Among the many fascinating documents is a list of physicians that Merck sought to “neutralize/discredit” because they were not favorable enough to Vioxx.  Some of these names come with an ominous all-caps and bolded “NEUTRALIZED” under their names.  Each physician has noted down their contact information, affiliations, a detailed description of why they are problematic, and a recommended plan of action.

Dr. John J. Condemi, a speaker for Searle (a Merck competitor) was someone targeted for neutralization. According to the documents Dr. Condemi had the following background: “Thought leader in the community and Upstate NY; speaking on behalf of Searle as an advocate and investigator; recently enrolled him in a clinical trial (RA) after many months of promises and hard effort; not entirely certain this wasn’t too little, too late; speaking to community physicians at programs sponsored by Rochester Blue Cross Blue Shield (80% market share in a 90% managed care market); have not been in attendance at these meetings, but can imagine that VIOXX has not been mentioned nearly as often as Celebrex; has trained many of the RHU in the Upstate area and is considered the expert by many (thus, the reason BC/BS has used him as a speaker); has done studies on FOSAMAX and SINGULAIR but for some reason was slighted by us for VIOXX; wants to be involved with VIOXX.” As this document shows one of the ways to win physicians is to enroll them in “clinical trials.”

The plan for Dr. Condemi is as follows: “Provide scientific information; research; interested in NSAID-induced asthma; provide investigator slides to balance presentations; personal visit by a “heavyweight” from MRL or CDP (Greg Bell or Greg Geba) to discuss where we want to go with VIOXX; could work with him to develop a clinical pathway for COX-2 inhibitors in a managed care setting; panel with Dr. Singh of Stanford and some others to focus on pharmacoeconomic studies which verify reductions in PPI or H2 blocker use.  – He is in a clinical trial; – He is attending a program given by Dr. Geba  – Speaker – doing a good job”

Dr. Max Hamburger, President of a large, private Rheumatology practice in Long Island (New York) is listed as having become an ADVOCATE. Here the hook was not a clinical trial but rather financial support.  Hamburger’s practice was important to Merck because it included “high volume prescribers” who were users of Celebrex (an anti-inflammatory drug that competed with Vioxx).  Here is how Merck characterized the situation presented by the practice: “companies that provide funding will receive preferred status with its members and those that do not will have trouble accessing the IPA members; first endeavor is to put together a “Standards of Care” retreat meeting to develop a document that will serve as their manifesto (to include a drug formulary and how the members will treat certain diseases, preferred medications); price tag is $25,000 to support this meeting and to have access during it.” In its recommendation the document concludes: “Financial support of private practice rheumatology IPA – (has taken place). Has been turned around.” Such horse-trading is worthy of a grade B movie.  It is important to remember that we are talking about highly expensive and dangerous medicines.  And patients who trusted their physicians to provide the best-possible clinical advice, not suggestions based on which drug company was willing to finance their practice.

This types of relationships form part of the context for a recent JAMA article recommending that professional medical associations sharply curtail their reliance on drug companies for financing (Rothman et. al. Professional Medical Associations and Their Relationships With Industry: A Proposal for Controlling Conflict of Interest, JAMA 2009;301:1367).  The document offers a number of specific recommendations and concludes: “PMAs should work toward a goal of $0 contributions from industry; they should not collaborate in or profit from industry marketing activities; PMA leaders and executive staff should be free of conflict of interest and, in time, so should the entirety of the board and the members of the practice guideline committees.“  Since so many of the “leaders” in organized and academic medicine have close financial ties to industry, this is essentially a call for revolution.

How much such a revolution come about?  It would seem to us that the only way would be in the context of a universal, publicly funded and administered health care system which is measured by its ability of efficiently protect and promote the health of the populace.   Is that a revolutionary idea?

posted by Matt Anderson, MD