Customer Reviews

On the Take: How Medicine's Complicity with Big Business Can Endanger Your Health

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Thirty years ago Dr. Kassirer was my chief when I was a medical house officer in Boston. (That will serve as my disclosure of possible conflict of interest although we have had little contact since that time.)
He has been a wildly successful nephorlogist/researcher, clinician and teacher. As editor of the New England Journal of Medicine, he constantly expressed concerns over possible conflict of interest and its influence on published medical literature.
This book is a highly researched and extensively documented look at conflicts of interest and potential conflicts of interest in the medical literature and other closely related areas of medicine. Sometimes there are situations where potential conflict of interest has little or no influence on our decision making. As amply documented in On the Take, there are other times when conflict of interest may impact our decision making to the detriment of our patients. This book examines when and how the harmless potential conflict of interest moves into the realm of a serious, even ethical, dilemma.
Amazingly, these conflicts may extend beyond the published medical literature to consensus papers and clinical guidelines increasingly embraced by the government and major medical societies and these conflicts of interest may even intrude into organizations designed to protect the consumer like the FDA (Food and Drug Administration) and the CDC (Center for Disease Control).
We as physicians minimize the extent to which potential conflicts of interest influence us in our medical practice - a view not widely shared by patients or government regulatory committees.
Dr. Kassirer presents a number of suggestions to improve the situation. Some of these are already being implemented by major medical journals. Others will depend on the integrity of individual practitioners.
This book should be a must-read for medical students - both those planning to do medical research and those who will use the medical research to guide their medical practices.
Martin G. Kistin, M.D.

I rarely write reviews, but in this case feel obligated to point out what a tremendous service Dr. Kassirer has provided. As a physician, I have always been concerned about the influence of gifts and outright payments to doctors and researchers in promoting pharmaceuticals and other healthcare. However, I had no idea how extensive and pervasive it is. Dr. Kassirer has done an outstanding job in giving us a picture of the truth. This is a very well written book. I strongly recommend that all medical students and physicians read it, and suggest that everyone interested in healthcare do so.

As a minor point: Dr. Kassirer does not address the same influence which is present in alternative and complementary medicine--whose practitioners often benefit from the negative press of scientific (allopathic) medicine. In fact, it is just as bad or even worse in those types of care.

Finally, I must point out that I have never met Dr. Kassirer and have no financial inducement to write this :-)

Paul Gahlinger, MD, PhD

Fact-dense, well referenced, yet balanced in tone and easy to read, this book is the best exposé I have ever read on the financial conflicts of the medical profession caused by the efforts of Big Pharma, which for this review will include device and test manufacturers as well as drug makers. From pens and pads to cruises and fake consulting arrangements, Big Pharma has caused financial conflicts in many physicians and others "on the take". Many of the consulting deals are to give talks, ostensibly based on good medical science, that promote a product. Much of this is shown to occur at Continuing Medical Education courses sponsored by Big Pharma in which gifts are freely dispensed, reprints of journal articles favorable to products are handed out, and financial ties of the "consultants" giving talks are minimized or concealed.

Academic researchers are tainted as well. By being encouraged by their universities to obtain grants with overhead from Big Pharma, they must do research that helps in product development. Agreements may delay, prevent or pollute the publication of results. When a product possibility from a government (usually NIH) grant is seen, federal legislation passed 20 years ago allows the researcher to patent discoveries, form a company, and do clinical trials on his own potential product. While this may have led to valuable results, the potential for bias at every step due to financial conflict is clearly laid out.

Journals fare little better, even the prominent JAMA, NEJM and Annals of Internal Medicine. Papers that may have been ghost-written by Big Pharma on clinical trials with selectively favorable results are published [see Joel M. Kauffman, Bias in Recent Papers on Diets and Drugs in Peer-Reviewed Medical Journals, J. Am. Physicians & Surgeons, 9(1), 11-14 (2004)]. Editors and peer-reviewers may have ties to Big Pharma. Editorials and comments in medical journals may be written by authors with financial conflicts of interest. Revealing such conflicts is mostly on the honor system at present.

Clinical guidelines for physicians are promulgated by committees whose members often have close ties to Big Pharma. The products included in formularies of HMOs, Medicare and other insurers, the only products that will be paid for, are influenced by Big Pharma, whose general lobbying efforts are already legendary.

Dr. Kassirer gives many specific examples of financial conflicts. Far from quitting with the devastating description of how bad things are, he goes on to make specific suggestions for reform, while being very realistic about their success without federal action for certain conflicts. He lists many desirable changes, such as no gifts from Big Pharma at all, boycotting meetings sponsored by Big Pharma, disclosure mandated for all financial ties, and selection of journal editors, officers of medical societies and leaders of medical schools who have no financial conflicts. He did not seem to indicate the degree of influence of Big Pharma on the FDA.

Trying not to alienate most of the medical profession, Dr. Kassirer wrote that most MDs are basically ethical and went into the profession for non-financial as well as financial reasons. Reductions in income with increased work loads due to inadequate compensation from HMOs and Medicare is one of the reasons so many MDs have looked outside normal practice for income.
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He dropped a few hints that most major classes of drugs are more beneficial than they actually are [see Joel M. Kauffman, "Drugging Cardiovascular Disease", J. Am. Physicians & Surgeons, 9(4), 98-99 (2004)], and that alternative practices are not worth much [see Joel M. Kauffman, "Alternative Medicine: Watching the Watchdogs at Quackwatch", Website Review, J. Scientific Exploration 16(2), 312-337 (2002)].
This is a very minor blemish on one of the great exposés of all time, the "Unsafe at Any Speed" of the medical madness in the USA today.
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Daniel Haley's "Politics in Healing" describes the squashing of alternatives.
Charles T. McGee's "Heart Frauds" exposes the mythology behind so much medical advice.
H. Gilbert Welch's "Should I Be Tested for Cancer?" gives the evidence for the harm in excessive testing.
John Anderson's "Overdosed America" reveals the extent of perverted clinical drug trials.
Merrill Goozner's "The $800 Million Pill" give the lie to Big Pharma's claim that high prices are needed for the discovery of breakthrough drugs, as does...
Marcia Angell's "The Truth About the Drug Companies", which also suggests how the perversion of drug trials can be halted.

Dr. Jerome Kassirer is the former editor of the New England Journal of Medicine and a physician-educator with impeccable credentials. He has written an insightful and illuminating analysis of how big business money has harmed physicians and the patients they serve. This volume is a must read for physicians who have experienced some of the events described in the book and for patients whose interactions with their physicians may have been influenced in ways that they couldn't have appreciated.

Much of the book focuses on the activities of pharmaceutical
companies that spend more than $30,000 per year on each U.S. physician to promote and market products. Physicians have been exposed to a variety of marketing tactics over a period of years. The resulting changes in physician behavior, e.g. conflicts of interest, erode the core of trust that binds physicians and their patients together. These conflicts of interest also taint the information physicians rely on to treat their patients. Dr Kassirer also focuses on medical journals, professional organizations, research organizations and prestigious federal agencies that have been coopted by the insidious influence of big business money.

The book provides an analysis of how this problem has developed and makes specific suggestions on treatment. Although the writing is hard-hitting, it is balanced and fair. The problem is huge. This book may do just what Dr. Kassirer requests: initiate a sustained public outcry against inappropriate practices.

Dr. Kassirer, Distinguished Professor in Tufts University School of Medicine and former Editor-in-Chief of the prestigious New England Journal of Medicine, is a representative of the medical profession of another era which earned and retained our confidence and respect. His book is a call to the physicians today to resist the insidious effects of subtle and not-so-subtle conflicts of interest in accepting funding from the pharmaceutical industry. Scores of examples are documented of greed, venality, laziness and ignorance which have led physicians and professional organizations to compromise their integrity in the quest for financial support. As Executive Vice-President of the American Heart Association's New York City Affiliate for thirty years I personally watched this corrosive influence tempt and occasionally even subvert this once-proud organization into compromising its intellectual standards. Dr. Kassirer indicates that in the ten years since I retired, their resistance has weakened. The book is a must-read for physicians of conscience and a warning to consumers to be careful where they place their trust.

Having retired after 25 years in the health care business, I was encouraged to see a physician call it like it is. Normally doctors are protective of their profession, all while recognizing that there are a few bad apples in the field. It's the 80-20 rule all over again. Easily 80% of physicians are dedicated more to their patients than their pocketbooks. But the 20% who, in effect, take bribes from drug and technology companies to push product that too often is not in the best interest of their patient should have their licenses suspended or revoked.

Money talks, and it speaks not only to physicians. The profits that drug and technology companies make are shared with the politicians who allow this conflicted system to continue. US health care interests give $100 million per year in campaign contributions to ensure that the system remains corrupted. They like it just as it is, thank you. Get the money out of politics and you'll see this travesty fixed overnight.

But that could be said about every other issue as well: energy, immigration, corporate corruption, et al. If politicians were concerned about corruption, they'd fix it at the top and then demand fixes down the line.

The recent financial meltdown illustrates yet again how capitalism is vulnerable to exploitation and serious instability because of greed. Our health care system is a particularly egregious example of this problem. A major reason why costs are spiralling is rather obvious if one pays attention: drug companies, medical technology companies, insurance companies, hospitals, and some (not all) doctors and researchers are simply making too much money! They get away with it because a shell game has been set up in which the costs are largely hidden in Medicare/Medicaid and insurance premiums, with insurance premiums in turn hidden as "employer benefits." But rest assured that you and I (the public) are paying for all of this through increased taxes, reduced incomes, and higher costs of products and services. After all, where else but the public does money ultimately come from?

All of this is context for this book by Dr. Jerome Kassirer, a highly respected doctor who was Chief Editor of the New England Journal of Medicine for over 8 years. Kassirer particularly focuses on how drug companies (and medical technology companies) use every method they can to try to influence doctors to use and promote their products, thus imposing greatly increased cost on the public, often with little or no health benefit, and often at increased risk to the public due to unnecessary or inappropriate research participation, testing, and treatment. Big pharma especially spends a huge amount of money pushing drugs (more than $30,000/year per doctor!) because their resulting boost in profit is even higher, and they employ methods which are rountinely unethical and sometimes illegal.

Many (not all) doctors collude in this ruse because they naively and wrongly believe that their judgment is not being adversely affected (countless anthropological and psychological studies on gift exchange refute this), and some are motivated outright by greed because they make a lot of money in the process. As one might expect, this corruption extends not just to individual doctors, but also to hospitals, research institutions, and medical professional organizations, among others. When the medical profession is "on the take" in this way, not only does cost and risk to the public go up, but a vital bond based on trust is also broken, to the detriment of everyone.

Kassirer's solution is tight governmental regulation with a high level of transparency. This solution is not only appropriate, but it's also pretty much the only viable option we have, since we can already see that the medical profession isn't going to adequately regulate itself, and drug companies will certainly continue to do whatever they can get away with. Of course, as with capitalism in general, the problem is that these various participants in the lucrative health care system are wealthy special interests, and they will do whatever they can to resist regulation which goes against their financial interest. Kassirer is aware of this and he recommends that the public apply pressure to help implement such regulation, but I worry that it won't happen, at least not until we reach the point of extreme crisis (we're certainly getting there). Time will tell, and suppose I should try to be optimistic ...

Meanwhile, for anyone who wants to learn more about this disturbing situation (to put it mildly), I can certainly recommend this book. Kassirer is eminently qualified to write it, his tone is measured and balanced, and he provides plenty of detailed data and examples to back up his assertions (the details are actually more than I needed, but I can see that he had to provide them).

The free stuff brought in by the reps starts out innocently enough. I remember the free lunches they'd bring in during residency. Starts out as tubs of enchiladas and sandwiches. After I became staff, "free" meals improved. Now "educational" lectures are held at Ruth's Chris with an open bar. Some will bring dates to these dinners, just call them "doctor" (nudge-nudge-wink-wink).

Colleagues who are sufficiently enthusiastic about these products were then recruited to go on the road giving the lectures for lucrative speaking fees. I've seen this first-hand, but the extent of the problem not fully known to me until reading this book.

The pharmaceutical reps take great pains to gradually seduce influential doctors in the community to shill for their products. Many of these products are at best of questionable benefit (beware of papers which only find a reduction in relative risk); at worst, the products are potentially deadly.

Patients should be careful in which doctors they put their trust in. In a patient-doctor relationship, the only outcome which should matter is the benefit of the patient. In reality, the sought outcome is often the benefit of the provider in the form of prescribing dangerous medications, unnecessary procedures, etc.

I was very pleased to read this book. I was very surprised at the lengths the companies go to get their products in the hands of doctors who in turn are driving the price of healthcare in the US to unafordable leves. Highly recommend this book

Someone we know was recently incarcerated in a hospital for weeks on end for what should have been a fairly minor health concern. We firmly believe that this patient was nearly doctored2death. By the time the patient left the hospital he was on no less than 20 some pills depending upon the day. We PROMPTLY switched doctors to a D.O. and someone more interested in the overall patient, and less conflict of interest issues with pharmaceuticals and the world of internal medicine. Now, the patient is on about 7 pills a day, depending upon the day. Amazing isn't it. Thank you for this book. It helped figure things out and could have saved our family members life.

"Tragically, the World of Medi-Sin (c) has become more about a healthy bottom line rather than healthy patients." (c)
TheAngryPatient