Tuesday, July 15, 2008

May God Save Us from the Fury of the...Physicians?

Author Arlene Weintraub, in a June 27, 2008 article in BusinessWeek, made much of what was painted as an inappropriate relationship between some leaders of a smoking cessation clinic in New Jersey and the pharmaceutical giant Pfizer, maker of the immensely popular smoking cessation drug Chantix. In the article, and in the CBS Evening News piece on the same topic, this relationship was used as an example of what was described as the larger problem of "physicians on the take" from drug manufacturers. There are a few problems with the article, and with the assumptions it hand-feeds the reader.

Most consumers and potential consumers of American Medicine are not well-versed on the true nature of pharmaceutical companies, or the nature of the relationship between American clinicians and those companies - a fact that Ms. Weintraub takes full advantage of in her article. If Ms. Weintraub's implications are to be believed, then almost every physician with a pen and a prescription pad is offered a cash reward for writing a particular medication. Let me assure you that this is not the case. I have never been offered, and would never accept, such a kickback. In fact, such things are not only immoral and unethical, but are illegal. That, however, is not what occurred in this case, despite the veiled accusations.

Smoking is a known killer. Cancer is the most feared complication of this practice, but is by no means the most common or the most deadly. Elevated blood pressure, chronic lung diseases, and cardiovascular complications dwarf cancer in terms of poor health and mortality from smoking. Until Chantix, the success rate for stopping was abysmally low - somewhere around 10-15%. Chantix doubled that rate of success. Like all medications, however, Chantix had some side effects. In the vast majority of cases, these side effects were either not present, or were mild enough to be tolerated until the completion of the course of therapy. Each patient and physician had to make a decision about the risk:benefit ratio and whether treatment with Chantix was right for them. This is the way it should be. For example, much less hot-button medications also have side effect profiles that must be considered when thinking about starting treatment. Aspirin has been known, on rare occasions, to cause life-threatening Stevens-Johnson syndrome. It would be incorrect, however, to make the statement that aspirin is an unsafe medication. In fact, it has probably saved more lives (and cured more headaches), both in its modern form and its original one - willow bark - than any other pharmaceutical.

So what about the physicians so viciously attacked in the article? Were they hired guns for Chantix, subjecting hapless patients to life-threatening complications just for their own monetary gain? Many alarmists, like Ms. Weintraub, would like us to think so. In fact, they were not paid for prescribing Chantix. They were paid, like many other physicians, to give lectures about the new pharmaceutical. This is common practice. And who better to be a spokesperson for the wildly successful medication that someone who uses more of it than almost anyone else? This was the case with the UMDNJ physician and psychologist named in the article.

Allow me to give an example a little closer to home for me personally. Almost all physicians have a personal formulary. That is, they have a group of medications that they know very well and trust. In my case, either fortunately or unfortunately, depending on your perspective, my own formulary is made up almost exclusively of medications that are now generic, meaning that no pharmaceutical company is now likely to pay for their active marketing, as they are now sort of in the "public domain" for lack of a better term. If someone approached me, however, and asked me to go on a lecture tour to talk to medical students, potential patients, and other physicians about Bactrim (trimethoprim/sulfamethoxazole), for example, I would be happy and honored to do so. I believe in Bactrim. I've seen it work time and again. I've come to trust it. I also realize that it has side effects, as do all medications, and so I have familiarized myself with these and I know what to watch for and I know when to discontinue the treatment. My time has value, though, and I would expect to be compensated for the time away from my office I had to spend giving those lectures. This is the reality of the situation in which the New Jersey physicians found themselves.

There was nothing remotely inappropriate or unethical about what they did. The only mistake they made - and it is a mistake that most of us are guilty of - is underestimating the lengths to which some will go to demonize physicians and pharmaceutical companies in this new, highly-charged environment. The suggestion that somehow they placed their own avarice ahead of the welfare of their patients is more than simply wrong. It is slanderous. I do not know what agenda is being pushed by the author of this article. I have to assume that in some way, the pot is guilty of calling the kettle black.
It would be interesting if she and the other alarmist journalists were held to the same level of scrutiny concerning any possible conflicts of interest they might have. I would have to assume that Ms. Weintraub benefited in some way by writing it.

There is another, more troubling aspect to this new poorly-founded alarmism. If one single person uses this ridiculous, unscientific, and misleading article as a reason to resist treatment by the best available medication for smoking cessation, and that person subsequently dies from a smoking-related disease that might have been avoided by the use of Chantix, then Ms. Weintraub and her conspirators at CBS News carry the guilt that has traditionally been borne by us physicians alone. When similar articles were written about Celebrex (celecoxib), people discontinued its use out of the fear that ensued, and resumed more traditional anti-inflammatory medications. Those older medications were (and are) felt to be more dangerous than Celebrex ever was. I have often wondered how many people have suffered or died needlessly as a result.

It is the most serious sort of business to be responsible for people's lives. That is why it is difficult to become a doctor. That is why we take an oath. And, it is likely, that is why people like Ms. Weintraub work tirelessly to lay us low - they do not believe in the kind of trust or faith we try so desperately to be worthy of. As a result, the uninformed die or are made ill. Ms. Weintraub will not be to blame - those who shout "Fire!" never are these days. As usual, physicians and the companies that make the medications we all depend on will take the blame, and we will continue to play foolishly into the hands of those who are blind leading the blind.