so much across the room reflected as from a mirror, but more as if I stood within a hologram of him, as if I were going about my affairs in the world from within a mask or shell shaped like him.  I suspect I am not only beginning to see through his eyes and to hear through his ears, but to feel his feelings.  I fear I next will begin to have his memories, so gradually to cease to seem myself (whom I have come to doubt and criticize), to become him, the one of the two of us I have come to accept and to trust as more whole, more humble, more human.  I am becoming  my father.

I sit in a medical seminar, a review course where several hundred well-educated well-behaved credentialed physicians seek to maintain their respectable appearances.  For a solid week from dawn to dusk I have been open, receptive, fed as if a compliant dependent baby bird.  Years ago I rigidly resolved to no longer pay to sit and listen to such lectures, that I would thenceforward participate only if I were myself the lecturer, if I were the one to be listened to, if I were the one to be paid.  Such arrogance as mine is a rebound or pendulum-swing of humility:  I had humbly served my patients sincerely in long suffering, I had learned from them each indelible lesson of reality which had been inscribed on their unique bodies and life-histories (the truths which appear in no published textbook).  So, I came haughtily to refuse to listen to others lecture their authoritative algorithms and protocols projected orderly on the wall in a production designed to render the professors’ egos huge, glossy, smooth and shiny.  I was angry at their fatuousness, their belief in the truth of whatever they heard themselves articulate.

My father may have tolerated medical lectures more gracefully than I, and perhaps he had hidden his self-righteous anger as well as he could, but he could not avoid crucial exposures and reactive explosions at least on some occasions:  when his fellow physicians would not accept a black physician; when his fellows would not deign to serve the black community as patients; when his fellows would not work at the veterans’ hospital, insisted the sick and injured veterans be carried to their own offices for their own convenience.  When some leaders of religious congregations my father participated in made real estate cabals for the sake of their own profit, my father could no longer contain his anger’s own physiology, so he had his myocardial infarction, his bypass surgery, his stroke.  In one day he lost seven languages, but without language came to communicate effectively for the first time in seventy-five years, learned to listen.  He became imperfect, human (not at all like a doctor).  He began to learn (to make his own bed, his own breakfast, to feed and pet the cats).  He began to love more simply, and thereby became more easily loveable.

Now, what shall I do?
Father’s Day, 2000

 

That was several years ago.  Now it all has made me very sad and very tired.  Allergic to the arrogant egotism of other doctors, I had resolved never again to attend any medical lecture unless I was listened to.  Brief contemplation confirmed that such a resolution smacked of arrogant egotism.  Humbled by confrontation with my own haughty self-image I recently enrolled in a big CME-fest where hundreds would be guests of the health-business corporate sponsors.

Enthusiastic as a new kindergartner I came early, took my free bagel, took my seat and prepared to attend assiduously and appreciatively.  The coffee was hot.  The Power Point projectors were in focus announcing the first presentation.  The big fat ring-binder syllabus was clean and thorough-looking. The microphones worked without feedback.  The physician-speakers appeared polished, bright and erudite.  I admired the preparation and I anticipated an uplifting and tolerable two days of thirteen one-and-a-half hour presentations touted as the latest research and official committee guidelines for treatment of the various major diseases.

It took a presentation or two for me to begin feeling a new dis-ease.  The presentations reviewed various drugs in their generic identifications, but the data and the opinions tended to make my doctor-mind prefer only one of them as I asked myself the practical question:  Which of them I would prescribe for my patient with those symptoms.  Then I began to recall some of the names I had seen when I got my bagel and coffee, the brand names of the first-favored drugs.

I looked at my syllabus more closely, starting at the order of the scheduled talks, correlating those with the list of sponsors in the back of the notebook, and I realized by the beginning of the third presentation that I could name the sponsoring specific brand for six of the seven lectures of the first day.  One puzzled me, for it didn’t appear to have its own sponsor until I heard the presenters report the beneficial urologic side-effects of a drug marketed and approved by the FDA as an antidepressant.  The presenters pointed out this was not an “on-label” indication for the drug.  When I asked, in the question period following the presentation, if their purpose was to promote this “off-label” use of the drug, they angrily and flatly denied it (though I could see no other purpose).

I looked to the second day’s agenda and with no difficulty or delay I took the six remaining sponsor drugs and matched them with the promotional lectures scheduled for me to hear the next day, in the package with my free bagel, hot coffee and gift bags, pens, paperweights. 

I thought to leave abruptly, but maturity has brought me a small bit of patience; I know that even if I have a sudden dramatic insight I can wait for a next truth which certainly will follow.  I saw the entire program was made to appear as research and education but was indeed promotion and subliminal indoctrination.  I was not really tempted to stand on my folding chair to loudly announce the fraud, for it was patent to anyone else to see it if they wished.  But I saw that the plan worked.  My colleagues ate it up, for no one else met my gaze as I searched the hall.  They chewed bagels and took notes, surrounded by piles of logo-laden pelf.

My disappointment was not so much a surprise, but a gut-wrenching slap that made me faint, flat and nauseated.  They had shifted from the old crew of ivory tower academic authorities to a team of polished doctor-salesmen to promote their products.  Now it was apparent to me the drug companies use a basically new and different method:  First, pick a product name and marketing campaign; next select a molecule to fit the name and campaign; then choose a clinical application which creates a new market for itself (perhaps even the creation and acronym of a new disease); hire bright technical writers to compose research papers and statistics; finally groom and train doctor-prostitutes to present the lectures which have been written for them to read.

There was something of good old American democracy, though:  Each lecture promoted just one product, and each sponsoring product got just one lecture.  There were no wild-card lectures as each slick hour and a half presentation had its own sponsor.  I wondered if these spots cost the drug companies (passed on to the American sick and poor) as much as those I see on television during the Super Bowl.  There was no confusion, no disorder, and no confession that this was not education but marketing.  Was I the only one who saw the Emperor’s greedy pudenda unadorned?

After the day’s program I waited patiently until almost everyone had left, everyone but the bright attractive young PhD pharmacist who had given the welcoming word at the beginning of the morning, the conference coordinator for the corporation which had put on the show (not itself a pharmaceutical manufacturer but undoubtedly a well-paid servant of that industry).  I approached her calmly and politely, began with an honest compliment.  “Thank you for your hard work.  I have never been to such a well-organized professional conference.  Every detail was nailed down tight; everything smooth, well-oiled, exactly on time.”

She nodded attentively, so I dared to go on.  “You and your co-workers have done excellently, no doubt, but I don’t think I will be able to come tomorrow.”  Her eyebrows gave a slight rise, attentive to what she sensed coming.  “I don’t think I could quite stomach it, as I have looked ahead and see which brand is sponsoring each of tomorrow’s lectures.”

Surprised by me, but honest and professional no doubt, she surprised herself by saying, “Yes.  Isn’t it terrible?”  She said no more, probably not daring to.  I immediately saw the untold story of a serious professional taking a job anticipated to be at the pinnacle of pharmaceutical research at a salary beyond her expectations, later discovering that she was being used as a saleswoman, now unable to easily consider quitting.  “Don’t worry,” I offered, “I’m not asking any of you to do anything different.  It’s just that I can’t come back, not for just a bagel and a half dozen hours of ‘continuing education’ credit.  It’s too painful.”

The most painful thing is to see that my profession and my society sold out long ago, and the profiteering drug manufacturers took over control of all research and education in health care.  They have done it thoroughly.  And permanently, no doubt.  There is no longer clinical or scientific truth to be had in institutions or in media.

Dehumanization and competition are the sorts of mechanisms that have produced these problems.  In health care, dehumanization takes place very simply when attention is focused on the welfare of something or someone other than the real patient (like profit-seeking corporations).  Competition is dyseconomic because it wastes resources that might be used to help persons who are or would be patients.  (Competition does not lower costs when it produces reduplication of technical skills and facilities within the same market, and when it produces huge additional costs of promotion and advertising.)

A ground level revolution of patients and clinicians is not yet visible anywhere on the horizon.  I fear a turn-around will not come for a very long time.  I am a revolutionary unashamed to revert to Hippocrates’ standards of twenty-five hundred years ago, to pay attention to the welfare of the patient and to refuse to exploit the patient.

If this sounds vague and mushy it is only because we are not used to the idea that we might somehow change the misbehaviors of the pirates.  We have again been convinced that power justifies anything.  These corruptions arise in our own culture and economy out of our tolerance of greed and abuse of power.  We admire the rich and powerful, and ignore the chicanery by which they exploit us.  The problem is not so much with the greed and shameless misbehavior of the drug manufacturers (and insurance industry, and health corporations, and proliferating government bureaucracy) as with the attitudes of the American people.  We must change.

If reason and fairness are not attractive enough, perhaps we can revert to feelings of indignation or outrage in the face of exploitation and perversion of values.  Perhaps we can evoke a sense of shame in those who have acted criminally or inequitably.  To do that we will have to correct rather than merely criticize them.

I cannot imagine how I can accomplish this.  I fear no others will join me—unless, perhaps, you are willing?

 

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