2005 speaker series: Dr. Joseph Rohan Lex, Jr., M.D. FAAEM the physician-pharmaceutical industry relationship.

• Position: Fellow of the American Academy for Emergency Medicine

MR. MEARNS: Good afternoon, everyone. My name is Geoff Mearns and I'm the Dean of Cleveland Marshall College of Law and it's my pleasure to welcome you here to what I guess is chapter two of the inaugural lecture in the Journal of Law and Health lecture series.

If you had the pleasure of being here yesterday, you know that you are in for an informative and engaging presentation by Dr. Lex. And so without any further ado, I'm going to introduce Evelyn Holmer, she is co-editor-in-chief of the Journal of Law and Health and she will introduce Dr. Lex.

MS. HOLMER: Good evening. On behalf of the Cleveland Marshall Journal of Law and Health, I'd like to welcome you here this evening.

Before I get started, as a friendly reminder, if you haven't done so already, if you could just pull out your pagers, BlackBerries and cell phones, make sure you have them on vibrate or silent, I would greatly appreciate that. All right. On to getting started.

Being one of only a handful of law reviews which encompass both the fields of law and health, the Journal seeks to serve Cleveland and its healthcare community by facilitating a link between the medical and legal professions. The Journal prides itself on constantly examining healthcare law from all angles, be it medicinal, constitutional or political. And in doing this, there are a variety of forums, be it from presenting speakers to publishing medical works to publishing law reviews. In fact, a transcript of tonight's presentation will be published in our next issue, numbered 18-2, which is due out in December, knock on wood.

Pursuant to this spirit, it is our honor to host Dr. Lex tonight. Dr. Lex is a graduate of the University of Texas Health Science Center and served his internship and residency at the Thomas Jefferson University Hospital in Philadelphia. He is a member of the Society for Academic Emergency Medicine, a member of the Physicians for National Health Plan, and also a Fellow of the American Academy for Emergency Medicine. He currently serves on the faculty at Temple University School of Medicine as an assistant professor of emergency medicine.

Dr. Lex's educational experience is outmatched only by his list of accolades, and this is where he's going to get embarrassed because we did this last night. Dr. Lex is the recipient of the Presidential Unit Citation of Valorous Action in Vietnam, the Combat Medical Badge for Service in Vietnam, the Temple University Excellence in Teaching Award, and the Vickery Award for Outstanding Contributions For Emergency Medicine Education, amongst many others.

Ladies and gentlemen, please join me in welcoming for the second time in our series Dr. Joseph Lex.

DR. LEX: Do I need to speak louder using the lavaliere? Are you okay if I wander? Cool. Because I'm going to wander. All right.

Tonight's topic is actually four combined into one. If you thought last night's talk was truncated, two hours into one, tonight I'm going to cram four hours into one. So hang onto your hats.

I could actually divide this into four different talks. First of all, there's the ethics on giving gifts. Then there's the intertwining of academia and industry, which is pretty nasty, when you get fight down to it. Then there's just the whole psychology of promotion. And finally, food, flattery and friendship. I hope to spend a little bit of time talking about some logical fallacies in pharmaceutical promotion. So I've got lots of things to get in here.

First of all, I've got to make confession. Once upon a time, I ate drug rep doughnuts and pizza. And I craved freebies at national meetings. I used to get my little bag and go around, stuff the bag full of stuff. I attended drug company sponsored meals at one time in my career. I used to drink from a Monistat mug, I wrote with a Rocephin pen, I did all of these things. I even once, please forgive me, I went to a Phillies game on a drug company's dollar and I sat in their private box.

But that was a long time ago and I wish that I knew then what I know now. I have been clean for about fifteen years.

Now, I'm going to give you this: I have knowledge that pharmaceutical research and development is employing. Ten years ago age was a death sentence. Thirty years ago renal failure was a death sentence. Fifty years ago cancer was a death sentence. There have been remarkable strides in the pharmaceutical research, although much of the research actually comes from universities and is funded nationally rather than by the pharmaceutical industry. That's a whole different topic.

I will just acknowledge that some good comes out of the pharmaceutical industry. In addition, it is still happening. Not two days ago Bayer Pharmaceuticals announced that they were long moxifloxacin, one of their expensive new antibiotics, to be tested in the treatment of tuberculosis, and if it is found to be successful, they promised they will distributed it at cost in third world countries to try to eradicate tuberculosis. So drug companies are doing good things. And I'm not going to argue that.

My premise is that physician interactions with marketing representatives result in inevitable and irreconcilable conflicts of interest or the appearance of conflicts of interest. Our patients in medicine are the ultimate losers from such interactions.

So for recovery we have proposed these things, people who feel the way I do. We have to admit that we are powerless over pharmaceutical paraphernalia, that our lives have become unmanageable. We will make a searching and fearless moral inventory of ourselves, our desks and our work areas. We are entirely ready to remove all of these defects of character, as well as pens, penlights and notepads. And having have this spiritual awakening as a result of these steps, we try to carry the message to others, and to practice these principles in all of our affairs.

Does this sound familiar? What's TANSTAAFL? Who is a Heinlein fan? What does TANSTAAFL mean? There ain't no such thing as a free lunch. This is a quote. There ain't no such thing, and if there were, these drinks would cost half as much. Reminding us anything that is free costs twice as much in the long run or turns out worthless. This is from The Moon is a Harsh Mistress, 1966, Robert Heinlein.

But I hear you say or I hear my colleague physicians say nearly all organizations agree that it's okay to take small gifts from the drug companies. Or if, you know, if they don't market it to us as physicians, they are just going to turn around and market it directly to the consumer and the consumers aren't going to know how to handle that information. At least we can process and deal with that information. Or, you know, you are really an insulting boor to think that I can be bought so cheaply, that if I can be bought by a pen or a notepad, but you know something, I'm going to remind you that, as a lawyer and as a physician, we have a fiduciary relationship with our patients or with our clients. And what does this mean?

A fiduciary, we have a specialized knowledge or expertise, we hold the trust of others, we hold high standards of conduct, we avoid conflicts of interest, and we are accountable or obligated, both ethically and legally. This is the place where medicine and law have the same set of ethics.

I am a member of a profession. As a professional, society has asked that I serve its interests over my own interests. And in return, society trusts me to do what is right. This trust allows my profession to self-govern. Just as it allows your profession to self-govern.

The problem is, when we get into the promotional pharmaceutical, I'll get into that a little bit more, because most physicians are hard working, and most physicians desperately want to act in the patient's best interest, physicians do not like the image of being bought by drug companies. We like to see ourselves as independent thinkers, and this is not a very popular message among physicians. It's really not. Because most physicians think they are over all of this stuff that I am talking about. But I want to show you something that I hope will make you understand where I'm coming from.

Companies are businesses, we live in a capitalist society, that's not going to change anytime soon, and pharmaceutical companies are not evil empires, for the most part. They are businesses. They are businesses. They are the most profitable business in the world, by far. They make huge amounts of money, and I'll show you statistics in a little while. They spend far more on marketing than they do on research and development, despite what they want to tell you. A majority--or more money goes into marketing than it does into research and development, and the reason they spend the money on marketing is simple. It works.

In fact, as a business, it is their obligation to make as much money as possible for their stockholders. If the money they put into marketing did not work, it would be unethical for them to spend it on marketing because it was not returning a profit. So this is their ethics and this is what we have to look at. It's a different set of ethics from the fiduciary relationship that we have with our patients or our clients. Their business is the business of business. It's to make money.

Drug companies do not advertise to capture our forebrains. They advertise to capture our hands, which write the prescriptions, they capture our subconscious, and sometimes they capture free advertising space on our shirt, our coffee meg, our pen, our notepad, our stethoscope. The marketing strategies use proven methods of promotion. Otherwise they would not be using them. They are aimed at the subconscious, and they have effects which are unavoidable and unconscious. And the reason they use them is they work. It's that simple. And doctors don't want to accept this. It's really not a matter of choice.

Where do we fit in the picture as physicians? We are the ones who write the prescriptions. We are the ones who are driving...