Last week, after the launch of a new database detailing doctors' financial ties with drug companies, Dr. Daniel Carlat sat at his computer and began searching for information about colleagues.
He found several doctors who had potentially compromising relationships with the pharmaceutical industry. But he was surprised to find that several other physicians he considered "very ethical people" had received thousands of dollars in payments from pharmaceutical firms.
"You don't want to use a very broad brush to characterize all the physicians" listed in this database, said Carlat, an outspoken Massachusetts psychiatrist and frequent critic of his profession. Some may be top-notch clinicians or researchers, while others may have questionable credentials.
How, then, should consumers interpret information they find in the new ProPublica database, the first to make extensive information about drug company payments to doctors easily accessible? Here are things you should consider:
•Recognize that extensive research has found that small payments can sway doctors, even subconsciously, while influencing the medications they prescribe to patients. Many doctors discredit the research; others say the evidence is clear and convincing.
"All protestations to the contrary, the evidence shows that physicians are susceptible to influence," said Dr. Adriane Fugh-Berman, director of PharmedOut, a Georgetown University Medical Center project that educates doctors about how drug companies influence prescribing practices.
•Make sure the drugs you're taking are safe, effective and appropriate for the medical condition. If your doctor has ties with a drug company, find out whether the medications you're taking are made by the same company. If so, ask your physician about the drugs, why they're right for you and whether equally effective, less expensive alternatives are available.
•Try not to adopt a confrontational posture that might put your doctor on the defensive. Ask open-ended questions such as, "Can you tell me more about your relationship with Company X?" or "Can you give me more information about this medication?" said Guy Chisolm, director of the conflict-of-interest program at the Cleveland Clinic, the first academic medical center to disclose physicians' ties to the pharmaceutical industry on its Web site.
•Get a second opinion if you have any concerns about the therapies you're undergoing. "If what you learn about your doctor is making you anxious in any way, get an opinion from another expert," said David Rothman, president of the Institute on Medicine as a Profession and professor of social medicine at Columbia University's College of Physicians and Surgeons.
•Consider looking for another doctor if you get an angry response or the cold shoulder. "I don't think the fact that someone is making money from drug companies based on their expertise is necessarily a bad thing, but I don't think doctors should hide it either," said Dr. Walter Stadler, a professor of medicine and associate dean for clinical research at the University of Chicago Medical Center. "Doctors shouldn't be ashamed of what they're doing, and maybe, if they are, they shouldn't be doing it."
•Try to put the information in perspective. "If you have a doctor who's given a talk or two, that's not worth losing sleep over," said Dr. Jerry Avorn, a professor at Harvard Medical School. "But if your doctor is making tens of thousands or hundreds of thousands of dollars a year, that's a different story."
The ProPublica database (propublica.org/topic/dollars-for-doctors) examines payments in 2009 and the first half of 2010 from drug companies to doctors for lectures, consulting or advisory services, and a few other types of activity. Funding for research is not included.
ProPublica assembled the information from public reports posted online by Eli Lilly and Co., GlaxoSmithKline, Pfizer Inc., AstraZeneca, Merck & Co., Johnson & Johnson and Cephalon Inc. All drug and medical-device companies will be required to publicly disclose payments to physicians by 2013 under new federal legislation.
Since last week, hundreds of thousands of people have looked at the information, according to ProPublica, an independent investigative news organization.
Michele Friedman, 42, of Chicago, said she's curious about her doctor and plans to check the database.
"I examine every possible source of information about a therapy or a drug before I decide on it," said Friedman, who is self-employed and pays for her own health insurance. "After all, it's my health."
Like Friedman, most people want to know about physicians' relationships with the drug industry, and many worry about the potential impact on the doctor-patient relationship, according to a new survey of 1,250 adults issued last week by Consumer Reports.
That report, based on phone interviews conducted in October, found that 77 percent of respondents said they would be "very" or "somewhat" concerned about the quality of their medical treatment if they learned their doctor received payments from pharmaceutical firms. Seventy-four percent said they disapproved of physicians receiving such payments for promoting drugs to other doctors.
Seventy percent of consumers said they wanted their doctors to raise the issue if the doctor was planning to prescribe a product from the company involved. Only 2 percent said their doctors had acknowledged taking payments from drug companies.
Recognizing the concern, several Illinois physicians said they were taking another look at their practices.
"I haven't offered patients this information to date, but, clearly, this issue of disclosure has gained a lot of traction, and I think we're going to have to change how we do things," said Dr. Peter Toth, a family practitioner in Sterling, who earned $185,002 from drug companies in 2009 and the first half of 2010.
"I think if doctors brought this up with patients, most wouldn't have any problem," said Dr. James Webster, a professor of medicine at Northwestern University's Feinberg School of Medicine and president emeritus of the Chicago Board of Health. "As far as I'm concerned, I think doctors should make this information available in their waiting rooms."
Separately, a June 2008 poll of 1,009 adults released by the Pew Prescription Project found that 64 percent of Americans think it's important to know about their doctors' financial ties to drug companies. Respondents took a dim view of several activities, with 86 percent saying that companies shouldn't give free dinners to physicians, and 80 percent saying that payments for serving on speakers bureaus shouldn't be allowed.
In patient surveys and focus groups, people have told the Cleveland Clinic repeatedly that "they thought they had a right to know" what doctors are making from the drug industry, Chisolm said. It's not enough to list companies with which physicians are affiliated, he said, people want hard numbers and a better understanding of what doctors are doing.
That also is true for the institutions where physicians work, which have varying standards for what they consider a conflict of interest. At what point scrutiny should be triggered is ambiguous.
"It's a little like pornography: I can't tell you what the level is, but I know it when I see it," Stadler, of the University of Chicago, said.
But, as a general rule, "once payments to a doctor get above $25,000 a year from a big pharmaceutical company, I start paying more attention to the details of what's going on," Stadler said. That can include finding out whether a doctor is doing company-sponsored research or using only products from those companies
Ultimately, the decision to find out whether there are ties between a doctor and a drug firm depends on the circumstances.
Bonnie Carney, 54, of Chicago said she almost surely would not look up her longtime internist because "she's very commonsensical, practical and she understands my lifestyle."
But if she were referred to a specialist, Carney said, she might turn to the ProPublica database before making an appointment.
"If a doctor I didn't know made a lot of money from drug companies, I probably wouldn't even go see them," Carney said. "Knowing that might make me feel a bit of doubt, and I think it has to be a trusting relationship."
Putting an end to freebies
Two years ago, the Pharmaceutical Research and Manufacturers of America adopted voluntary guidelines calling for drug companies to stop giving doctors free pens, calendars, sporting bags or tickets to entertainment events. Similarly, the American Medical Association, the Association of American Medical Colleges and the American College of Physicians have recommended that physicians stop accepting gifts, free travel to educational conferences and expensive meals at fancy restaurants.
The most comprehensive examination of the relationships between physicians and the drug industry comes from an April 2007 article by researchers from Harvard Medical School and Yale University's School of Public Health. In a survey of 1,662 doctors conducted in late 2003 and early 2004, it found:
•94 percent reported some type of relationship with drug companies.
•83 percent received food at work from firms.
•78 percent got drug samples.
•35 percent were reimbursed for attending professional meetings or continuing medical education sessions.
•28 percent were paid for consulting, giving lectures or enrolling patients in clinical trials.
— Judith Graham