July 15, 2005
To Sell Their Drugs, Companies Increasingly Rely on Doctors
For $750 and Up, Physicians Tell Peers About Products; Talks Called
Educational
Dr. Pitts's Busy Speaking Tour
By SCOTT HENSLEY and BARBARA MARTINEZ
Staff Reporters of THE WALL STREET JOURNAL

NEW YORK -- On a recent Wednesday evening, neurologist Lawrence Newman
spoke to a dozen doctors in a private alcove off the soaring dining
room of Guastavino's and made the case that migraine headaches are
seriously underdiagnosed.

Migraine treatment "should be bread and butter for primary-care
doctors," he told attendees at the midtown Manhattan restaurant. While
patients might say they're having a sinus headache, there's a good
chance it's actually a migraine and can be treated with a migraine
drug, Dr. Newman said.

It was a message friendly to migraine-drug makers, and no wonder: The
sponsor of the talk was GlaxoSmithKline PLC, maker of the best-selling
migraine pill Imitrex. Glaxo picked up the tab for dinner, paid Dr.
Newman a fee, supplied some of his slides, and scattered Imitrex
notepads on the table.

Drug makers have seized upon an effective tool for getting their
message across to doctors: other doctors.

Across the U.S., thousands of doctors such as Dr. Newman, an associate
professor of clinical neurology at Albert Einstein College of Medicine,
have signed up as part-time lecturers for drug companies. At small
meetings, often over lunch or dinner, these physician-pitchmen tell
their peers about diseases and the drugs to treat them, often pocketing
$750 or more from the sponsor. Dr. Newman declined to discuss his fee.

In 2004, 237,000 meetings and talks sponsored by pharmaceutical
companies featured doctors as speakers, compared with 134,000 meetings
led by company sales representatives, according to market researcher
Verispan LLC of Yardley, Pa. In 1998, events featuring sales reps and
physicians were about equal at just over 60,000 each, Verispan says.

The growing use of talks by doctors comes as drug makers face criticism
over other sales tactics. Direct-to-consumer advertising has drawn fire
and some companies are voluntarily restricting the practice. The
industry's nearly 100,000 salespeople in the U.S. are facing resistance
from doctors who complain about being besieged in their offices. Drug
maker Wyeth plans to cut its main sales force, which calls on
primary-care doctors, by as much as 30% this year.

Companies formerly curried favor with doctors by taking them on free
golf outings or filling up their cars with a tank of gas in exchange
for listening to a sales pitch. But a voluntary marketing code adopted
by the largest drug companies three years ago barred such inducements.

Hiring a doctor as a speaker and providing a free meal for the
attendees is still acceptable -- and, data suggest, highly effective.
An internal study done by Merck & Co. several years ago calculated the
"return on investment" from doctor-led discussion groups was almost
double the return on meetings led by the company's own sales force.

Drug makers and the doctors they sponsor say the talks are educational.
Dr. Newman, the speaker at the Guastavino's dinner, said he refuses to
give talks centered on a single drug or those he considers promotional.
When one doctor at the dinner interrupted with a question and said the
talk was really about Imitrex, Dr. Newman smiled and disagreed. He said
doctors should choose a medicine to match their patients' condition,
then rattled off the generic and brand names of Imitrex and six rival
drugs.

Dr. Newman said he gives about three industry-sponsored talks a month,
usually during the day rather than at dinner. He said he tells
pharmaceutical companies, "Your job is to sell the drug and my job is
to educate."

Mary Anne Rhyne, a spokeswoman for Glaxo, the second-largest drug
maker, says: "The purpose of these events is to share information with
health-care professionals about disease, diagnosis and treatment,
including the use of our medicines." Glaxo makes no secret of its
sponsorship of the events: Its sales representatives give out written
invitations with the Glaxo name on them.

Those who question the talks say drug companies are bombarding doctors
with one-sided information through the seemingly neutral medium of
independent speakers who often have prestigious affiliations. "An awful
lot of the doctors in the audience are naive about the fact that these
are really sales talks," says Jerry Avorn, a professor of medicine at
Harvard Medical School and author of a recent book that criticized drug
companies' marketing.

Also, speakers who make thousands of dollars in fees from drug
companies aren't required to disclose their side job to patients,
although they are expected to disclose their ties in scientific papers.

Training Sessions

Some critics see a problem not only with talks such as the one Dr.
Newman gave but also with the sessions at which companies train their
doctor-speakers. Steven Bernstein, an internist at the University of
Michigan Health System in Ann Arbor, thinks drug makers may bring more
doctors to speaker training than they need because the training is
itself excellent advertising. Doctors are invited, says Dr. Bernstein,
to "try to convince them to utilize these products, and second, to use
them as a marketing arm for the firm's products to their colleagues."

The drug industry's voluntary marketing code says companies should
train speakers and consultants only if they intend to use them. The
code responds to criticism of a practice popular in the 1990s under
which companies would give doctors an all-expenses-paid trip in
exchange for a brief "consulting" opinion about the company's drug.
Scott Lassman, assistant general counsel at PhRMA, the drug trade
group, says he believes companies are observing the code.

Some doctors have earned considerable sums from their moonlighting as
speakers. Subir Roy, a gynecologist who teaches at the University of
Southern California, received $61,250 in fees and an additional $11,117
for expenses in 2002 from Wyeth, according to a list compiled by Wyeth
and submitted by Dr. Roy to the U.S. District Court in Phoenix. During
that year he spoke 53 times about Prempro and Premarin, Wyeth's drugs
to ease the symptoms of menopause. The drugs were in the news that year
because a big federal study suggested Prempro could increase the risk
of heart attack and stroke in women.

The data about Dr. Roy emerged after a former Wyeth sales
representative filed suit against the company, saying it failed to stop
Dr. Roy from making unwelcome sexual advances on her. Dr. Roy denies
doing anything improper. The former sales rep, Anissa Groves, alleges
that Wyeth fired her because it didn't want to jeopardize its ties with
Dr. Roy. A Wyeth spokesman, Chris Garland, said the company treated Ms.
Groves appropriately throughout her employment and that her departure,
nearly two years after her allegations about Dr. Roy, was unrelated to
her complaint.

In a December 2004 deposition, Dr. Roy said he no longer spoke for
Wyeth but gave talks for several other drug makers in 2004 including
Pfizer Inc., Merck, Johnson & Johnson and Novartis AG. He said then
that he maintains no private practice and relies on speaking to
supplement his salary from USC.

In an interview, Dr. Roy says, "My interest is in dissemination of
accurate information." Wyeth's Mr. Garland says talks by speakers such
as Dr. Roy are intended to "educate health-care providers with
information about Wyeth products" and the diseases they treat.

David Pitts, an internist in Grants, N.M., says he speaks about once a
month on behalf of pharmaceutical companies, less than he used to. "You
have to figure all your time traveling and going through airports. Once
you average that in, it can end up being not nearly as lucrative as you
might think," Dr. Pitts says.

Dr. Pitts was paid by Merck to speak at 134 events in 1999 related to
Zocor, Merck's anticholesterol drug, according to an internal Merck
document titled "Speaker Utilization as of 12/29/99." Other Merck
documents say the maximum payments for the types of talks Dr. Pitts
gave ranged from $1,500 to $2,000, suggesting he could have made
$200,000 or more from Merck in that year. Dr. Pitts declined to
estimate his income from Merck but says, "I was a popular speaker and I
had trouble saying no when reps asked."

In a Merck slide presentation dated December 2001, two Merck employees
observed that doctors who attended lectures or more intimate
roundtable-type discussions were much more likely to increase their
prescribing of certain medications than those who spent time with a
Merck sales representative.

According to the document, doctors who attended a lecture by another
doctor wrote an additional $623.55 worth of prescriptions for the
painkiller Vioxx over a 12-month period compared with doctors who
didn't attend. Doctors who participated in the more intimate
discussions wrote an additional $717.53 worth of prescriptions for
Vioxx, which Merck pulled from the market last year over concerns about
cardiovascular side effects. That compared to an increase of only
$165.87 in Vioxx prescriptions by doctors who attended a meeting with a
salesperson.

Return on Investment

After factoring in the extra cost of hiring a doctor to speak, Merck
calculated that the "return on investment" of the doctor-led discussion
group was 3.66 times the investment, versus 1.96 times for a meeting
with a sales representative. The document concluded that peer
discussion groups led by doctors "provide the best return on investment
for A-rated physicians," an internal term for doctors who write a lot
of prescriptions. "A-rated physicians are not responsive" to meetings
led by sales representatives, it said.

Merck declined to discuss the document's conclusions but in a written
statement the company says its policy has always been to supply
"accurate and balanced" information to doctors. "One way Merck provides
such information is through physician speakers...," the statement says.

While the total number of company-sponsored doctor talks is rising,
both Merck and Wyeth say they have taken steps to rely less extensively
on individual speakers. Doctors speaking on Merck's behalf now do so an
average of five to 10 times a year, the company says. At Wyeth,
speakers can't appear more than 25 times or earn more than $25,000
giving talks each year.

Companies say they're putting in caps to avoid the appearance that
they're trying to influence any individual doctor's choice of drugs
with outsized speaking fees. Several cases brought by the U.S.
government against drug companies in the past have involved allegations
that companies paid doctors in exchange for prescribing drugs.

Meanwhile, companies are stepping up training of new speakers. Pfizer
trained hundreds of speakers last year to help the company launch
Caduet, a single pill containing blood-pressure reducer Norvasc and
cholesterol-lowering Lipitor.

One of those trained was Dr. Bernstein of the University of Michigan
Health System. He is active in efforts to counter the pitches of
drug-company salespeople by telling doctors and pharmacists at his
organization about generic drugs and other alternatives. He says he
accepted an invitation to be trained to talk about Caduet in order to
learn more about his opponents' strategy. About 185 doctors attended
the session at the Omni Mandalay Hotel in Dallas in April 2004.

For attending a welcome dinner and reception on Friday night, and 5½
hours of training plus lunch the next day, Dr. Bernstein earned a $750
fee. Under the terms of the invitation, he agreed to give at least one
talk afterward, for which he would have been paid another $750. Pfizer
provided him with a deck of PowerPoint slides for presentations. A
Pfizer sales rep was supposed to make arrangements for the talk.

But Dr. Bernstein said he was never approached to fulfill that part of
the bargain, fueling his suspicion that companies may be training more
speakers than they need. Pfizer confirms that it is training more
speakers than it used to, but a spokeswoman, Mariann Caprino, says:
"The majority of the speakers that we have trained are used and used
often." She adds: "We would never knowingly train them and not use
them."