This week, PLoS Medicine, a Journal of the Public Library of Science, has published a collection of articles on the topic of Disease Mongering. (Thanks to my friend Annette, who sent me the table of contents today via e-mail.)
Disease Mongering, a term coined by the late journalist Lynn Payer, former health editor at the NY Times, refers to the creation or expansion of disease definitions by the pharmaceutical industry in an attempt to create a market to match the drugs that they manufacture.
The topic has been getting a lot of discussion lately, spurred by the recent publication of Ray Moynihan and Alan Cassels’ book Selling Sickness: How the World’s Biggest Pharmaceutical Companies Are Turning Us All Into Patients. (Here’s a Newsweek interview with author Moynihan.)
No one argues that the pharmaceutical industry creates medications that save lives and cure disease. It’s the medicalizing of things like sexual dysfunction and menopause that are the problem. Or the pushing of drugs like Fosamax for low bone mass in patients without risk factors for osteoporosis other than age. (Trust me, the reps are in here once a week pushing that.)
What I find fascinating is that those who are fighting against disease mongering have taken a lesson from the big pharma playbook, and are using Big Pharma’s own marketing tactics against them. They are “creating buzz” with the media campaign around Moynihan’s book, legitimizing their argument further by publishing it in a scientific journal (PLoS), and now, just as the Pfizer did in the 1990’s to create a market for Viagra, they are convening a conference to teach others about the issue. Brilliant!
The Role of the Physician in Disease Mongering
We physicians must become cognizant of the role we play, often unwittingly, in disease mongering. They get us involved by ploying us with medical education, written and delivered by “thought leaders” in the field, who themselves have a research or clinical interest in the topic at hand, and sometimes are paid consultants to the companies whose drugs they discuss. This sort of education need not be drug specific to be effective, so the MD’s feel as if we are not being bought or used, but are participating in legitimate medical education.
What we don’t see is that we are being used. Big Pharma has learned that if they spend their advertising dollars on disease creation and awareness, they sell more drugs. Rather than fighting over their share in a stable market, they simply grow the market. And, if they “partner” together on disease awareness, they all win.
The problem for me as a physician is that it is becoming almost impossible to distinguish between real medical education and industry- sponsored marketing. Especially when there is so much overlap. And there really is overlap. Industry-sponsored medical education has lots of real knowledge within it. If not, we would never had gotten into this situation in the first place, trust me.
So I try. I really try to distinguish when I’m being marketed to and when I’m being taught. Problem is, I sometimes can’t. Because it is getting harder and harder to identify who’s benefitting from the “medical education” I receive.
Prime example – today, I received a “Newsletter” about menopause and hormone replacement. “Okay”, I thought. “Let’s see which HRT manufacturer sponsored this one.” I looked on the back. Noticeably absent were pharmaceutical sponsorships or disclosures from the panel of experts whose photos appeared on the cover of the newsletter. Just a logo for the Foundation for Better Healthcare.
I went to FBHC website, which describes the organization as a non-profit group whose mission is “Moving clinicians from Knowledge to action”. Action – what action? A prescription, perhaps?
The FBHC has patented a tool they call ROEI – Return on Educational Investment. This term usually refers to educational returns. But look at this statement from the group’s mission: The Foundation for Better Health Care consults with organizations interested in supporting medical education and who want to measure return on investment. What kind of return on investment? Well, according to the conflicts information published at various CME’s sponsored by the FBHC, its executive director owns stock in practically every major pharmaceutical company known to man. Is that the kind of return on investment they mean?
The FBHC seems to be a legitimate non-profit group whose goal is to educate my patients and me. They certainly seem to be holding lots of conferences and CME activities, and they are advertising for CME monitors to assure the objectivity of their educational activities. And to be honest, the activities they sponsor seem just fine to me. But each one is industry sponsored, from what I can tell. And when I see that its director is playing big in the Big Pharma stock market, it has to make me question what this organization’s objectives really are. And toss the Newsletter they sent me into the trashcan.
I’m not trying to point fingers at this foundation as the bad guys – I just happened to get their newsletter today, so I’m picking on them. But let’s be honest – my own professional organization uses industry funds for every single meeting, and I can’t recall a medical conference or meeting in recent memory that I have attended that was not in some was sponsored by an “unrestricted grant from Company X.” I myself have beem paid honoraria to present at meetings.
But I think it’s gone too far. I worry that these non-profit educational consortiums are really fronts for industry sponsored education. And if they are not, it doesn’t matter, because I really don’t trust medical education anymore.
Breaking Up Is Gonna’ Be Hard To Do
Iona Heath, a GP in the UK, writes in the PLoS journal that the first step in combating disease mongering has to be a genuine disentanglement of the medical profession from the pharmaceutical industry. And I agree – the time has come to disengage. But I expect it’s not going to be an easy process. Because the ties between us are so deep and so long, and are getting harder and harder to identify.
It reminds me of when I was trying to dissect out a nerve from the sacral plexus in anatomy class. I couldn’t do it without bisecting the nerve, and came away both frustrated and as usual, stinking like formaldehyde.
Category: Second Opinions
hi. i really liked ur blog. some of the posts where you talked about medicine and how you treat were great.I am a medical student from India. And incidently, right now I have my Obs/Gyn posting going on…isn’t that great.don’t really know about cooking so can’t comment.
hope to continue getting words of wisdom.
As someone who works in the pharmaceutical industry, I have been taught a different perspective altogether. While it is certainly true that marketing by pharma has changed aggressively in the recent years, it is also pretty true that the pharma industry is put under pressure to create new drugs and new markets by the medical community at large and by the govermental bodies such as NIH.
Let’s take statins as an example. The distinction of LDL and HDL was not well known or understood until the pharma industry researched it. In fact, one of the the first major statins was Mevacor, which had been discovered YEARS before use, but it’s use was widely unknown.
As the industry was able to educate physicians and patients alike, management of the disease became widely known, and yes, lots and lots of tablets have been prescribed, and billions have been made. However, people are living longer and better as a result, and the economic of hospital care are still less attractive then pharamceutical management.
Clearly this is one example, and since it was successful, the model has been adopted widely by the industry. This is where the problems come in…not all drugs are so important, and that’s where the drug industry falls prey to critics. Look at sleep aids – that revenue in this market sector is up in direct proportion to advertising spend…
Last point to my ranting…it still costs over $850 million on average to bring a drug to market, and 95% of compunds fail. The companies are under enormous pressure to make money on the drugs that they have approved so that they can afford to do more research. Some companies spend more than others, but did you realize that Lilly spends 25% of their revenue on the research pipeline? That’s enormous. I don’t see medical centers spening this much money on research, so who is going to do it? Big pharma will.
You may resent it, but I don’t think that the medical community hasn’t also created the beast by allowing it to be fed. On the black/white continuum, this issues lies smack in the gray.
Schtruggling:
“So many pharmaceutical companies are schtruggling to being drugs to market…”
Just kidding, you KNOW I had to say that.
Seriously, this post was not meant to be a total bash on the Pharma industry, just a good poke at one aspect of it – stealth marketing via medical education.
I couldn’t agree with you more on everything you said. If this were black and white, it would be easy. But you are right, it’s one big gray area. And you are absolutely correct that the medical community has played an enormous part in creating the beast.
Let me state again that the pharmaceutical industry has saved lives, including those of people I love. WIthout drugs, I could not do what I do for my patients. Heck, I couldn’t live without my Valtrex (life would be one long fever blister…)
But I think we’ve both gone too far, docs and Pharma alike. We need to step back and examine ourselves and this beast we have created together. Looking at medical eucation is a good first step, I think.
Amen, sister!
And as for advertising, education and Valtrex, I’m so glad that we have brought the term “genital herpes” into our living rooms during prime time tv. That one is always fun to explain to my 9 year old. Now I am informed, and I know the virus sheds even without visible outbreaks! Thanks!!!
It’s a very complex situation. One that should be bashed about with humor and sarcasm since it’s too big to get back into perspective at this time.
In the meantime, it pays the bills!
even though we’re all schrugglin’ just a keep our heads above warder….
This is a very good post. I think, however, that this problem is not just about pharma. There is something larger afoot here.
I am perplexed by the number of patients I get who expect a complete answer to everything. If a patient says, “My foot cramps at night, why is that?” and I say, “Gee, I don’t know,” they look at me as if I am a fool. I know I have lost patients on occasion because I told them I didn’t know why they had a certain symptom or problem.
From my standpoint, if a symptom is not something that will kill you, than I am OK with chalking it up to the unexplained. Not that it has no explanation, but the effort to find the answer out is so expensive that it may not be worth the effort.
Patients spend so many hours watching news spots, “medical minutes,” and yes, pharma commercials that they become convinced that there is a diagnosis and explanation for everything. So patients and doctors go on wild goose chases to label every problem, and find a drug or treatment for every symptom.
Doctor and patients have trouble with uncertainty. God bless ’em, they’re human. But somehow we have to get over that and stop this endless labeling. In my experiences with the doctor culture, I find that doctors are great classifiers and labelers. It is what we are taught.
But all this labelling does not prevent the inevitable. One day, we will all get the disease that kills us, whether it has a name or not. Sorry to be dark, but it’s the truth.
Pharma, and all advertising, is based on fear. Fear that we are missing that one thing that will make us happy. But don’t worry, it’s available at a store near you!
That is the cycle that doctors need to break. How? Whatdaya think I am, Socrates?
mchebet:
Couldn’t agree more. The pharm industry (and the health screening industry, ala’ the new HPV test, don’t get me started on that marketing campaign…) have learned from the media that there is money to be made by tapping into people’s fears (and hopes). Ifeel like I have spent years battling the media’s fear mongering, and now I’m battling the advertising by pharmaceuticals.
What I did not get into in my post is the fact that we are selling drugs for so many things that really are lifestyle issues, and are best treated that way. But our health insurance doesn’t pay for gym memberships or yoga classes,or psychotherapy or sex therapy, or weight watchers memberships. They pay for drugs, so that’s what patients ask for and get..
How do we break the cycle? One patient and one doctor at a time. Shall we go first, you and I?
I’m with you. I’ll have a post on my site about this, eventually. Sometimes I am tempted to say all drugs should be sold OTC. I know that sounds crazy, but there is a logic to it. If patients could get whatever they wanted from the drug store, they would come to doctors for ADVICE rather than for pills.
As a doctor, I am most comfortable when I am giving my patients advice. That is my job. Anyone can hand out pills, but only the skilled can hand out wisdom.
Unfortunately, patients don’t see it that way. They come for the pills, not for the guidance. Maybe there needs to be some kind of a doctor’s advice public campaign in which patients are encouraged to see doctors just for opinions. If a patient leaves my office with nothing but my advice, that is a good outcome. How often does it really happen, though?
In my mind, I do not sell scrips. I sell advice. In reality, I probably sell scrips. That is what we need to stop.
In my head, I have written a blog entry on this topic that I call “The Hammer and the Hope.” Hopefully I get to actually write in within the month.
This was a great post.
I will blog more on the specifics of how this affects me on my blog when I have some time.
I had an experience today that frustrated me. Basically there is a new prostate cancer test that can be done after a prostate is removed to try to help you predict the risk of having a cancer recurrence in 5 years.
I had a diuscussion with the rep that works for the company that does the test.
I explained to her that I understood the test, but I didnt think it would change the way I treat patients and wouldnt order it.
Next time I see her I can tell her that she is monging and be done with it.
Fantastic Post!!!!!!!!!