Doctors Failed To Disclose When Drug Companies Were Paying Them

JOHN DANKOSKY: This is Science Friday. I’m John Dankosky. Ira Flatow is away. When you submit a paper to a medical journal, one thing you’re supposed to do is disclose any conflicts of interest you might have, like payments from drug makers or relationships with biotech companies. Anything that could consciously or unconsciously bias your findings. Anything that people reading should really know about.

But over the past few months, investigations by ProPublica and The New York Times have shown that the honor system has major cracks in it. Journals are asking, but a lot of the time doctors aren’t telling. Katie Thomas is a reporter at The New York Times who co-authored one of these recent investigations and she’s here to tell us what she found. Katie Thomas welcome to Science Friday. Thanks for joining us.

KATIE THOMAS: Thanks for having me.

JOHN DANKOSKY: And if you’re a medical professional, we’d like to hear from you. How do you approach conflicts of interest? You can give us a call to ask your questions or give us your thoughts at 844-724-8255. That’s 844-SCI-TALK or you can tweet us @SciFri. First of all, this is amazing reporting, Katie. Maybe you can start by telling us how this investigation first came about.

KATIE THOMAS: Sure. It started several months before our first story, when my colleague, Charles Ornstein at ProPublica, just got a tip from a reader who had pointed us to the chief medical officer at the time at Memorial Sloan Kettering Cancer Center. His name is Dr. Jose Baselga. And he’s a leading cancer researcher, very well-known in the field.

And this reader just pointed us to the fact that in many of his journal articles, and in conference presentations, and in other public appearances, he wasn’t reporting any disclosures, even though if you dig around even just a little bit on the internet, you can see that he had multiple relationships with a lot of different companies. So we thought that was interesting, particularly just because he was such a leader in the field. And we started looking for ourselves and ended up writing a story about it in September of 2018.

JOHN DANKOSKY: So you’re suggesting it wasn’t really hard to find out that he had some of these potential conflicts and that he wasn’t really disclosing them.

KATIE THOMAS: Right. Some of them were easy and some of them were harder. But the first place that we looked and that we were surprised that he had gone so long without disclosing, because some of this was so simple to look up, was a federal database called Open Payments. And on that database, anyone can enter a doctor’s name and see a list of payments that the drug companies and device companies pay to doctors. And that wasn’t all of the– I can get into the details about how that’s not everything, but it showed us that he had some significant relationships with major drug companies that weren’t being reported.

JOHN DANKOSKY: Maybe you can talk more about the types of conflicts we’re talking about. And maybe even just describe what we mean by conflicts here, because I think a lot of people who aren’t in this field might not understand what a conflict is that should be disclosed.

KATIE THOMAS: Sure. Yeah, and there’s a wide range of relationships that doctors or researchers will have with drug companies. And just stepping back a little bit, a lot of people will say there’s nothing wrong with it. And in fact, some collaboration with the industry is really necessary. I mean, after all, the drug and the device industries are the ones that bring us our new medications and our new devices and all of the things that are lifesaving that we as a society really need.

And of course, we would expect those companies to be consulting with the leading scientific researchers. I mean, that’s something that I think everyone wants. But the issue that we looked at was disclosure and transparency. How much are these researchers disclosing these relationships, and how much are they getting paid, and in what form? So there’s a range of types of relationships. There is consulting relationships where they get paid a straight payment for work that they do.

There’s a lot of work– and this is something that we ended up reporting on quite a bit– that doctors do with start-ups. And those are not as easily discovered– some of those relationships. And often those are also in the form of things like stock options, ownership equity, equity stakes, and not just straightforward payments. I mean, those are probably the main areas. There’s speaking engagements. There’s all kinds of interactions that doctors have with drug companies.

JOHN DANKOSKY: But that role right up to people serving on boards of drug companies–

KATIE THOMAS: That’s right.

JOHN DANKOSKY: –which puts them into a real conflict of interest, because they’re supposed to do right by their university or their research facility. But they’ve also– if they are a member of a board of a company– they’ve also got to do right by shareholders.

KATIE THOMAS: That’s right and that’s a key issue that we ended up looking more closely at. So Dr. Baselga, who was the first article that we wrote about, was on the board of two publicly-traded companies. He was on the board of Bristol-Myers Squibb, a drug company, and Varian Medical Systems, which makes radiation equipment. Both of those are involved in the cancer field and here he is a top executive at Memorial Sloan Kettering.

And when you serve on the board of a company, as you pointed out, you have a fiduciary duty to that company. And so the question that we asked is, is that a conflict of interest when you’re a top leader at a nonprofit medical center like Memorial Sloan Kettering and you also were on the board of a publicly-traded company?

JOHN DANKOSKY: What has happened at Sloan Kettering since your articles came out?

KATIE THOMAS: They’ve made a number of changes. Dr. Baselga– a couple days after our first story– he resigned. He later stepped down from the boards of Bristol-Myers Squibb and Varian. The Chief Executive, Dr. Craig Thompson, he was also on the board of Merck and another board called Charles River. And he eventually stepped down from those two companies as well.

We did several other stories that took a closer look at the relationships that Memorial Sloan Kettering and its leaders had with companies. And they ended up making several changes as a result of our reporting. The most recent one was that they said that the leaders of their company would no longer serve on corporate boards. That was the new policy that they decided to pass.

JOHN DANKOSKY: I want to bring on another guest who’s been researching these conflicts of interest in medicine and how we tackle them. Eric Campbell is a Professor of Medicine and Director of Research at the University of Colorado’s Center for Bioethics and Humanities. Eric Campbell, welcome to Science Friday. Thank you for being here.

ERIC CAMPBELL: Thank you, John. Hi, Katie.

KATIE THOMAS: Hi.

JOHN DANKOSKY: Eric, I’ll start with you. And I’d love Katie’s thoughts on this, too. How widespread is this problem? We’ve been talking so far about this one high-profile case that was a lead story from ProPublica and The New York Times. But this goes much deeper than Sloan Kettering, certainly.

ERIC CAMPBELL: Yeah, I think the evidence– there’s actually people that do research on how often researchers fail to disclose. And the findings are pretty consistent that in most journals, it’s probably somewhere around 20% to 30% of people fail to fully disclose conflicts of interest. It’s difficult because when you’re dealing with physicians who are researchers it’s pretty easy to find out if they disclosed, because you can just look them up in the Open Payments database. But the issue is when you’re dealing with PhDs, because they’re not included in that database. And that makes it much more difficult to accurately estimate the frequency with which people fail to disclose.

JOHN DANKOSKY: I should say that– on the topic of disclosure– you told us that you wanted to disclose a conflict of interest yourself. So what is it?

ERIC CAMPBELL: Oh, absolutely. In the spirit of our discussion, in addition to being a professor at the University of Colorado, I currently serve as a paid expert witness in law cases against drug companies related to conflicts of interest in medicine and research.

JOHN DANKOSKY: So this is something you’ve been studying for quite some time, and it’s something that you’ve testified about as well.

ERIC CAMPBELL: Yes, I testified twice before the US Senate and in law cases as well.

JOHN DANKOSKY: So these conflict of interest aren’t a new problem. We’re talking about the current state right now. But over the last 20 years or so, Eric Campbell, what has been done? What have people been doing to try to solve this problem?

ERIC CAMPBELL: Mm-hmm. Yeah, it actually dates back to the ’50s, when there were Senate hearings on the issues of conflicts of interest in medicine and research. And that was brought up again in the ’80s with Senator Gore, and it appeared again in the 2000s with Senator Grassley. There have been a number of kind of watershed moments in the history of conflicts of interest, but I think the big ones are the growing recognition by universities and medical schools that this was something that they needed to tackle.

A second watershed moment was, obviously, the requirements by journals that people disclose– when we know they don’t always do it, but they’re required to. And then finally, was the Physician Payments Sunshine Act and the requirement that drug companies disclose to the American people how much they paid physicians related to marketing and research and so on. Those are really the big things.

And what’s happened is the frequency of relationships has declined over that time. In part, due to the increased transparency, I think. And in part, due to institutional policies at medical schools, teaching hospitals, and also at the American Medical Association that attempted to limit what people consider to be inappropriate relationships.

JOHN DANKOSKY: We’re talking about medical research and conflicts of interest. And if you want to join us 844-724-8255, or 844-SCI-TALK. We have a call here from Jim, who’s calling from New Haven, Connecticut. Hello there, Jim. You’re on Science Friday.

JIM: Hi, thanks for taking my call. I guess, the person who made the last call made the point I wanted to make. So I actually am a physician. I also have an academic appointment and I work in big pharma. And what I wanted to point out is the pharmaceutical company has very stringent obligations in terms of legal requirements that our attorneys make us report every single nickel we give to a physician under any circumstance. And I can tell you within pharma, the lawyers are all over this in terms of oversight to make sure we do that.

JOHN DANKOSKY: So you say within the pharmaceutical industry, Jim, the lawyers are making sure you do this. Do you hear some of what Kate and Eric are talking about, though, that non-disclosure to journals is a big problem in your field? Jim? Maybe Jim has left us. Katie, I’m wondering if you can maybe pick up on what Jim said? I mean, he’s saying that pharma is policing itself as far as making sure that people who work on both sides of this fence are disclosing as much as possible.

KATIE THOMAS: Right. And as I mentioned there, and Eric did as well, there’s the Open Payments System, which is a relatively new federal database where the drug companies are required to report their payments to physicians. But one thing that came up in our reporting was a pretty big gap, especially in the area of cancer research, but a lot of other areas of research as well, which is that a lot of these doctors are doing work with start-ups that don’t have any approved products yet.

So they’re doing early research, sometimes clinical studies, everything that you would need to do to get a drug to market. But they don’t have those reporting requirements before they have an approved drug. So there’s a whole host of companies that they don’t have to report this. And that’s where– when I mentioned that there was some additional digging required– that’s what I was talking about. There’s dozens of companies out there that are start-ups and that are putting drugs on the market, but they don’t have to report this.

JOHN DANKOSKY: Eric, I think it’s probably important to take a step back a little bit and really explain why this matters to people. I mean, what is the problem of conflict of interest of the type that you and Katie are talking about to people who go to the doctor, people who are worried about the medical system?

ERIC CAMPBELL: Sure. So for physicians– the primary interest of physicians is the health and welfare of their patients. And secondary interests, like making money, or getting free dinners, or being a consultant with drug company, have the potential to change what doctors do. And the behavior that these relationships change is it changes their prescribing behaviors. It’s associated with a change in prescribing behaviors.

Research has been on tons of it– a pile of research so big, if it fell on you it would kill you– to show that, in fact, gifts from drug companies to doctors are associated with increased prescribing of that company’s products and services. Research in the opioid industry in opiates has shown, just this week, that in fact, what matters is not really how much money doctors get paid, but the number of gifts and payments they get. And what happens is that when doctors get paid by companies, for example, that sell opioids, they increase the prescribing of opioids.

And this research that just came out is fantastic, because it then looked at regional differences in rates of overdose from opioids and found that it was associated. And that’s the real key here is that doctors’ financial conflicts of interests can influence the drugs and devices that patients get and that can have important health consequences for the patient.

JOHN DANKOSKY: I’m John Dankosky, and this is Science Friday from WNYC Studios. And Eric Campbell, I’d like to continue on that, especially because the opioid epidemic in America is such a big concern to so many people. You’re saying that this most recent study looks at the places where opioids are the biggest problem, you’re seeing doctors who are actually over-prescribing in those places. And it is fascinating that it’s not about people taking hundreds of thousands of dollars, it’s about people just getting some free meals.

ERIC CAMPBELL: Right. The marketing industry and the drug industry has known for years that small gifts can be very influential in influencing what people do. And it can occur below the consciousness of people, because it builds reciprocity. And many doctors deny that these have an effect on what they do. In fact, one of the interesting things that I always do is I ask doctors if getting a gift influences what they do. And very few doctors say it influences what they do. But when you ask them if it influences their colleagues, like 80% of them say, oh, yes, it totally influences my colleagues. It’s like a self-deception, if you will, about the effects and how powerful small gifts and food are on what people do.

JOHN DANKOSKY: I’m wondering, Katie, if you can connect some of what Eric’s talking about with some of your reporting. The prescribing of, say, opioids at the doctor to patient level with the types of conflicts that you’re reporting on big research universities working with pharma, maybe not talking as much about it as they should. Make a connection for our listeners, so that they understand why this is such a big problem in their lives.

KATIE THOMAS: Right. And I should say that in the stories that we did– especially, we did a broader story looking beyond Dr. Baselga and at other researchers who failed to disclose– we were not reporting that their research was biased or skewed, necessarily. But it does raise the question– like Eric was saying– this question of reciprocity and unconscious bias, unconsciously allowing these relationships to infiltrate your research, that people have raised with us as potential concerns. There are also studies out there– Eric will be more familiar with them than me– that show that research that’s funded by industry tends to be more positive than research that’s not, for example.

JOHN DANKOSKY: Eric, could you quickly pick up on that, if you would? We just have a little less than a minute before the break.

ERIC CAMPBELL: Sure. There’s actually a fairly decent body of literature to show that studies that are funded by drug companies are significantly more likely when they’re published to present results that are both positive regarding the safety and efficacy of a company’s products and services, than they are if those studies are not funded by industry. And there’s a lot of potential reasons why that is, but it has been shown over and over and over again.

JOHN DANKOSKY: Eric Campbell is a Professor of Medicine and Director of Research at the University of Colorado’s Center for Bioethics and Humanities. And Katie Thomas is a reporter for The New York Times who’s been covering the business of health care and also covering conflicts of interest in research. After the break, we’re going to talk more about this issue and get to some of your questions as well.

This is Science Friday. I’m John Dankosky. We’re talking about medical professionals who don’t disclose their conflicts of interest in scientific journals. My guests are Katie Thomas, a reporter for The New York Times, who’s been working on stories about this with ProPublica. Eric Campbell is a Professor of Medicine and Director of Research at the University of Colorado’s Center for Bioethics and Humanities. I want to get some of your phone calls in here as well. Robert is calling from Cleveland, Ohio. Hello there, Robert, you’re on Science Friday.

ROBERT: Hello. You know for all of the reasons that you’ve brought up on your program today, I don’t think there should be any money going from pharmaceutical companies to doctors. About 5 and 1/2 years ago I was, oh, about 60% to 70% crippled by an antibiotic. I don’t know if most people know this, but if you took a generic drug, you have no legal rights, you can’t sue. My many consultations with doctors and other people that have been affected by this antibiotic since that time has shown me that the doctors do not pay much attention to what the patient says. They listen to the pharmaceutical reps.

[DIAL TONE]

JOHN DANKOSKY: Well, Robert, thank you very much for your phone call. And I’m sorry, I think we lost you there. I’d like to ask Eric to maybe follow up on this. What Robert just told us is something that an awful lot of people in America feel right now, is that if they read a story by Katie Thomas in The New York Times that says that researchers or doctors are getting big money from pharma, then they’re not going to listen to the patient, they’re going to listen to the person who’s making the antibiotic, or making the cancer drug, or making the opioid.

ERIC CAMPBELL: Mm-hmm. Well, there’s actually some data on this. My colleagues and I survey doctors about how often they use generics compared to brand name drugs to treat some diseases. And what we found is that the doctors were more likely to say they use brand name drugs if they had been visited by drug companies and if they’d accepted meals. And the reason is that drug companies, in general, don’t market generics. They market high-priced brand name drugs.

I would disagree with the caller somewhat. I don’t think we should sever all relationships with doctors and researchers, because in fact, research grants and contracts are the fundamental mechanism by which we have the drugs and the good devices that exist in medicine today. So I would be more circumspect in suggesting that perhaps practicing physicians should not be allowed to take things like meals in their offices. They shouldn’t allowed to go to tickets and attend the Super Bowl or go to Florida and take their family to Disney World. But that research relationships are really in a different class. And for physicians who do research, allowing them to have principled relationships in scope of research is really an important concept.

JOHN DANKOSKY: So Katie, what are some things that you think could make this system better? Now that you’ve been studying this and reporting on it for a while, I mean, what are some of the things that are missing here that maybe through some oversight or maybe just through more information could help us understand a little bit better and avoid these conflicts?

KATIE THOMAS: Sure. Some of the things that people have pointed out to us– the first one is consistency from the medical journals. We heard from a lot of researchers who were very frustrated that different journals have different rules. Some go back two years. Some go back three years. They have different rules about what’s considered relevant. And so some sort of streamlining– a better streamlining of what their rules are for disclosure across these journals would be good.

And then, also, others have pointed out some way for reporting from these smaller companies, these start-ups. And then just going along with the idea of streamlining this, there’s been a push for a more centralized way of reporting these conflicts. Again, the Open Payments Database is one big source of information, but it’s not everything. And The New England Journal of Medicine is actually developing a system like this with the AAMC, the American Association of Medical Colleges, which would have researchers put all of their conflicts into one central place. And that might help with automatic, more clear disclosure.

JOHN DANKOSKY: And Eric, do you have some thoughts on this quickly– things that we could do better.

ERIC CAMPBELL: Yeah. I think the medical research community could potentially just embrace the fact that why don’t folks just disclose everything that they have. In other words, not systematically pick and choose what is relevant or not. But make a database in which researchers’ conflicts of interest are widely available and then journal editors can look them up, and the reviewers can look them up, and so on.

The other thing I think is that I still think we need to do a better job about helping researchers understand why it’s so important to both trust in science and trust in our academic institutions, to make sure that they personally are vigilant in doing it. Because at the end of the day, I think the last thing any researcher wants is to be on the other end of a story by Katie Thomas about conflicts of interest.

JOHN DANKOSKY: Yeah. And the idea of making sure that we actually have confidence in this entire system is probably something, Eric, that’s really important to you. That we trust the researchers, that we trust our doctors.

ERIC CAMPBELL: Right. I think the profession of medicine when it’s studied is consistently one of the most highly regarded fields in which people work. And I think it’s essential to maintain that trust for a profession, but also for the people that the profession serves, because trust is a really important concept in medicine.

JOHN DANKOSKY: Eric Campbell is a Professor of Medicine and Director of Research at the University of Colorado’s Center for Bioethics and Humanities. Eric, thank you so much for joining us. I appreciate it.

ERIC CAMPBELL: Thank you, John.

JOHN DANKOSKY: Also, thanks to Katie Thomas, a journalist at The New York Times. Thank you for all your great work, Katie. I really do appreciate it.

KATIE THOMAS: Thanks for having me.

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