{"id":42357,"date":"2013-12-17T22:16:28","date_gmt":"2013-12-18T03:16:28","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=42357"},"modified":"2013-12-17T22:16:28","modified_gmt":"2013-12-18T03:16:28","slug":"before-i-we-sleep","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2013\/12\/17\/before-i-we-sleep\/","title":{"rendered":"before <strike> I <\/strike> we  sleep&#8230;"},"content":{"rendered":"<br \/>\n<blockquote>\n<div align=\"center\" class=\"big\"><a href=\"http:\/\/theweek.com\/article\/index\/254230\/beware-the-fine-print-of-glaxos-big-drug-marketing-announcement\" target=\"_blank\">Beware the fine print of Glaxo&#8217;s big drug-marketing announcement<\/a><\/div>\n<div align=\"center\" class=\"big\"><strong><font color=\"#200020\">The Week<\/font><\/strong><\/div>\n<div align=\"center\" class=\"medium\">by Peter Weber<\/div>\n<div align=\"center\" class=\"small\">December 17, 2013<\/div>\n<p align=\"justify\">On Tuesday, British drugmaker <a target=\"_blank\" href=\"http:\/\/us.gsk.com\/html\/media-news\/pressreleases\/2013\/gsk-announces-changes-to-its-global-sales-and-marketing-practice.html\">GlaxoSmithKline vowed to unilaterally disarm<\/a>  in the controversial marketing war that has helped fuel the  pharmaceutical industry&#8217;s robust growth in the past 30 years. This is  potentially a big step toward curbing conflicts of interest and doctor  payola, especially if other drugmakers follow suit. But right now the  fine print leaves plenty of wiggle room. Here&#8217;s what GSK is doing: First, it says it will stop paying doctors  to promote its products at medical conferences, dinners, training  classes, or other events for &quot;audiences who can prescribe or influence  prescribing.&quot; The company won&#8217;t directly pay for doctors to attend such  conferences, either. The other big change is to how GSK pays its sales  force, dropping the practice of tying compensation directly to the  number of prescriptions written by doctors each sales rep visits.  Instead they&#8217;ll be paid based on their technical knowledge, client  feedback, and GSK&#8217;s overall performance.<em>.<\/em><em>.<\/em><\/p>\n<p>    <em> <\/em><\/p>\n<div align=\"justify\"><strong><font color=\"#200020\">Here&#8217;s where the fine print comes in:<\/font><\/strong><\/div>\n<ul>\n<li>\n<div align=\"justify\">First, the new  rules won&#8217;t change much of anything in the large U.S. market: Under its  deal with the Justice Department, GSK has already adopted the proposed  global sales rules in the States, and a provision of ObamaCare mandates  that pharmaceutical firms publicly disclose how much they pay doctors,  with the amounts available in a searchable government database starting  next fall. That has led the entire industry to ease up on the doctor  junkets and speaking fees already.     <\/div>\n<\/li>\n<li>\n<div align=\"justify\">Second, industry shifts make the education part of the sales mission  less important: Well-informed specialists are prescribing more and more  medications, replacing prescriptions from generalists and primary care  physicians. Drugmakers have already <a target=\"_blank\" href=\"http:\/\/online.wsj.com\/news\/articles\/SB10001424052702304858104579263640414302348\">laid off tens of thousands of sales reps<\/a> since 2006, when the sector peaked at 105,000 sales jobs.     <\/div>\n<\/li>\n<li>\n<div align=\"justify\">And third, it&#8217;s not clear GSK&#8217;s changes are as far-ranging as they  sound. The company maintains that it still needs to educate doctors  about its products, and says it will still &quot;support fair, balanced, and  objective medical education for health care professionals&quot; through  &quot;unsolicited, independent educational grant routes.&quot; These grants have  often been given out through for-profit companies that rely on drug  company largess, <a target=\"_blank\" href=\"http:\/\/www.nytimes.com\/2013\/12\/17\/business\/glaxo-says-it-will-stop-paying-doctors-to-promote-drugs.html?hpw&#038;rref=business&#038;pagewanted=all\">says Harvard Medical School&#8217;s Dr. Jerry Avorn<\/a>, a critic of Big Pharma&#8217;s marketing practices.<\/div>\n<\/li>\n<\/ul>\n<div align=\"justify\">Caveats aside, kudos to Glaxo for getting ahead of the curve on cleaning up marketing practices that <a target=\"_blank\" href=\"http:\/\/www.washingtonpost.com\/business\/economy\/an-effective-eye-drug-is-available-for-50-but-many-doctors-choose-a-2000-alternative\/2013\/12\/07\/1a96628e-55e7-11e3-8304-caf30787c0a9_print.html\">notoriously push up medical costs<\/a>  while boosting already bulging pharmaceutical coffers. Here&#8217;s hoping  the changes are real &mdash; and contagious to the whole industry.<\/div>\n<\/blockquote>\n<div align=\"justify\">I have always been teased about drawing graphs and diagrams all the time. When I was a medicine resident, my friends called them <em>nardograms<\/em> and would giggle when I presented when the first one [overheads back then] flashed on the screen. As a psychoanalyst, as you can imagine, there wasn&#8217;t much to graph, but there were diagrams aplenty. I think it&#8217;s that I&#8217;m visual and think in pictures. Usually, I see the graph in my mind, but I can&#8217;t see magnitudes until I actually draw it out. But of all the little graphs I&#8217;ve peppered this blog with over the years, this is the one that stunned me the most when I drew it:<\/div>\n<div align=\"center\"><img loading=\"lazy\" decoding=\"async\" height=\"204\" width=\"500\" vspace=\"7\" border=\"0\" src=\"http:\/\/1boringoldman.com\/images\/nem-2013-1.gif\" \/><\/div>\n<div align=\"justify\"><img decoding=\"async\" hspace=\"4\" width=\"190\" vspace=\"6\" border=\"0\" align=\"right\" src=\"http:\/\/1boringoldman.com\/images\/psychnet-2.gif\" \/>The one on the left is from Dr. Nemeroff&#8217;s CV. It&#8217;s the number of Pharmaceutical companies he was associated with [advisory boards or speaker&#8217;s bureaus]. And the one on the right is from one of Senator Grassley&#8217;s printouts back in 2008 when he was investigating the KOLs who weren&#8217;t reporting their income to universities accurately. On the ordinate [y axis] is the number of presentations of the type GSK says they are stopping <strong><font color=\"#200020\">PER MONTH<\/font><\/strong> Dr. Nemeroff was giving. They were all over the country. At this time, he was chairman of Emory&#8217;s psychiatry department, editor of the Neuropsychopharmacology Journal, on boards and committees. And this is the count of publications <strong><font color=\"#200020\">PER YEAR<\/font><\/strong> with him on the author by-line:<\/div>\n<div align=\"center\"><img decoding=\"async\" width=\"300\" vspace=\"7\" border=\"0\" src=\"http:\/\/1boringoldman.com\/images\/nemeroff3.gif\" \/><\/div>\n<div align=\"justify\">Most of those presentations were part of a GSK program called PSYCHnet. Here&#8217;s the blurb:<\/div>\n<div align=\"center\"><img loading=\"lazy\" decoding=\"async\" height=\"415\" width=\"520\" vspace=\"7\" border=\"0\" src=\"http:\/\/1boringoldman.com\/images\/psychnet-1.gif\" \/>    <\/div>\n<div align=\"justify\">Notice the non-commercial title of the presentation. But then look at the second boxed in part of the blurb. Notice that GSK kindly provided slide kits. Note also the injunction about how to only use Paxil specific promotional materials in response to questions to stay within FDA guidelines. I understand that the audience was often <em>seeded<\/em> by local reps to make sure those questions came.<\/div>\n<p align=\"justify\">In this case, there was a GSK\/NIMH grant worth a mint headed Emory&#8217;s way among other things &#8211; I guess a well-earned perk. While this wasa worst case, it was an example of the rampant use of physicians as stealth sales reps throughout American [and World?] medicine. Dr. Nemeroff may be the worst, but the collective impact was staggering, larger than we&#8217;re likely to ever know. Whether GSK&#8217;s pledge to stop this kind of thing comes from a religious conversion or from more terrestrial concerns, it&#8217;s the biggest of deals.<\/p>\n<p align=\"justify\">All of my medical life, pharmaceutical advertising has been part of things, part of being a doctor. I never gave it much thought, What was different about the last twenty-five years was that they found ways to advertise without it showing. It never used to occur to me that an article in a medical journal like the American Journal of Psychiatry was constructed under the tutelage of a drug company. I never thought of famous physicians as <em>Key Opinion Leaders<\/em> &#8211; people whose notoriety was a commodity to be bartered for its impact on my prescribing habits. If that was going on in my distant past, I didn&#8217;t know it and I would have considered it fraud. Now, it&#8217;s so ubiquitous that it&#8217;s the rule rather than the exception, and it has produced an enormous amount of confusion &#8211; too much to fathom. And a lot of that confusion is because the famous doctors became KOLs. Maybe Nemeroff, my chairman, was the absolute worst, but there were plenty of others at places like Harvard and Stanford, the venerated halls of learning in medicine and psychiatry. That I was on a clinical faculty at a place where those things were happening and didn&#8217;t really know it is a testimony to the very stealth that is on trial here.   <\/p>\n<div align=\"justify\">One could greet this announcement with &quot;whoopee!&quot; or &quot;uh oh &#8211; watch out!&quot; I greet it as a sign that things might finally be moving in the right direction, but that this is no time to think about taking any but the briefest of holiday rests. Said the poet,<\/div>\n<ul>\n<div><em>The woods are lovely, dark and deep.<\/em><\/div>\n<div><em>But&nbsp;<\/em><em><\/em><em><strike> I&nbsp;<\/strike><\/em> we have promises to keep,<\/div>\n<div><em>And miles to go before&nbsp;<\/em><em><\/em><em><strike> I&nbsp;<\/strike><\/em> we sleep,<\/div>\n<div><em>And miles to go before&nbsp;<strike> I&nbsp;<\/strike> we sleep.<\/em><\/div>\n<\/ul>\n","protected":false},"excerpt":{"rendered":"<p>Beware the fine print of Glaxo&#8217;s big drug-marketing announcement The Week by Peter Weber December 17, 2013 On Tuesday, British drugmaker GlaxoSmithKline vowed to unilaterally disarm in the controversial marketing war that has helped fuel the pharmaceutical industry&#8217;s robust growth in the past 30 years. This is potentially a big step toward curbing conflicts of [&hellip;]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[2],"tags":[],"class_list":["post-42357","post","type-post","status-publish","format-standard","hentry","category-politics"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/42357","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/comments?post=42357"}],"version-history":[{"count":17,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/42357\/revisions"}],"predecessor-version":[{"id":42386,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/42357\/revisions\/42386"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=42357"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=42357"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=42357"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}