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MELISSA BLOCK, host:

From NPR News, this is ALL THINGS CONSIDERED. I'm Melissa Block.

ROBERT SIEGEL, host:

And I'm Robert Siegel.

This week, NPR, ProPublica and other news organizations published a database of doctors who take money from drug companies. It names over 17,000 doctors who have received more than $250 million in payments. Today, we report on the doctors in the database who are paid to give speeches.

BLOCK: NPR has talked to former drug company employees and doctors and found that drug companies train their representatives to target certain doctors for speaking engagements. Those are the doctors who write the most prescriptions in their communities.

As NPR's Alix Spiegel reports, that's because the companies know that paying a doctor to speak about a drug can dramatically increase the number of prescriptions he or she writes.

ALIX SPIEGEL: Mathew Webb left a sales job in menswear for a sales job in pharmaceutical drugs 10 years ago and suddenly found himself surrounded by money. As a representative for a major drug company, he was expected to entertain doctors two or three nights a week. There were elaborate sporting events in private stadium suites, five-star restaurants. At that point, openly using money to influence doctors was considered almost standard practice.

Mr. MATTHEW WEBB (Pharmaceutical Representative): Representatives who were actually starting to go into the physician's office and saying, hey, you know what, you came to my baseball game, you know, I entertained your whole family, why aren't you writing my product?

SPIEGEL: But much of this came to a crashing halt shortly after Webb signed up. See, in 2002, the pharmaceutical industry's trade group, known as PhRMA, published a new set of rules. Rules that substantially changed the game for reps like Webb.

Today, can you take doctors golfing?

Mr. WEBB: No, you cannot.

SPIEGEL: Can you take doctors boating?

Mr. WEBB: No, you cannot.

SPIEGEL: Give out pens?

Mr. WEBB: No, you definitely can't give out pens.

SPIEGEL: Give out pads of paper with brand names on them?

Mr. WEBB: No.

SPIEGEL: The tropical vacations are done, the free tickets are over. But the practice of trying to influence doctors with money hasn't disappeared, it shifted.

Today, when a rep like Webb wants to get a doctor to write prescriptions for his drug, there is still one almost foolproof way to get that task accomplished.

Mr. WEBB: I would say, can you speak for me on this product? Because I knew in the back of my mind if I could get him to speak for me, he's going to write more product.

SPIEGEL: It's estimated that over 100,000 doctors take money to speak for pharmaceutical companies in America. And on the surface level, speaking is a very straightforward transaction. Totally above board. The drug company gives the doctor a vetted slide presentation and the address of a popular restaurant, where a room full of other doctors gather over dinner and wine to listen to him talk.

The speaker is supposed to educate those other doctors about the drug's benefits and drawbacks in hopes that they might use the drug in their patients. That, anyway, is how many of the doctors who do the speaking, see it.

Dr. LANCE CLAWSON (Child and Adolescent Psychiatrist): I'm going out there trying to educate other doctors how to treat ADHD appropriately and safely.

SPIEGEL: This is Dr. Lance Clawson, a child and adolescent psychiatrist in Maryland, who's in ProPublica's database as a speaker. And his view of what he's doing is pretty typical of the doctors I spoke to. Clawson feels that though the money is nice, fundamentally, he feels like he's doing a good deed.

Dr. CLAWSON: The fact that children are being treated for ADHD inappropriately is a really bad thing. So, I'm going out there and trying to teach people how to do a good job.

SPIEGEL: But the practice of doctor speaking looks much different from the other side of the fence, from the rep side. For the past month or so, I've been talking to pharmaceutical reps. I've talked to about 18 in all. Today, you're going to hear from two.

That rep you just heard from, a man I'm calling Mathew Webb, who recently left the business and doesn't want us to use his real name out of fear of financial repercussions. You'll also hear from a woman named Angie Maher. She left the industry two years ago after becoming a whistleblower in a lawsuit.

Now, according to Webb and Maher, companies train representatives to approach doctors in a very specific way, using language that deliberately fosters this idea that the doctors who speak are educators, and not just educators, but the smartest of the smart.

For example, every drug rep I spoke to for this story used the exact same phrase when approaching a doctor with a pitch to become a speaker. That phrase: thought leader. Give me your pitch.

Ms. ANGIE MAHER (Former Pharmaceutical Representative): I would say, great news for you today, my company has identified you as a potential thought leader.

Mr. WEBB: I was really thinking about thought leaders in the area that I would like to get to speak.

Ms. MAHER: They just think that you would be a great thought leader on hypertension. How does that make you feel?

Mr. WEBB: And I really thought about you, and I wanted to know how you felt about speaking.

Ms. MAHER: And they would go, wow, me?

Mr. WEBB: When you do say thought leader, I think it's a huge ego boost for the physician. It's like a feather on their cap. They get a lot from it.

SPIEGEL: You see, most doctors have a very specific idea in mind when you ask them what constitutes a thought leader. Most doctors, including Dr. James Dickie and Dr. Lance Clawson of Maryland, cite two important qualifications. James Dickie begins.

Dr. JAMES DICKIE (Endocrinologist): A thought leader is a physician or anyone in a community, obviously, that is well respected, I think, by their colleagues. And the other way to be a, quote, "thought leader" is to be an academic researcher. And then, by definition, you become a thought leader.

SPIEGEL: But some drug reps like Angie Maher have a more cynical view of why drug companies choose the doctors that they choose. It's not about how well respected you are, she says, it's about how many prescriptions you write.

Ms. MAHER: I think nowadays a thought leader is defined as a physician with a large patient population that can write a lot of pharmaceutical drugs, period.

SPIEGEL: Now, I don't want to overstate this, because reps recruit plenty of genuine thought leaders to speak for drug companies. Still, every rep I talked to had a stable of stories about profoundly unimpressive doctors that they'd recruited as thought leaders. Reps recruit these doctors, Matthew Webb says, basically for the same reason that a robber robs a bank - because that's where the money is.

But because they're not really impressive, Webb says, reps like him try to set their talks in places that won't attract a crowd. Think chain restaurants.

Mr. WEBB: I needed to try to get some business from these guys because they were really high volume physicians. And I would use them, but I would try to use them in, you know, I'll make them, like, go to an Applebee's or something and talk to a few physicians.

SPIEGEL: Now, Webb and Maher recruit even doctors that aren't well respected because - and here is the hard reality about the practice of doctor speaking -though doctors believe that they are recruited to speak in order to persuade a room of their peers to consider a drug, one of the primary targets of speaking, if not the primary target of speaking, is the speaker himself.

Mr. WEBB: Other people would start using it, but the big bump would come from the speaker.

SPIEGEL: In fact, here's exactly how the money works out, at least for Matthew Webb. He says he would give a high-prescribing doctor about $1,500 to speak. And that would result, after that speech, in that doctor writing between $100,000 and $200,000 in prescriptions of his company's drug.

Mr. WEBB: That much money easily. So, yeah, it was a good return on investment.

SPIEGEL: Let's linger for a moment on that last phrase: It was a good return on investment. To calculate return on investment, companies look at how much money was spent on a doctor versus how much the company made from him in prescriptions. This is something that companies monitor very, very closely.

Ms. MAHER: Whether it's a lunch, a dinner program, paying a physician to speak is tracked.

SPIEGEL: What happens is that drug companies buy the doctors' prescription data from firms like one called IMS Health. Those firms use pharmacy records to track the prescriptions of almost every doctor in the United States.

Mr. WEBB: So, the way we could tell honestly is you could look at their four-week data and you could see how many prescriptions he wrote more than he used to write. So that's how we know.

SPIEGEL: That's how they knew that the number of prescriptions the doctor was writing had gone up, which brings us to a very thorny moral question. Do the doctors who do the speaking know that their prescribing habits have changed? If they know, then in a sense, they're being bought. They are taking money to write prescriptions. If they don't, then they're unwittingly being played.

When I asked Dr. James Dickie if he thought that speaking changed the amount of a drug that he prescribed, he was very clear.

Dr. DICKIE: Absolutely not. The physicians who are in the audience may notice it if they have been educated to that drug and the benefits of that drug and they may see an increase in writing. But specifically in my own? I don't believe so.

SPIEGEL: Then I told Dr. Dickie about the things I'd heard from reps like Angie Maher and Mathew Webb, he seemed genuinely surprised, disturbed and began to wonder out loud if, in fact, he was affected.

Dr. DICKIE: It would really bother me.

SPIEGEL: Why would it really bother you?

Dr. DICKIE: Because I perceive myself as always prescribing in the best interest of my patient. And even unconsciously, if I was unduly influenced, that would really bother me. I usually pride myself on keeping up my guard to prevent undue influence.

SPIEGEL: But Angie Maher says that it's almost impossible for a doctor to keep up his guard. She points out that before doctors speak to their peers about a drug, they review slides provided by the company, talk to the company medical officers. And this process, she says, focuses the doctor on the most positive aspects of a drug.

Ms. MAHER: What is happening is that you are being manipulated to talk about the drug out loud, kind of like talking themselves into knowing that what they were saying they were actually believing. And if they believed what they were saying, then they would write more drug.

SPIEGEL: David Switzer is a doctor in Virginia who writes about the interaction between doctors and reps on a popular Internet website called Cafepharma. And as someone who has thought a lot about these issues, he says he doesn't believe that most of the doctors who speak are conscious that their prescription writing changes.

Dr. DAVID SWITZER (Writer, Cafepharma): The majority of doctors, I think, would honestly say, oh, that stuff doesn't work on me.

SPIEGEL: This attitude, Switzer says, is essentially programmed into them in medical school. In med school, they're taught to think critically, and they're also taught that they have been taught to think critically. Which, in a way, Switzer says, handicaps them when it comes to reps.

Dr. SWITZER: They come to the table with the belief that because they have gone through this rigorous academic training that they are somehow impervious. I just don't know that we're as good at that as we think we are.

SPIEGEL: For his part, drug rep Mathew Webb says that he can see the effects of this system even in his own family.

Mr. WEBB: My father has diabetes and I know one of his biggest complaints is that every time he goes to the doctor, it's, you know, let's try this medicine this time. Let's try this medication this time, even though my dad's controlled. Everything is working fine, but his doctor's constantly changing him around. And he is a speaker for several companies in our metropolitan area. So...

SPIEGEL: The drug industry's trade group, PhRMA, says that in their view, the current rules on speaking are sufficient. And a spokesman for the group said the group was unaware of any direct evidence that paying a doctor to speak might influence his prescribing habits.

Even so, a growing number of universities and hospitals no longer allow doctors who work on their staff to speak on behalf of drug companies. And under the new health care law, by 2013, every doctor who takes money from a pharmaceutical company will be listed on a government website.

Alix Spiegel, NPR News, Washington.

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