Photo by Kelly Ramirez
Dr. Ray Ramirez is concerned that rampant sponsorship in the animal health sector results in the spread of biased information.
"Can you hear me now?"
Many of us may remember that line from actor Paul Marcarelli as he played pitchman for Verizon in the early 2000s, helping to propel the mobile carrier to No. 1 in the United States at a time when cell coverage was spotty. Then, in 2011, Marcarelli switched to pitching for Sprint, prompting some folks to follow — apparently because a likable, geeky character who seemed credible told them to do so.
Was he truly helping customers get better service for less money, or was he just promoting whichever carrier paid him more?
Who pays for what someone says publicly matters.
That is why we, as veterinarians, should be skeptical of pharmaceutical companies that partner with or sponsor speakers at conferences, meetings held by professional associations and other gatherings.
This point was driven home to me by an article in The New York Times by Dr. Daniel Carlat. It was published years ago but is still on my mind. A psychiatrist, Carlat explained how he was recruited by Wyeth Pharmaceuticals as a paid "medical educator" to help introduce the drug Effexor XR to treat depression.
Carlat told of being astonished by the detail available to company representatives about how much of their drug individual doctors prescribed. Such prescription data mining is facilitated by the American Medical Association, according to Carlat. Pharmacies, he wrote, do not release the names of doctors who write prescriptions but do provide their U.S. Drug Enforcement Agency numbers. The AMA shares doctors' DEA numbers, for a price. Drug companies can then easily match doctor name with prescribing habits.
The article reminded me of a visit by Boehringer-Ingelheim representatives to discuss the cardiac medication Vetmedin after I bought my practice in 2008. Launched widely in 2003, Vetmedin was still a relatively new drug.
Reps: Hello, Dr. Ramirez. We wanted to see what you thought about our drug Vetmedin and prescribing it for your patients with heart failure.
Me: It's great! I love it, and my clients are so ecstatic when they start their dogs on the drug and see the improvement in quality of life.
(Reps eye each other with a "That is not the data we have!" look. I know what they are thinking.)
Me: Are you wondering why I don't show up on your sales logs?
Reps: In fact, yes. We were told you have not bought any.
Me: That's because I use an online pharmacy to prescribe through, so I don't have to keep all the different sizes and minimum orders on my shelf, yet still have any medication available to my patients.
This, basically, is the same disquieting level of company knowledge that Carlat describes, only with more middle groups involved.
Carlat goes on to relate an instance when he realized he was glossing over substantial drug side effects. During a presentation with a group of psychiatrists in which he referred to a large study paid for by Wyeth, he reported that patients were liable to develop hypertension only if they took Effexor at doses higher than 300 milligrams per day.
"Really?" one psychiatrist in the room said. "I've seen hypertension at lower doses in my patients."
"I suppose it can happen, but it's rare at doses that are commonly used for depression."
He looked at me, frowned and shook his head. "That hasn't been my experience."
That interaction bothered Carlat, the frown replaying in his mind.
Prior to the Covid-19 pandemic shutdown, it was very common to have two to four dinner meetings per year where a veterinarian could get one or two hours of continuing education for free as we were fed and listened to a vendor's information on a medication, testing procedure or new vaccine.
At many of those, my colleagues around the table and I would talk among ourselves about pitfalls of the promoted product. If there was ever a question expressing doubt raised to the presenter, the question was always quickly answered, and the discussion moved on. Most of us figured, "They are paying for dinner; we should not completely divert their presentation."
Besides wanting to be polite, we veterinarians often assume that presenters will be unbiased when they recommend a product, test or vaccine, even when the presenter is paid by the company. And we expect they will be forthcoming with any concerns.
That may be a little naive on our part. Besides, don't we all have an internal meter that can sense when something a presenter says is not quite right?
Carlat wrote in the New York Times article that during his next "lunch and learn," he mentioned that hypertension issues weren't seen in the research because the studies were mainly short-term and that possibly another class of drugs would be just as effective.
The next day, he was visited by the pharmaceutical company district manager, who said, "My reps say you were not as enthusiastic, but I told them even Dr. Carlat can't hit a home run every time. Have you been sick?"
Carlat got the message loud and clear — he was of no value to them no matter how much "medical education" he provided if he did not enthusiastically endorse their product.
So he walked away from being "Dr. Drug Rep" — at significant financial cost. His practice income was around $140,000, and the "drug money" he was paid during a year of talks was $30,000.
2018 Western Veterinary Conference
VIN News Service photo
Demonstrating the pervasive commercialism at veterinary gatherings, advertising found a place even on an escalator at the 2018 Western Veterinary Conference.
Do we think this sort of thing does not happen in veterinary medicine?
At large conferences, we see prominent product advertising everywhere. It is hard to believe that just a generation ago, veterinarians would have frowned upon any company that did not contain its advertising to the vendor hall. When I was a younger veterinarian, it was rare to have speakers sponsored by companies at national conferences and other large professional gatherings. (I've been in practice since 1986.)
Today, even for small regional conferences, drug companies contact the organizers to "make it easy on finding a speaker — and we will pay for everything." This is very enticing to veterinary association meeting organizers. The main expenses are speaker fees and facility rental. Any way to reduce those costs is extremely tempting.
As a case in point, I offer my own Mississippi Valley Veterinary Medical Association. (I've been in leadership roles at the MMVMA for five years, currently serving as president.) We have an annual meeting that is typically attended by 120 to 150 people. There was a time when the conference did not include vendors. Maybe 30 years ago, a company asked if it could have a vendor booth. MVVMA agreed. After that, other companies wanted a table at the meeting, too. Then, having a sponsor started being popular. The sponsor would choose a topic and pay for food and a speaker at the dinner meeting.
Like Carlat described, sometimes the data presented by a speaker is incomplete or doesn't make sense in the context of listeners' experiences. I recall presentations on Borrellia vaccines put on by two different companies during different years and how their data conflicted. I think doctors are onto these types of discrepancies and beginning to discount the value of such talks. Over time, doctors lost interest in the MVVMA dinner meeting. It became commonplace that 60 colleagues would pay for the dinner but fewer than 30 would attend. Finally, the association decided at the last annual gathering not to have a dinner meeting. No attendees even asked about it.
The speakers seem to clearly understand the game being played. I have heard at a local conference a speaker pause to say, "Who is sponsoring me again? Oh yes, we like using their product," and then dutifully not mention other competing drugs or products. But if giving a presentation after the vendors have gone home, a speaker might say, "This other product is just as good."
I've given talks on occasion and enjoy it. Sometimes when I propose a talk, I'm asked, "Who do you know who would sponsor your talk?" Because I don't have or obtain a sponsor, I'm not invited to speak.
What is the solution? If you share my concerns, voice your views to the associations you belong to and organizers of conferences you attend. And recognize that there will be a cost to eliminating sponsorship culture. If we truly want independent information, we have to be willing to pay for it.
I, for one, am willing to pay for independent conferences, and if I am invited to speak, I'm willing to take a smaller speaker's fee. I'll put my money where my mouth is.
Can you hear me now?
Dr. Ray Ramirez is a graduate of the University of Illinois Urbana-Champaign College of Veterinary Medicine. He worked in an emergency clinic and an American Animal Hospital Association-accredited practice before becoming a full-time relief veterinarian in 1989 to make more time for family. In 2007, he bought a practice in central Illinois and almost went bankrupt — but didn't. He still owns and practices at that clinic. He also speaks at conferences "to help my colleagues avoid my mistakes" and has written a book-length fable, "The Reluctant Practice Owner," to be published this year.