Warren Joseph is a podiatrist on a mission. He wants the medical world to become better informed about the devastating consequences of diabetic foot ulcers. He says he has no problem that Pfizer, the world's largest drug company, pays him to get the word out. Since 2009, the Roxborough foot doctor has made $67,000 in speaking fees, plus $4,600 for consulting and $13,000 in expenses.
The bigger point, Joseph says, is that diabetic foot ulcers cause more than 80,000 amputations each year. By getting the word out, "I'm saving limbs," says Joseph, who specializes in treating diabetics.
He is among thousands of doctors in the United States who are paid by the companies making the drugs they prescribe. Many critics see this as a conflict of interest that's damaging to the medical profession and, ultimately, patients. They question whether doctors can be objective about prescriptions when drug companies pay them handsomely.
Last week, a database showing how much money the seven biggest drug firms have paid physicians was launched by the nonprofit investigative reporting group ProPublica. The list covers 17,700 individuals who have amassed $258 million in payouts since 2009.
Of those, 384 doctors made more than $100,000.
The companies had posted these payments online, but they were hard to understand. On the ProPublica site, patients can do a search to see if their doctors got anything for speaking, consulting, and other services.
Drug firm payments to doctors have long posed a huge ethical challenge in medicine.
Tufts University psychiatrist Daniel Carlat used to think it was harmless that Wyeth Pharmaceuticals was paying him about $30,000 in yearly speaking fees, he said. He was, after all, educating other doctors on how to recognize and treat depression - and Wyeth's drug, Effexor, did look good in studies at the time, in 2001.
But subsequent studies started to suggest that the side effects might outweigh any advantage, he said. "Gradually I sensed a subtle pressure to embellish the advantage of the antidepressant that I was speaking of and downplay the side effects."
In 2002, Carlat quit working for Wyeth, now part of Pfizer.
Some of the biggest earners in the Philadelphia region said that they were doing some good by educating other doctors about conditions and new treatment options - and that they believed in the company's products.
Delaware County physician Anthony Rooklin, who has gotten more than $175,000 in speaking fees from GlaxoSmithKline P.L.C. since last year, said the company's drug Advair was a godsend to his asthma patients. "I've been treating asthma for 35 years. This drug in many cases revolutionized the care of asthma."
An immunologist and allergy specialist, Rooklin said his talks often described asthma to general practitioners and other nonspecialists. "My approach is to teach physicians how asthma works, how you approach it, and what your options are as far as treating it."
Though Advair came first, it now has several competitors, including Merck's Singulair, and if someone in the audience asked about a particular case, Rooklin said, he might recommend another drug if it was more appropriate.
Another big earner in this region, Philadelphia urologist Richard Harkaway, also has made more than $175,000 in speaking and consulting fees from GlaxoSmithKline since last year. He said he believed in the company's drugs to treat prostate conditions.
"I provide education to doctors who like to hear me talk. I have funny stories to tell, and I put a lot of time and energy into this," he said.
Harkaway said he had been asked to speak for several drug companies. He said that he had supported himself through college working as a stand-up comedian, and that his ability to hold an audience attracted the drug firms.
"I made rules for myself," he said. "I would only speak honestly about drugs I truly believe in and would provide education." He gave about 45 talks all over the country in the last year, he said.
Harkaway said that he didn't mind that ProPublica publicized the speaking fees that he and other doctors garnered, but that he minded the insinuation that the money influenced how he would prescribe drugs.
He said it was a different story when drug companies bought gifts or junkets for doctors. He said he wouldn't work for this company if he didn't believe it was making good products and going the extra mile to protect patient safety. "Glaxo is an amazing company," Harkaway said.
GlaxoSmithKline got attention this week for agreeing to pay $750 million and admitting that it had made poor-quality medicines at a plant in Puerto Rico. There was no evidence that the drugs had harmed patients, and the poor-quality drugs did not include Advair, according to documents.
Critics say that the practice of giving outright gifts to doctors is declining, but that paying them for services is flourishing.
"The real story here is the pervasive influence that marketing has on doctors and ways drug companies exert their influence," said physician David Grande, a health-care expert at the University of Pennsylvania. While several big earners said they were focused on educating fellow physicians, Grande said, "the goal for the drug company is to sell more drugs."
Others expressed concern about the influence of these talks. Doctors in the audience are learning about drugs through what amounts to drug company marketing, said Allan Coukell, executive director of the Pew Prescription Project, an advocacy group funded in part by the Pew Charitable Trusts. "I think we need prescribing to be guided on independent evaluations of the scientific evidence."
In response, GlaxoSmithKline spokeswoman Mary Anne Rhyne said doctors "provide valuable knowledge" and "can help their peers with information." Because there are differing opinions on the practice, she said, the firm voluntarily posts payments to physicians on its website.
Pfizer offered a written statement, saying the company relies on doctors "to help inform their peers about treatments and approaches, along with the risks and benefits of our products."
Psychiatrist Carlat said he had realized he hadn't been giving audiences an objective picture while working for Wyeth. He was never told that he had to say good things about its drug Effexor, he said, but felt pressure to anyway.
"To some degree, future speaking assignments and therefore future checks depend on how you treat their drug," Carlat said. "You know why you're getting paid."
He said it was also likely that his speaking job had influenced his prescribing habits.
Doctors tend to prescribe drugs they know, Carlat said. "You're flown to conferences to learn all about the drug, so your world becomes saturated with Effexor knowledge. That naturally keeps the drug foremost in your mind."
When he started speaking, he said, studies showed that Effexor worked for depression a little better than Prozac and other, older competitors, but later studies showed it was only marginally better. And it had a side effect that the competitors didn't: It led to high blood pressure in some patients.
Marketing by doctors, Carlat said, "is generally a net negative for American medicine, since it distorts medical practice in favor of the latest products, which aren't necessarily the best products."
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