Speaker 1: Today we will be speaking with Dr. John Abramson, who's been on the faculty
of Harvard Medical School for 25 years and is author of the new book Sickening How Big
Pharma Broke American Health Care and How We Can Repair It. A really great to have you
on today and I appreciate your time. Speaker 6: David, it's a pleasure to be with
you. Thanks. Speaker 1: So, you know, when we talk about
the modern state of American health care, there's many cooks in the kitchen, so to speak.
And we can talk about insurance companies. We can talk about big pharma, we can talk
about our political system. And there's all of these different factors. In your book,
you talk specifically about big pharma. Talk to us about why, as a doctor, that's where
you decided to focus in this book. Speaker 6: Right. So I think the biggest American
medicine has enormous problems are costs are way off the charts. The health of Americans
is so inferior to the other wealthy countries that about 480,000 Americans die in excess
each year. There's trouble all over the place. I think the biggest cause of this trouble
that is unrecognized is the extent to which the pharmaceutical and device industries control
the knowledge that doctors rely upon to formulate their ideas about the best way to treat their
patients. Speaker 1: So explain how that leads to particular
outcomes and disease management, which is often what it is that that doctors are doing
quite, quite frankly. How what is that relationship? Speaker 6: So let's look at the cancer moonshot
issue, which is in the news now with President Biden.
Speaker 1: Yeah. Speaker 6: The anti-cancer drugs dominate
clinical research. They're very expensive. We could cut cancer deaths in half in the
United States by attending to preventive therapies. Preventive interventions stop smoking, obesity,
environmental risks. So what we're doing because the money's to be made in developing new drugs
and marketing them. What we do is create a body of of of so-called knowledge. That's
the result of research that's commercially sponsored. That's about drugs, drug therapies
for cancer. And the preventive side gets virtually no attention because there's no money to be
made in it. What we've got is a a market failure where the money is invested in high cost therapies,
whereas the benefit could be reaped much more quickly, less expensive, more effectively
by attending to preventive approaches. Speaker 1: So at the primary care level, often
an idea is floated that you could compensate doctors not based on the number of things
that are done, for lack of a better term, but instead for the sort of successful management
of a patient and actually keeping them healthy rather than sick. And of course, the devil
would be in the details in terms of exactly how you do it and how you measure and how
you compensate. But that's an idea that's mentioned to put the focus back on prevention
rather than treatment. Does that not if you could do that, does that not even really do
enough? Because what you're describing is so widespread and established?
Speaker 6: Yeah, it doesn't do enough. It's a good idea. I think that paying primary care
docs to take care of people instead of performing units of work would be a good idea. And I
think trying to minimize the number of procedures that are done by changing the payment for
those procedures is a good idea. And that would be more effective with specialists than
it would be with primary care docs. So you could capitated specialists for a geographic
area and they would make so much money on salary. And if they did extra, say, cardiac
surgeries, there wouldn't make money. You know, if they did extra breast biopsies, that
wouldn't make money. So that that's one way to approach it. But the really the core lesion
is that the actual knowledge that doctors are trained to trust is invested in because
it's going to maximize financial return to the drug companies. It's that knowledge that's
the problem. And the idea that those that that the research projects get turned into
articles in medical journals that are mostly written by the drug companies that are peer
reviewed. But virtually nobody in health care understands that peer reviewers don't have
access to the data and the guidelines that are written that set the standards for good
community practice and can be produced as evidence in malpractise cases if you don't
follow them. Those guidelines. Writers don't have access to the clinical trial data. And
having spent ten years in litigation, I know that what's in that clinical trial data, the
real data is often very different from the data that ends up in medical journals. So
what we've got is doctors who are compelled to practice so-called evidence based medicine,
which is means the bottom two lines of the abstract in the medical journal. And that's
what they said, without understanding that the whole research enterprises is biased towards
making money, that the results aren't peer reviewed, that the guidelines aren't peer
reviewed. And what the doctors have been trained to trust is the information that's going to
best help them take care of their patients is not trustworthy.
Speaker 1: There's this example that I haven't read about, admittedly for a little bit, so
I hope I get the details mostly right, and I think maybe it's related to exactly the
mechanism you're talking about, which is when it came to cholesterol, there was a point
in time and again, I don't know if it was a couple of years ago or more like a decade
or 12 years ago, where the sort of line at which point one might consider recommending
a statin to a patient was lowered. So basically just the threshold was changed. Nothing really
changed about one's likelihood of a cardiac event. Nothing. Nothing really changed other
than instead of saying, I don't know if it was from 210 to 200 or 222, just a change
was made. And it was. Now, if the patient is above this level, consider a statin. I
don't know the origins of that change. I don't know if that change was based in what we might
call good, good science or as you talk about kind of profit driven science or something
else. But would that be the type of thing that is influencing doctors to make certain
decisions that can be very profitable? Speaker 6: That's exactly right. And there
are two aspects to that. One is there's never been a study that compared statin therapy
to lifestyle intervention. So the drug companies don't want to do that study because they can
only lose because they have all the statin business. The other part is that I was the
lead author of an article in the British Medical Journal in 2013, which was exactly the time
that you're talking about when the standards were changed. Yeah. And the numbers for cholesterol,
the study results are not transparent. Docs don't have them, guideline writers don't have
them. But there's an organization in Oxford called the Cholesterol Treatment Trials Collaboration
that has the data. They made a fashion bargain with the drug companies that they would receive
their patient level data and do meta analysis on that data. And by combining the statistical
power of all the different statin drugs effects in clinical trials, they would be able to
show that statins worked for more people. Excuse me. So the city receives the primary
data, but part of their Faustian bargain was they wouldn't release the primary data. So
they control what doctors think they know about these things. So I wrote I was the lead
author of this article in BMJ and we recalculated the CTS numbers that they had published in
The Lancet that justified lowering the threshold for treating people with cholesterol lowering
medication. And we showed that for people at low risk who don't have heart disease,
who have less than 20%, ten year risk, that there was not a mortality benefit, that that
their data didn't show a mortality benefit and that you had to treat between 100 and
140 people for five years with a statin to prevent one nonfatal heart attack or stroke.
So we wrote that and unfortunately, we made a little mistake in interpreting the frequency
of side effects in a complex study, but it had nothing to do with our conclusion and
the head of the city went absolutely ballistic. Charged into the BMJ editor's office and demanded
retraction of our article, which yeah, it was an international kerfuffle. It didn't
get much coverage here in the United States, but it sure got coverage in Europe and it
was pretty stressful. The editor appointed a six person panel to independently evaluate
the demand for retraction. The panel voted unanimously that there was nothing about our
article that required a deserved or merited retraction. And on we went. But the CTT being
about a million times more powerful than me and my three coauthors had dominated the press.
The headlines so long about this attack on statins that we couldn't get our message across
to the public, which is, hey, if you are a low risk person, you may want to take statins,
but you got to understand it's not going to improve your longevity and you have to treat
100, 240 people for five years in order for one to avoid one nonfatal cardiovascular event.
And that's your decision? It's not you know, I'm not saying yes or no. I'm saying doctors
should tell patients that that's what the situation is and make let the patients make
a decision based on their own values. Speaker 1: Right. To talk about something
a little more, maybe superficial as it might be within the big pharma space. No, my dad's
a psychiatrist, and he will often talk to me about pharmaceutical reps, come to visit
and they bring little footballs and they bring pens and they bring, you know, notepads and
all of this sort of thing. And they drop off literature and sometimes there's invitations
to lunch and sometimes there's other things that kind of go beyond that. And of course,
there's this very strange dynamic where on the one hand, if it were straight up said
the idea of the reps is to encourage the prescription of medications, many people would say that's
obviously bad. The doctors should simply be deciding on the merits whether there's a medication
that's appropriate for an individual or that it isn't. And then the pharmaceutical companies
will typically say that's not why the reps are there. But at the same time, if the presence
of these reps made no difference, it doesn't seem like a worthwhile expense for the pharmaceutical
companies. So there's this kind of weird dynamic where what are we to interpret to be the point
of these representatives? And what does what do we know about the impact on the rates of
prescriptions of drugs when there are versus are not pharmaceutical reps?
Speaker 6: Well, that's an easy question. We know if a doctor accepts a lunch that is
valued at $20 single lunch, that will significantly change his or her prescribing patterns. So
obviously, the drug companies aren't stupid enough to engage in this activity because
it makes them money that makes them more than it cost them. That the core issue here, it
makes no sense on the surface, but the core issue is that doctors in general like to reciprocate
politeness and kindness and warmth, and they're not in the habit of being discourteous to
people who come saying they're trying to help them. So the drug reps come and they bring
information. Some of it is reprints from journal articles, some of it is glossy charts that
are very easy to interpret. But that information is delivered because of its marketing value,
not because of its informational value, because it's that's the information that's selected
that will most likely convince the doctor to prescribe or consider prescribing the drug.
So we've got a situation where the drug reps are playing one game. They're taught how to
shake hands, they're taught how to look in the eye. They're taught how to keep notes
about the kids birthdays and their wives anniversaries. And they ask all those questions and the doctors
are trying to get the best information they can as quickly. Lee as they can to best serve
their patients. And it's not a fair fight because the drug reps know that their job
is to increase prescriptions. They get bonus on that. They get evaluated on it. They have
minders that go out and watch them perform their sales spiel and they get graded on their
sales spiel. So it's a situation that exploits doctors desire to have good information and
innate reaction, to be polite, where politeness is offered to them. The drug reps know how
to exploit the politeness. Speaker 1: What's the lowest hanging fruit
here? If we were to be able to make some changes to the way the system works, as you talk about
a lot of the information on which doctors are making decisions, is information controlled
by or created in generated funded by the pharmaceutical companies? All these different things that
we've talked about, we haven't even touched on the direct advertising of drugs to people
via television, which is almost completely unique to the United States. What's the lowest
hanging fruit that would give us the most dramatic improvements?
Speaker 6: Yeah. So the lowest hanging fruit is so low that it's a stunning commentary
on the power that's controlling American medicine. When a manuscript is submitted to a medical
journal, usually the company has played a role in preparing that manuscript. And the
manuscript contains a very brief summary of the data from that study to the peer reviewers
in the medical journal. Editors don't get the data to see if the manuscript is accurate
and complete. But the manufacturers produce what's called a clinical study report. It's
an official document. It's often two or 3000 pages long of tabulated data that purports
and usually does present the outcomes that the researchers said they were going to study.
So they can't pick and cherry pick their outcomes. This is a two or 3000 page document that is
prepared and it's searchable. And the the drug, the medical journals, they complain
that they can't do a transparent peer review because they don't have the resources to go
through the primary data and get statisticians to line up the data with the way the drug
company coded it and all that. And there's truth to that. But this clinical study report
exists. It would cost nothing, nothing for the journals to say. When you submit your
article, your manuscript, you must submit a clinical study report if you want to redact
a little bit about how we make the gel code or whatever, you can do that if you think
it's a corporate secret, but you must submit that. So why don't the journals do this obvious
thing? And once you learn how to get around the clinical study reports, as I did in litigation,
it's pretty quick to figure out what's going on. Why don't they do it? They don't do it
because they're in an enormous conflict of interest position. They make a lot of their
money from selling reprints back to the drug companies for the drug reps to hand out to
docs like your dad. Mm hmm. So if the New England Journal is going to make $900,000
selling reprints of the Vioxx article that misled doctors and had convinced them that
it was safe to prescribe and didn't increase the risk of cardiovascular death. The New
England Journal wants to have that article published in its pages and sell 900,000 reprints.
If they had the clinical study report, they would have known that the article was misleading
would be two kind of word, but misleadingly omitted three heart attacks and didn't present
the data on cardiovascular risk. And the New England Journal would have understood that
this was a bad drug. It never should have been on the market, and it should have been
withdrawn immediately when the results of that study came out. But the New England Journal
won't do it because they're going to miss the reprint sales and the Lancet and JAMA.
And it's that's the way it works. They missed their reprint sales. Their advertising revenues
will go down. Their impact factor will go down. They won't be the world recognized as
the world's greatest journal. So what's happening is the prestige, much like the prestige of
H. Brigham in Boston, where they M.G. Brigham, they're fabulous world class hospitals. They
spend a fortune on advertising for their branding. And the journals are in the same business
of maintaining their branding for their journals. And that means that they're willing to sacrifice
the quality of the information that doctors get when they read their journals in order
to maintain the branding factor of the journals. Speaker 1: Are eye opening stuff, much of
it not the most exciting to read about, but it is important to know what's happening.
We've been speaking with. Dr. John Abramson, who, by the way, we just lost your video,
but we could hear you fine the entire time and it couldn't come as a better at a better
time, since this is the end of the interview. There you are. You're back. The book is Sickening
How Big Pharma Broke American Health Care and How We Can Repair It. We're linking to
the book and we really appreciate your time today.
Speaker 6: Well, thanks very much for having me