Psychiatrist Daniel Carlat’s article in today’s New York Times Magazine provides valuable insight into the ethics of drug marketing.
Carlat tells how he became an “educator” for Wyeth in 2001. He visited primary care and psychiatric offices to talk about Effexor XR, Wyeth’s antidepressant. Carlat was paid $500 for a one hour “Lunch and Learn” talk; $750 if he had to drive an hour. His narrative forms a five-step morality play:
1. Carlat began the role with naïve optimism that he could be a well-paid but objective educator for a drug that he liked to use in his own practice.
2. After a rosy start he moved into a phase of rationalizing the distortions he recognized he was building into his presentations.
3. There is then a moment of epiphany, when a psychiatrist in a group he is speaking to challenges his playing down of the hypertension risk the drug creates: “He looked at me, frowned, and shook his head…I felt rattled. [The] frown stayed with me – a mixture of skepticism and contempt. I wondered if he saw me for what I feared I had become – a drug rep with an M.D.”
4. After the epiphany, Carlat made his presentations more balanced and objective. Here is what happened: “I was visited by the same district manager who first offered me the speaking job. Pleasant as always, he said: 'My reps told me that you weren’t as enthusiastic about our product at your last talk. I told them that even Dr. Carlat can’t hit a home run every time. Have you been sick?’ At that moment, I decided my career as an industry-sponsored speaker was over. The manager’s message couldn’t be clearer: I was being paid to enthusiastically endorse their drug. Once I stopped doing that, I was of little value to them, no matter how much “medical education” I provided.”
5. The final phase, embodied by the New York Times article, is public confession and a pledge to abstain from drug company funding in the future.
I don’t fault Wyeth for its marketing strategy. Capitalism is about selling. If we physicians turn up our noses at the mores of commerce we are being hypocritical. After all, we market our own services to patients and colleagues every day.
But I agree with Carlat that physicians should not carry out the marketing function for drug companies. To do what he found himself doing violates at least two of the nine principles in the AMA code of ethics: “A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception” and “A physician shall continue to study, apply, and advance scientific knowledge, maintain a commitment to medical education, make relevant information available to patients, colleagues, and the public…”
So what should be done? Carlat’s candid narrative makes clear that disclosure isn’t enough. “Caveat emptor” – let the buyer beware – is an appropriate guide for commerce. It is not, however, compatible with professionalism. The story Carlat tells shows how the “educator for the drug company” role shifts the clinician’s primary commitment to scientific objectivity and advancing patient interests to a marketing function.
When patients, physicians, and the public suspected that managed care incentives were corrupting clinical judgment an enormous backlash emerged. The conflicts created by the “educator” role are at least as severe. The medical profession needs to push back against physicians taking on the role of drug marketers with the same vigor it brought to bear on managed care. Marketing by drug companies is part of the way our economy works. But as Carlat shows so clearly in his personal testimony, having physicians participate in the marketing effort as “educators” is incompatible with professional ethics.