Research

Lessons From a Professor’s 10-Year Fight to Rein In Pharmaceutical Promotion

June 20, 2017

PharmedOut
Adriane J. Fugh-Berman, the founder of PharmedOut, a project at Georgetown U. to detach continuing medical education from the promotional influences of the pharmaceutical industry: "It’s promotion — it is all promotion, every bit of it. It may be hard to see. There have been surveys of doctors on whether they see industry bias in teaching modules, and 95 percent of them say no. But they’re not trained to detect bias."
In the cramped basement of a research building at Georgetown University, some 200 scientists and doctors assembled this past week to share homemade cookies, hear how opioids and other drugs are unsafely and overaggressively prescribed, and figure out what doctors, hospitals, universities, and others should do about the problem.

It was the 10th annual conference of an educational project at Georgetown known as PharmedOut. The project began in 2006 with a $398,000 award from a $21-million grant program created by state attorneys general who had sued Warner Lambert, a drug company that had admitted to illegally marketing an epilepsy drug called Neurontin for various unapproved treatments.

The project’s founder, Adriane J. Fugh-Berman, now a professor of pharmacology and physiology at Georgetown, devised it to teach physicians about the marketing practices of the pharmaceutical industry.

The money from the state attorneys general ran out after two years. Now, Dr. Fugh-Berman struggles to run the operation on a shoestring. PharmedOut’s annual budget, of about $60,000, relies heavily on donations as the organization tries to be heard alongside a pharmaceutical industry with about $1 trillion in worldwide sales.

The industry exercises much of its influence through continuing medical education (CME) programs — classes and seminars that doctors are required to attend to keep current in their fields, and that are almost exclusively provided with drug-company sponsorship.

Reflecting on her milestone conference, Dr. Fugh-Berman discussed with The Chronicle the challenges she faces and the future she anticipates. The following transcript has been edited for length and clarity.

Q. What’s the PharmedOut origin story?

A. With the grant from the attorneys general, we’d call up hospitals and say, "We’d like to provide CME, and we can pay for lunch." And it turns out you can get into any hospital saying that. That’s how the pharmaceutical companies do it — no questions asked. And the one question we were asked, repeatedly, was, "What pharmaceutical company are you with?"

My project manager was the one who had to make the calls, and it was making her mad, like she wasn’t explaining PharmedOut right. But she couldn’t explain it, because the culture was that providing luncheon seminars was what pharmaceutical companies did, and nobody else, so you must be a pharmaceutical company.

I remember visiting cardiologists at Howard University and them thinking, "Oh, God, another drug-company lecture." And after a while their jaws started to drop a little bit, and some of them asked me, "How did you get in here?" And it was not a hostile question. It was just like, "Wow, how did you sneak in here?" And I said, "Your organizers thought I was from a pharmaceutical company. Plus, we paid for lunch."

Q. Why is CME so hard to change?

A. It used to be that hospitals funded their CME offices, and that may still be true. But in many or most cases, CME is supposed to bring in money to their organizations, and they do that by running CME funded by pharma. They charge the provider of the information.

Q. How do you run PharmedOut on $60,000 a year?

A. We substitute labor for money. Homemade cookies have become like a hallmark for the conference. That was totally a cost-saving thing. And people loved it so much because they had never been at a conference with homemade cookies.

Q. What goes on the rest of the year?

A. We do research and education. The trouble is, it’s taking me five years to publish studies. Most journals take pharmaceutical ads, and the journals that take pharmaceutical ads rarely publish our work.

Q. What reasons do they give?

A. They don’t give reasons; they just reject the article. A while ago, the Annals of Internal Medicine published an article about how pharmaceutical ads were not accurate. Not ground-shaking news, but the journal lost a million dollars’ worth of funding, and the editors were made to leave. [The two editors involved told The Chronicle that while they felt that the journal was under stress after the incident, they had left voluntarily.]

If you had a diverse group of advertisers, you wouldn’t be so beholden. If you pissed off one faction, you’d still have someone else to fall back on. But they don’t.

Q. Why not? Money is money.

A. I think it’s just because it’s easy. Whenever we talk to doctors, people run up to us and say, "How can you have a meeting without pharma funding?" It seems like a stupid question to me. If you are trying to do a conference without pharma funding, you have to do more work. You have to make the cookies, or you have to get other exhibitors.

Q. What’s your biggest win?

A. Fewer doctors seeing drug representatives, and tighter policies at academic medical centers. My initial idea with PharmedOut was that we would first write things in the medical literature and then for consumers. And I never had to get to that second part because there was so much interest in what we wrote for the medical literature.

Q. Biggest disappointment?

A. The fact that we haven’t been able to get external funding, despite the fact that we’ve tried. No one could possibly do more with less, but I could do more with more.

Q. What do you expect in PharmedOut’s next decade?

A. I’m hoping that 10 years from now there will be no pharmaceutical company or medical-device manufacturer or biotech manufacturer funding any medical education. CME is not regulated by the FDA, because they say it’s education. And we’re saying, No, it’s promotion — it is all promotion, every bit of it. It may be hard to see.

There have been surveys of doctors on whether they see industry bias in teaching modules, and 95 percent of them say no. But they’re not trained to detect bias. I have trained students to detect marketing in industry-funded modules. We’re the only group doing this. It’s the kind of thing that’s easy for writers and English majors and people in the humanities. Doctors and scientists can’t tell the difference between persuasive writing and — I don’t know — words on a page.

Q. Carl Elliott, the University of Minnesota bioethics professor, gave a presentation at PharmedOut. He showed that some of the worst offenders in terms of promoting unwarranted and unsafe drugs later got promoted to top positions, often heading professional societies. How is that?

A. Normal is what you’re used to. And doctors and trainees in medicine, we live in a bubble that has different standards than people in the general public have.

Q. Not better standards?

A. No, definitely worse.

Q. But they’re doctors. They go into it for the purpose of helping people.

Medical school 'takes normal, idealistic young men and women, and it makes them bitter. The training is horrible, people are horrible to you, and you lose compassion, sometimes permanently.'
A. Carl Elliott and I have a competition, which I am winning, on how many people we can talk out of medical school, which both of us considered a soul-destroying experience. It takes normal, idealistic young men and women, and it makes them bitter. The training is horrible, people are horrible to you, and you lose compassion, sometimes permanently.

The first two years, in most schools, you’re just learning sciences. But when you get in a clinical setting, there’s totally a culture of abuse. It’s like a hazing situation, where you go through it and then you feel like you’re different and superhuman and part of this exclusive club, and you now get the license to abuse other people, other underlings. And patients ... forget it.

Q. How do we stop that? It almost sounds as if everyone who is a doctor now, you’d have to fire and start over. What do you do?

A. Cultures are very slow to change. The other thing about medical education in the clinical years is you’re basically encouraged to lie or make up answers if you don’t know the answer.

Q. How is that?

“There's a process called pimping, where you keep asking someone questions until they can't answer them anymore.”
A. There’s a process called pimping, where you keep asking someone questions until they can’t answer them anymore. I’ve been asked things like "What’s the brand name of this drug?" "OK, what’s the brand name in Britain?" "Which half of the molecule is this drug attached to?" You can always ask somebody one more question.

It generally happens during daily rounds. You pick on the lowest-ranking people, and you ask somebody questions until they can’t answer them anymore, and then you’re abusive to them for not knowing anymore.

You’re expected to know every single thing on your patients. You’re expected to be able to rattle off lab results, that kind of thing. I remember as an intern confiding to someone, "I find it very difficult to memorize 40 different lab results on every patient." And she said, "Well, why are you doing that? If they’re normal, just make up the numbers." I said, "Oh, is that what people do?"

Paul Basken covers university research and its intersection with government policy. He can be found on Twitter @pbasken, or reached by email at paul.basken@chronicle.com.

Update (10:20 a.m., 6/21/2017): A parenthetical note about the departure of two editors from a medical journal has been added to the text of the interview.