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Financial Ties Bind Medical Societies to Drug and Device Makers

Professional groups like the Heart Rhythm Society write guidelines on treatments and the use of medical devices, but researchers say their acceptance of sponsorships and grants from drug and device makers poses a conflict of interest that many patients never consider.

Billboards from a medical device company near Moscone Center in San Francisco, site of a Heart Rhythm Society convention. Photo by Robert Durell for ProPublica.

This story has been co-published with USA TODAY.

SAN FRANCISCO — From the time they arrived to the moment they laid their heads on hotel pillows, the thousands of cardiologists attending this week’s Heart Rhythm Society conference have been bombarded with pitches for drugs and medical devices.

St. Jude Medical adorns every hotel key card. Medtronic ads are splashed on buses, banners and the stairs underfoot. Logos splay across shuttle bus headrests, carpets and cellphone-charging stations.

At night, a drug firm gets the last word: A promo for the heart drug Multaq stood on each doctor’s nightstand Wednesday.

Who arranged this commercial barrage? The society itself, which sold access to its members and their purchasing power.

Last year’s four-day event brought in more than $5 million, including money for exhibit booths the size of mansions and company-sponsored events. This year, there are even more “promotional opportunities,” as the society describes them.

Concerns about the influence of industry money have prompted universities such as Stanford and the University of Colorado-Denver to ban drug sales representatives from the halls of their hospitals and bar doctors from paid promotional speaking.

Yet, one area of medicine still welcomes the largesse: societies that represent specialists. It’s a relationship largely hidden from public view, said David Rothman, who studies conflicts of interest in medicine as director of the Center on Medicine as a Profession at Columbia University.

Professional groups such as the Heart Rhythm Society are a logical target for the makers of drugs and medical devices. They set national guidelines for patient treatments, lobby Congress about Medicare reimbursement issues, research funding and disease awareness, and are important sources of treatment information for the public.

Dozens of such groups nationwide encompass every medical specialty from orthopedics to hypertension.

“What you’re exploring here is the subtle ways in which the companies and professional societies become partners and — wittingly or unwittingly — physicians become agents on behalf of the interests of the sponsoring company,” said Dr. Steven Nissen, chair of cardiovascular medicine at the Cleveland Clinic.

“It has a not very subtle effect on medicine,” said Nissen, an expert on the impact of industry money.

‘This is our business’

Nearly half the $16 million the heart society collected in 2010 came from makers of drugs, catheters and defibrillators used to control abnormal heart rhythms, the group’s website disclosed.

Officials of the Heart Rhythm Society say industry money does not buy influence and is essential to developing new treatments. Still, on Thursday the group unveiled a formal policy that, among other things, requires more detailed disclosure of board members’ industry ties.

“This is our business,” said Dr. Bruce Wilkoff, the incoming society president. “We either get out of the business or we manage these relationships. That’s what we've chosen to do.”

The society is one of a handful of groups that make public details about their finances. Most don’t. As non-profits, they must disclose their tax returns but not their specific sources of funding.

Nearly half of the Heart Rhythm Society's annual revenues come from corporate sponsorships, exhibits or grants.

Sen. Charles Grassley, R-Iowa, requested the information from the Heart Rhythm Society and 32 other professional associations and groups that promote disease awareness and research.

Their responses and reporting by ProPublica showed wide disparities in money the groups accept from medical companies, what they disclose and how they manage potential conflicts of interest.

With billions of dollars at stake, companies can court entire specialties by helping to bankroll doctors’ groups. The Heart Rhythm Society’s 5,100 members represent a particularly lucrative market.

One implantable cardioverter defibrillator — a device that jolts the heart back to a normal beat — can cost more than $30,000. A single electrophysiologist, a physician specializing in heart-rhythm disorders, can implant dozens a year. World sales of the devices totaled $6.7 billion last year, according to JPMorgan.

All the defibrillator manufacturers are at this week’s conference, including market leaders Medtronic, Boston Scientific and St. Jude Medical, which together gave the society $4 million last year.

These companies and others not only provided financial support to Heart Rhythm but paid many of its board members: Twelve of 18 directors are paid speakers or consultants for the companies, one holds stock, and the outgoing president disclosed research ties, according to the society’s website, which does not specify how much they receive.

Board members at other medical societies have similar arrangements. The American Society of Hypertension does not post disclosures on its website, but records provided to Grassley show that 12 of its 14 board members had financial ties to medical companies.

Grassley, the top Republican on the Senate Judiciary Committee, said these groups commonly say the money doesn’t affect what they do, but he has doubts. “I don’t think it’s believable,” he said. “There are a lot of incestuous relationships that really bother me.”

Big Booths Boost Devices

As competition among cardiac-device makers has intensified, so have questions about whether their products are being used and marketed appropriately.

In January, a study in the Journal of the American Medical Association found that more than one in five patients who received cardiac defibrillators did not meet science-based criteria for getting them.

Weeks later, the Heart Rhythm Society disclosed it was assisting a U.S. Justice Department investigation of the issue.

Two of the society’s biggest funders — Boston Scientific and St. Jude Medical — have paid millions since 2009 to settle federal allegations that they improperly paid kickbacks to unidentified physicians to use their cardiac devices. Neither company admitted wrongdoing.

Top sponsor Medtronic also has disclosed to shareholders that the Department of Justice is investigating the advice it gave purchasers on how to bill Medicare for defibrillators and payments it made to buyers of the devices.

In a statement, Medtronic said societies play an important role in educating physicians about their devices. Boston Scientific declined to comment, and St. Jude did not respond to questions.

At this week’s conference, Medtronic is front and center with a 12,000-square-foot booth to demonstrate its products and allow physicians to examine them.

Medtronic spent $543,000 at last year’s meeting on a similar exhibit, part of $1.6 million it paid to prominently display its name around the conference and fund educational grants. The Minnesota device maker also paid unspecified speaking or consulting fees to eight of the society’s 18 board members.

Your (sponsor) Name Here

These slides show "promotional opportunities" – and their asking price – that the Heart Rhythm Society offered to medical industry sponsors at its 2011 conference. Not everything was sold.
Source: www.heartrhythmsupport.org/sponsorships. See our interactive graphic.

Coffee Cup Sleeves: $10,000-$45,000

"Witness first-hand the exposure coffee cup sleeve advertising can provide for your company."

Cyber Center: $20,000-$50,000

"Attendees will have the added convenience of easy-to-access email and Internet stations."

Exhibit Hall Aisle Signs: $60,000

"Attendees can’t miss your prominent corporate or product logo on these directional signs in high traffic areas throughout the exhibit hall."

Exhibit Hall Carpet Logos: $2,000

"Maximize your company’s brand recognition on the exhibit floor with Exhibit Hall Carpet Logos."

Exhibit Hall Literature Bags: $15,000

"Attract high visibility throughout the convention center and beyond as attendees find multiple uses for the exhibit hall literature bag."

Hotel In-Room Drop: $25,000

"Your company's welcoming gesture is a lasting impression on the minds of Heart Rhythm 2011 attendees as they wind down after a busy day."

Hotel Key Cards: $45,000-$70,000

"A key ingredient to your marketing success! These room keys travel with over 7,000 attendees for four days."

Hotel Elevator Advertising: $10,000

"Elevator Advertising provides great visibility to a captured audience for your printed corporate name or product and expose for your company’s message to attendees."

Hotel Reader Board Advertising: $15,000

"Digital advertising offers high visibility in lobby and meeting room areas at the San Francisco Marriott Marquis and Hilton San Francisco Union Square."

Hotel Televator Advertising: $2,500-$5,000

"Exclusive to the headquarter hotel, the San Francisco Marriott Marquis offers 21st century digital messaging capabilities."

Online Session Planner/Abstract Viewer and Abstracts on CDROM: $65,000

"Assist attendees as they navigate through four days of educational content before, during and after the annual meeting."

Airport Advertising: $5,000-$19,000

"Attendees will be flying in from all over the country and abroad and San Francisco International Airport will be bustling with excited attendees."

News Rack Billboards: $45,000

"Newspaper rack advertising is available around the Moscone Center and throughout San Francisco downtown area."

Pocket Maps: $10,000

"Help attendees tour San Francisco with ease! As the sponsor, your company will be an assistant tour guide."

Saddle Banner Ads (formerly glass clings): $15,000

"Saddle banner ads always add a look of interest to the Scientific Sessions."

Shuttle Bus Panel Advertising: $50,000

"Shuttle buses will travel from various hotels to the Moscone Center."

Shuttle Bus Headrest Covers: $12,500

"This is a rare chance for product advertising as attendees relax in a captive setting."

Social Media Center: $40,000

"The Social Media Center will be utilized by thousands of attendees to express their thoughts and comments on the sessions, exhibits and meetings held during Heart Rhythm 2011."

The Link: $30,000

"The Link will allow attendees to relax and stay connected during Heart Rhythm 2011, offering comfortable seating and access to the internet through their laptop(s)."

Water Bottle Wraps: $10,000

"Water bottles are served as daily refreshment during the breaks inside the exhibit hall."

Water Stations: $12,000-$20,000

"These water stations will be strategically located throughout the Moscone Center, ensuring presence throughout the facility."

Slideshow:

The spending befits the company’s dominance of the world market for implantable defibrillators. It sold more than $3 billion worth last year.

Next booth down is the 8,100-square-foot spread of rival Boston Scientific, with $1.6 billion in defibrillator sales last year. The company spent $1.5 million on the society in 2010 and paid speaking or consulting fees to seven board members.

Physicians must traverse these and other booths to reach “Poster Town,” where the latest research findings, a big draw of the gathering, are displayed. “It’s very hard to get through there without being accosted,” said Dr. Paul D. Varosy, director of cardiac electrophysiology at the Department of Veterans Affairs’ Eastern Colorado Health Care System.

‘Tag and Release’

Through the years, groups such as the Heart Rhythm Society have expanded the range of sponsorships they offer to drug and device makers. Companies can now fund Wii game rooms or put their names on conference massage stations and on the shirts of the masseuses.

Some deals give companies more than name exposure. Last month, the American College of Cardiology attached tracking devices to doctors’ conference ID badges. Many physicians were unaware that exhibitors had paid to receive real-time data about who visited their booths, including names, job titles and how much time they spent.

Dr. Westby Fisher, an Evanston, Ill., electrophysiologist, called the practice “Tag and release.” College officials say they’ll do a better job of notifying doctors next year.

Attendees at the Rhythm Society conference also have tracking badges. Society officials say exhibitors are not getting doctors’ personal information.

Two years ago, the American Society of Hypertension teamed with its biggest donor, Daiichi Sankyo, to create a training program for drug company sales reps. The society says about 1,200 Daiichi reps have graduated — at a cost of $1,990 each — allowing them to put the “ASH Accreditation symbol” on business cards.

In fiscal 2009, Daiichi gave the society more than $3.3 million — more than 70% of its total industry funding — according to financial records it provided Grassley. Daiichi makes four hypertension drugs.

“I think it’s an obscenity,” said former ASH president Michael Alderman, professor emeritus at Albert Einstein College of Medicine in New York City. “I can see how it would play out in the doctor’s office: ‘I’m a Daiichi sales rep. But let me tell you something: The American Society of Hypertension is backing me.’”

Alderman and some other prominent members of the group quit after a dispute in 2006 about industry influence.

Current ASH President George Bakris said the training program is science-based and doesn’t focus on specific drugs. The reps “ought to know what they are talking about,” he said.

The 1,900-member group has revised its policies since 2006, he said. Financial conflicts disclosed by board members, however, are available only to members, who must request them in writing and explain why they want them, according to the group’s conflict of interest policy.

A Question of Influence

Bakris and leaders of several other professional groups say industry funding is essential for much of what they do. It reduces conference registration fees, subsidizes the cost of continuing medical education courses and provides money for disease awareness.

Dr. Jack Lewin, chief executive of the American College of Cardiology, said the money is helping build registries of cardiac procedures that track side effects and flag whether physicians are using devices in the right patients.

The “circus element” of the exhibit booths doesn’t unduly influence attendees, Lewin said. “I don’t buy a soft drink just because of the advertising… I buy it because I like it.”

Researchers say companies are not spending millions solely for altruistic reasons. “If it weren’t influencing the doctors, they wouldn’t be doing it,” said Dr. Gordon Guyatt, a health policy expert at McMaster University in Ontario.

There are fledgling efforts to push medical societies toward stricter limits on industry funding: 34 groups have signed a voluntary code of conduct calling for public disclosure of funding and limits on how many people on guideline-writing panels have industry ties.

“The general feeling is that the societies need to be independent of the influence of companies,” said Dr. Norman B. Kahn Jr., chief executive of the Council of Medical Specialty Societies, which helped draft the code.

Grassley, too, is continuing his efforts to make the groups publicly accountable. In initial responses to his December 2009 request for information, some said they planned to post financial information on their websites. This week, the senator followed up with letters to some groups, asking why they hadn’t done so.

He hopes the political pressure succeeds: “You might conclude that maybe they don’t want to give the information out because it might be embarrassing.”

What's Your Opinion? Vote on Facebook.

Thomas Sullivan

May 6, 2011, 9:49 a.m.

It’s been almost five months since the “investigative journalist” shop and authors of this article ProPublica published a story about physician-industry payments.

Unfortunately, nothing has changed in their approach about reporting the innovation and collaboration physicians have with industry, that improve the lives of millions of Americans.  Instead of actually “investigating” the nature of such payments, ProPublica uses the same framing bias it created last year in announcing its “Dollars for Doc” series. 

This means that all ProPublica did in their “investigating” was ask outright industry critics, such as Steven Nissen and David Rothman their opinions about such payments, and they failed to include any opposite perspectives. 

Had they done so, they would have realized that physicians overwhelming value industry provides that has lead to the remarkable improvement in healthcare and longevity of our lives.  They wrote this article from the perspective that everything industry does including exhibiting is bad is because ProPublica was hired to do so, where is the transparency in that.

Erin O'Sullivan

May 6, 2011, 10:23 a.m.

It’s easy for doctors to rationalize the utility of these bed-partners but ultimately this current industry-driven trend seduces the physician’s loyalty toward the product and away from the patient. 

Trusted providers are motivated to make care-giving decisions that reciprocate the very industry that butters their bread and not by what is in the patient’s best interest.

Regardless of the advances in medicine and any correlation to innovative strides in the medical supply industries and pharmaceuticals (something any patient can appreciate), there is a growing foundational crack in the relationship between patient and care- provider.

The registries are just another extension of industry. Most have been privatized and riddled with conflicts of interest.  These cozy little relationships with industry allow a select patient population to be tracked, if granted permission from industry, for the benefit of industry, not that of the patient population that are injured without impunity by greedy pharmaceutical and medical device manufacturers where profits take precedence over the safety of patients.  The data produced by these so called privatized “registries” are inaccurate at best and most likely harmful to victims of medical malpractice.

“Had they done so, they would have realized that physicians overwhelming value industry provides that has lead to the remarkable improvement in healthcare and longevity of our lives. They wrote this article from the perspective that everything industry does including exhibiting is bad is because ProPublica was hired to do so, where is the transparency in that.”

Mr. Sullivan, Could you provide links to your assertion that industry has led to the remarkable improvement in healthcare?  With documented evidence of rigged clinical trials and the plethora of death causing drugs that were approved by the FDA I just don’t think your assertion carries any weight in the debate.  Link please.

Thomas Sullivan -

Note this in the above article:

“In a statement, Medtronic said societies play an important role in educating physicians about their devices. Boston Scientific declined to comment, and St. Jude did not respond to questions.”

That’s a comment from industry. You said Propublica failed to include any “opposite perspectives.” You should read more carefully and with less of your own anger, bias and defensiveness. Perhaps that would allow you to assess articles like this in a more neutral manner… or is the drug/device company money you take making this an impossibility for you?

Rosemary Gibson

May 6, 2011, 11:09 a.m.

While voices in Washington rattle sabers about how the government is getting in between doctors and their patients, elected officials are reticent about how the medical-industrial complex has already come between patients and their doctors.  Meanwhile, health care reform unleashed the medical-industrial complex on 32 million more unsuspecting people.  The industry is licking its chops—10 percent of the population will have a new credit card with no spending limits, thanks to removal of lifetime limits on benefits.  Because intrepid reporters are shining a light on long-standing, self-sealing medical practice, the public is getting a glimpse of what goes on behind closed doors, just as the world finally realized what the banks were really doing with all our money.  Thankfully, some people are smarter and wisely fending off treatment recommendations that cause more harm than good.  See http://www.treatmenttrap.org

Yes, and every time I turn on my television or radio, read a magazine or newspaper, get online or drive down the street I am continuously bombarded with advertising. Exposure does not automatically equal buying in to every pitch you are exposed to - give the vast majority of physicians/researchers some credit.

Being knowledgeable about the various options available to patients is not the same thing as a conspiracy. Both physicians and their patients need accurate information to make informed choices.

In terms of research - money has to come from somewhere and the government doesn’t always step up. As well, even studies like the ALLHAT which slammed newer drugs used money and drugs provided by pharmaceutical companies to conduct the study. What are the solutions?

That said transparency is always the best approach in all endeavors.

This story implies (but does not illustrate) how these industries influence government officials who exert power and influence over unsuspecting Americans.

For example, OMSJ’s team recently cross-examined a Director of the Indiana Department of Health.  The witness was called by prosecutors as their medical expert in a criminal case in which the defendant faces nearly three decades in prison if convicted.

Under cross examination, it became painfully clear that her expertise was largely influenced by marketing that has nothing to do with medicine or science.  After about one hour of testimony, the physician admitted on the record that she knows little about the discipline that she is employed to oversee for the State of Indiana or was called to testify.

Based upon our involvement in more than 50 criminal and civil cases since 2009, we’ve found that marketing biases permeate the healthcare industry.  Although these experts effectively market drugs, devices and treatments to trusting patients, they routinely fail when forced to answer questions from OMSJ’s defense team.

OMSJ has already identified more than a dozen factually-innocent convicts who were likely imprisoned because of experts like these.

Clark Baker
Principal Investigator
http://www.OMSJ.org

If Thomas Sullivan believes most doctors see their patients as anything other than a dollar sign, he needs to come out from under that umbrella right now.  When there were actually “family physicians” who took care of whole families and also saw you in clinic AND in hospital as their actual living breathing patient, that might have been true.  But in the last four decades the facade of caring has gone out the window - a little more with each passing decade. Once they started “specializing”  it was all over but the crying.

Science is for sale.  So are most doctors, clinics, hospitals and private practices.  They are all schlubs on the take.

The worst, in my opinion, are pediatricians and dermatologists.  Two extremely unnecessary occupations if I ever heard of them.  Dermatologists scare people away from the sun and make patients believe certain skin diseases are lethal, or potentially so, when they are not.  Pediatricians are just plain charlatans who take advantage of the many gubment entitlement programs for young parents who could in no way afford the services of a pediatrician otherwise.  These bozo’s also push vaccinations as if they were totally harmless.  Six dozen innoculations before school age.  It’s sickening.  Hey vaccinations - lethal injections aren’t just for prisoners anymore.  Check out the web site at National Vaccine Information Center (NVIC).

Thank you Mr. Baker for all that you do to protect our healthcare rights.  It’s as if the pharmaceutical companies and medical manufacturers want to force us to purchase their drugs/devices in an effort for more profits.  And they are having their way with the American people from cradle to grave. 

One has to ask the question of the big Parma executives, are short term profits more important than killing and maiming the patient population with your toxic drugs/devices?  Just as the banks are too big to fail I’m afraid we have created a medical industrial complex that is going to be hard to defeat, but defeat is inevitable as the strain on the middleclass is beyond rational.  Take more drugs, have another vaccination, develop a new symptom; we’ll treat that too.  But the America population is sicker than ever before while the profits of the multinational pharmaceutical companies remain strong for now.  They oppose taxes on corporations and the filthy rich; they outsource our jobs and have dismantled the middleclass.  Where is your next meal coming from big Parma now that you have bit the hand that fed you?

Until

Sharon - Thank you for your kind words.

Your question about virtue and morality is best answered this way.

To patients, good medicines and doctors are defind by how healthy they keep us.  However, to pharmaceutical executives and hospital administrators, good medicine and doctors are defined by how much revenue they generate (e.g. “shareholder value”).

Hospitals and drug companies don’t profit from healthy patients, which means that patient health is little more than a marketing ploy to convince us that - if we can only get more tests and consume more drugs - we’ll be much healthier than we already are.

If tracked like real diseases, adverse drug reactions (ADRs) that kill or injure more than a million Americans annually would rank somewhere between the fourth to sixth leading cause of death in the United States.  Think about that the next time your doctor or television show tries to push drugs into your home.

http://jama.ama-assn.org/content/279/15/1200.full

Clark Baker
Principal Investigator
http://www.OMSJ.org

I’ve tried to register and comment because I wanted to tell my story to reporter.  But I still want my experiences with corruption-attempted bribery to be exact, by “one of the best” to be exact.  But this site just won’t accept it.  PLEASE CONTACT ME!! My experiences are really strange and weird.  But I have their records to back me up.

arnold KleinMD

May 6, 2011, 6:30 p.m.

In 1984 I developed the technique of lip augmentation with injectables. Medicis employed me as a consultant to teach the off-label use of Restylane in the lips throughout the USA and Canada. Medicis also employed Jean and Alastair Carruthers and paid them to inject and teach in the USA. This is highly illegal in that they had neither a green card nor a license. They had one big thing,political positions in US Dermatology Societies and editorial positions on the journals.They even allowed Jean Carruthers to present my data as her own at Johns Hopkins. I did a lip study for Medicis and had spent over 40 hours rewriting the lip paper with the assistance of Joe Burns to assure it was written by me and not authored totally by someone at Medicis. I had replaced the diagrams in this paper on several occasions. Frequently in lip articles the lip evaluation lines are put in the wrong place. I felt the paper had to be as accurate as possible. I also warned Medicis not to present this data to the FDA in that it contains my personal injection techniques. It is very unusual for someone else to present the data from another doctor but someone did present my data to the FDA to expand the lip study. Medicis was now on to using people with political positions in Dermatology such as Drs. Ron Moy*, Rhoda Narins* and Gary Monheit* as consultants. Since Pharmaceutical companies like Medicis wanted presentations at meetings and these people planned the meetings and control the Dermatologic Journals they could remain one happy family. One only need look at the literature on the Medicis toxin Dysport now and compare it with the literature from Europe 10 years ago. Suddenly they want us to believe it diffuses like Botox and it virtually acts in an indentical Manner. One must ask themselves, why did earlier studies show it acts quicker? It is a scientific fact that smaller molecules diffuse further. Diffusion depends on molecular size and Dysport spreads (diffuses) more than Botox . This is why injecting the frown with Dysport usually will gets most of the forehead above the frown. I shared over 35 articles with Medicis about this but they just don’t want to or care to understand the truth. Their theory, espoused by Monheit is that when toxin’s including Dysport reach the pH-neutral environment of the body and leave their acidic environment that their protein envelope surrounding the toxin opens releasing the pure botulinum molecule. And this is why all type A toxins diffuse equally. However Dr Monheit* does not obviously realize that Dysport is stored at a pH neutral and so it is not suddenly exposed to a pH change that causes its surrounding protein to leave. There goes Monheit’s* theory. Also Monheit and Kane have recommended much higher doses than those in package insert on internet courses. This also is illegal based on the bad act. Medical Societies and Medical meetings have now become nothing more than storefronts for the Pharmaceutical companies. The recent approval of Restyane for use in the lips by the FDA was based on my work. The techniques of injection were mine. This is not identity theft but intellectual theft which happens in Medicine everyday.
Arnold William Klein MD
Professor of Medicine and Dermatology UCLA
Consultant - FDA

Dr. Klein as a MD you are probably appalled at the unfairness of it all but to be honest your diatribe sounds very me oriented although accurate as to the shenanigans that happen at the FDA and in medicine.

Consider the story of a company that has the patent to a technology that will revolutionize diagnostics in this country and save billions in healthcare costs here and around the world.  It’s called proteomics and the first test was Ovacheck.  Woman at high risk of ovarian cancer could rest a little easier with this test that had an over 80% accuracy rate even in the early stages of ovarian cancer.  So if you’re me and have an 82% change of developing breast cancer and a 30% of developing ovarian cancer you can imagine the excitement this new diagnostic technique meant for me.  I could get screened by a drop of blood for the many cancers I am at risk for.  No more toxic treatments, no more worrying about cancer because this test could detect any cancer early and when cancer is detected early one doesn’t need the chemotherapy drugs or radiation.  And the screening would be minimal eliminating the need for me to pay $2,000 - $4,000 annually just for MRIs.  Why I use to tell people my breasts were the most expensive on the market and I don’t even have implants. 
But I digress.  Although the test has been available since 2002 and there are no other tests a woman can get that detects ovarian cancer you would think that the FDA would have rushed it to market in an effort to save lives.  Wrong, they decided to regulate it as a medical device.  For the first time in the history of the FDA they regulated a lab test as a medical device.  And oh by the way two or three doctors that worked at the NIH with the company on the technology left to compete with that company but not to prevent disease mind you – they were going to use the same technology to develop drugs to treat cancer tumors.  He’s the congressional testimony if you want some good bedtime reading.

  http://www.correlogic.com/newsandevents/congressional.php

And the company went bankrupt.  The test; I can get if I fly to Europe even though our tax dollars partially paid for the development of the test and our FDA which I have renamed the marketing department of pharmaceutical companies and the medical device manufacturers or for short the Fatal Drug Approvers, spends its time and our tax dollars sending warning letters to the sellers of benign products like beet juice extract and light therapy while I am dying from a disease caused by gadolinium based contrasting agent used for MRIs.  That’s right as a dermatologist you likely have seen this disease but have been instructed not to diagnosis anyone with it as the medical industrial complex once again covers up their genocidal mistakes.  I don’t get exams anymore Dr. Klein.  Can you guess why?

Emma Costello

May 6, 2011, 11:26 p.m.

To add a slightly different view to this, this sort of practice is outlawed in Australia somewhat.

Drug companies are not allowed to advertise their products unless it is freely available, ie can be bought without a prescription. This means that things like vitamins, paracetemol, asprin etc can be advertised, but prescription drugs for heart conditions etc can’t.

Companies who sell such drugs also have restrictions on what they can sponsor and advertise. I used to work for charities in the health field and we always had difficultly gaining sponsorship as a result. We could accept sponsorship from a company who makes dressings but we couldn’t accept anything, not even a silent donation, from any company that manufactures prescription drugs.

Whilst it made it hard for us at the charities, I can understand why it is not acceptable. If an organisation who supports thousands of arthritis sufferers accepts money from a drug company to advertise it’s products in their magazine it would be favourtism and possibly lead our supporters to believe that their drugs are better than all the others, which may not be the case.

It also means that the public are not lured to buy specific drugs that they see on the TV (I was amazed by this practice when holidaying in the US a few years ago!). If they go to the doctor with symptoms, the doctor prescribes based on those symptoms, not what the patient makes them believe they have to get a certain drug they’ve seen on telly.

The doctors themselves are still targetted on an individual level, but how else are they meant to know what drugs are available? It certainly isn’t as prolific as it is in the US though. so certainly come and have a look if you’d like to see a different way.

John F Rothrock, MD

May 7, 2011, 10:47 a.m.

“D” perhaps is overstating the case in pronouncing that “doctors are all schlubs[?] on the take”.

Regardless, after having spent 32 years in academic medicine-caring (literally and figuratively) for many thousands of patients, training medical students, residents and fellows, and assisting in the development of new therapies for stroke and migraine (wherein the investigative research often was funded by the increasingly demonized pharmaceutical industry), it’s immensely discouraging to hear this same sentiment echoed by so many of my fellow citizens.

While my profession’s integrity unquestionably has been sullied by a number of bad apples, and while I applaud legitimate efforts made to identify and restrain those individuals, I would suggest that “shotgun” efforts such as those promulgated by ProPublica-“investigative reports” short on balance and long on sensationalism, as Mr. Sullivan has indicated-are leading us to throw a lot of baby out with the bathwater.
 
D, do you honestly think we physicians are “all schlubs on the take”? If so, I suggest you stop by a burn unit, an ER at 2am or a charity care clinic and observe those at work. I am incredibly proud to have spent so many years in this profession, working alongside skilled and compassionate physicians and nurses devoted to the health and well-being of others, and I only hope that the next generation of our nation’s caregivers will feel the same as they approach the end of their careers.

Well, of course, the word all was used figuratively.  Maybe 1 in 3 is a schlub.

BTW, I had to go to the ER for a leg injury recently.  I am extremely allergic to cats and one of the workers in the ER obviously had a cat or two.  I ended up with a refill script for eyedrops which cost me $136 for 1 tsp of medicine.  Yeah, they’re caregivers all right.  They didn’t do much for my leg either.  My husband helped me more than the ER did.

Most of the doctors and nurses in this area of the country keep their jobs only because the job situation is helpless and hopeless right now, and because they have benefits and decent pay.  Considering the damage done by some of them, that’s a pretty decent reason.  I don’t doubt there are some compassionate caregivers, they are just few and far between.  Personally, I like to try to figure out ways to help myself and let them be compassionate with other people.

This is yet another reason why ProPubica is such a must read every day. Even though I know of the bigger picture about Big Pharma, the details and documentation of how this “marketing” works is essential. I am a comedy writer, and I can hope to spread this kind of truth in my own way. I don’t mean to troll you away from this wonderful site, so please make a note of my articles should you wish to read them, or if you click, come back here.

Side Effects: Big Pharma’s Brand Extension http://wp.me/pKBYM-vZ

Ask Your Doctor if “An Increased Risk of Death is Right For You” http://wp.me/pKBYM-bF

Dr. Rothrock:

The problem is not related to “a few bad apples” - it never is.  The problem is that laws like HCQIA (hick-wa) force “the good apples” to acquiesce to the bad apples, lest they become the newest target for the whack-a-mole practice of “sham peer review.”

Years ago, the Semmelweis Society International (SSI), doctors Gil Mileikowsky, Lucien Leape and others proposed that a “black box” solution would allow “good apples” to report “bad apples” without fear of reprisal… but even the success of that scheme would depend upon who opens the “black box.”  (http://www.semmelweis.org)

Since this is how commercial pilots anonymously report “bad apples” without fear of retaliation, why do you think that healthcare’s good-apple majority opposes such a scheme?  Could it have something to do with the pharmaceutical and healthcare companies that fund the leadership of professional and governmental medical boards, associations and hospitals?  Why haven’t the “good apples” pressured changes that would negatively impact their corporate donors?

So while “bad apples” may comprise five percent of all healthcare professionals, the acquiescent 94 percent are the ones who inflict the real harm; leaving the one percent who try to make a difference to find new careers as truck drivers or hanging themselves in their closets.

Protecting and defending the “good apples”...

Clark Baker
Principal Investigator
http://www.omsj.org
(a 501c3 non-profit corporation)

The watershed question may be: does cardiac device industry money affect what happens to the individual patient? Certainly, device reps educate doctors in proper use of very complex devices—a good thing. But the case can be made that industry money, especially for research, creates an atmosphere encouraging over-treatment, because there are few or no equally well-funded voices exploring the cautions. The end result may be that devices are inserted into people, especially the very old and frail, for whom they’re not appropriate. This is not a harmless thing, like getting a $35,000 toaster you wish you hadn’t bought.  In my family’s case, a hastily-considered pacemaker overly prolonged my father’s worst, stroke- and dementia-ridden final years, breaking my mother’s health and all of our hearts with nonstop caregiving.  There was nothing wrong with the device—it would have been a miracle for someone else. The problem is, there’s lots of funding to promote these life-prolonging devices, and not much funding to examine the larger moral and human issues surrounding their insertion.  For more details, please read, “What Broke My Father’s Heart: How a Pacemaker Wrecked Our Family’s Life,” by Katy Butler June 20, 2010.

http://www.nytimes.com/2010/06/20/magazine/20pacemaker-t.html


Author
Forthcoming: Knocking on Heaven’s Door: A Journey Through Old Age and New Medicine.” (Scribner/Simon & Schuster 2013.)
http://www.katybutler.com

Disclosure: I’m a cardiologist (finished my clinical training, still with two years of research during fellowship) who regularly attend these types of meetings.

I think this series of articles is highly relevant, but also unbalanced.  The pernicious influence of industry on medicine is a huge issue.  But to only present that without talking about the essential role of industry in research and development also misses the point.  Without funding support, there is also the real risk that good, cost-effective treatments will not be widely disseminated.

As much as I have great respect for Steve Nissen, there are others who have more nuanced views in this area.  I think you should also interview Jerry Avorn, whose group pioneered “academic detailing” as a solution to the dilemma posed by drug reps.  Or Elliott Antman, who pointed out at the last ACC meeting that it’s not enough just to criticize industry, but also to work towards concrete solutions such as, for example, training enough people with the statistical expertise who can independently ascertain the results of industry sponsored trials.

I see your point S Ye MD, however,  as a society we have locked ourselves into the privatizing of research, still that doesn’t let you and your profession off the hook.  Perhaps there should be an independent body funded by a percentage of revenue of any entity that wants to play in the research game.  A pay to play solution if you will, funded by the companies that benefit but have no control over the results of the research.  I also believe this is a problem in auditing as well where independence of the auditors is questioned because the industry they are auditing pays them for their services and for other lucrative consulting contracts, indeed the results of this arrangement are historically documented in case after case of corruption.  These bodies - research and auditing need to be independent and objective and serve the public at large not the interests of the for-profit driven multinational corporations that have absolutely no interest in the patient population except as commodities that produce revenues from cradle to grave.

And I also dispute your claim, “Without funding support, there is also the real risk that good, cost-effective treatments will not be widely disseminated”.  The information that is disseminated at these industry sponsored events is inherently flawed in favor of the product they are trying to sell to you.  There are no controls over the information presented to you as scientifically sound or independently verified therefore I opine that it is quite possible these meetings do more harm than good by giving your profession a false sense of security when buying into these often times toxic treatments industry wants you to buy.

Dr. Ye:

I agree that the report is unbalanced, but not in the way you suggest.

As a cardiologist in-training, what do you know about Redding Hospital’s cardiology department?  Chances are, they never discussed this at school… but you can read about it in books like OVERTEATED.

One of OMSJ’s current criminal cases involves a prominent physician-university professor who recently served as a prosecutor’s expert witness against her own patient – an obvious violation of HIPAA.  It is one thing to testify against your patient or husband by court order and another to volunteer evidence to prosecutors to deliberately harm your patient. 

This “doctor” is a senior official of several organizations that include the American College of Physicians (ACP).  ACP receives more than 99 percent of its funding from drug companies – one of which includes Bristol-Myers Squibb (BMS), which awarded ACP and this doctor $2.9 million less than two months after her testimony sent her patient to federal prison.

BMS is currently the subject of a multi-state whistleblower lawsuit related to the bribing of physicians to illegally promote their drugs.  This doctor unnecessarily prescribed one of BMS’ highly addictive psychotropic drugs to this patient even though the patient she sent to prison was consistently described by her own clinic as “asymptomatic.”

Although half of her patients have died while under her care is not a shock, the fact that she admitted this under oath is.  This is a leader of ACP - an organization that you may have already joined.

THIS is the “standard of care” in the medical industry.  This was the top AIDS expert who prosecutors called to testify against her own patient.  This is why this doctor’s organizations receive millions from pharmaceutical companies, while non-profits like http://www.semmelweis.org and OMSJ are forced to rely on private donations from people and organizations who are not subject to the retaliatory practices of the drug industry.

But don’t believe me.  You can research this yourself in the following way:

Three years ago, the Nobel-winning discoverer of HIV, Luc Montagnier MD, admitted that HIV can be cured within a few weeks with clean water and good food, but that the NIH and drug industry push drugs and vaccines because they can’t make money selling water and nutrition.  Montagnier even implicated NIAID Director Tony Fauci by name.  Don’t believe me – you can watch him say this yourself:

http://www.omsj.org/multimedia/nobel-laureate-exposes-scam

Now… if you REALLY believe that pharmaceutical influence doesn’t affect medical or scientific careers, share this video and Montagnier’s comments with your fellow researchers and clinicians at your facility and see long you last in your chosen field.

YES – this ProPublica report is unbalanced, but it doesn’t go far enough to report the corruption that kills and injures a million Americans every year – for profit.

If the Taliban killed or injured a million Americans every year we would take notice.  The fact that young researchers defend such industries is, at best, disturbing.

Respectfully,

Clark Baker (LAPD ret)
Principal Investigator
http://www.OMSJ.org

This article is nothing less than what we’ve come to expect from ProPublica.  The authors have taken something that has been widely discussed in other publications, re-packaged it and called it “investigative journalism.”  Kudos to them for taking credit for other people’s original efforts.  Bravo.

I find it interesting that the authors spent a considerable amount of time interviewing sources who had dissenting viewpoints that were not included in this article.  It is less about journalistic objectivity (and credibility) than it is about creating a name for yourself and selling senssationalism.  Why interview Chris White/AdvaMed if you aren’t going to bother including the information?  Why interview Dr. Black if you are not going to include her views?

PA:

I share your interest in reading the views of AdvaMed’s general counsel and hope that Chris White and Dr. Black will post their responses and objections here - along with a financial disclosure of AdvaMed’s corporate clients and sponsors.  After a quick examination of their website and Google, I found no such disclosures.

If you know them, please send an email with a link to this report so they don’t waste too much time looking for it.

tradeshowboy

May 9, 2011, 2:53 p.m.

I’m not a doctor, but there are a couple points that may be worth considering.
Medical societies rely on the revenues from these annual meetings for a large chunk of their budgets. They make that money by selling booths and soliciting sponsorships. The registration fees for the attending doctors don’t nearly cover it.
Doctors attend these events in large part for the CME credits and access to new research. What? You think they sit around reading journals other than The Wall Street?
There are rules in place that limit the blatant solicitations and hustles you see at non-medical trafe shows.

Larry Grossman

May 9, 2011, 5:32 p.m.

Physicians are highly educated and intelligent people who clearly can make distinctions about proper therapies that you clearly cannot.  The term is “learned intermediaries” and they should have the analytical skills to make informed decisions. Marketing = education about product benefits with the predetermined expectation that it is self-serving.  Come out of your Ivory Tower and recognize reality.  Grow up intellectually.  And what is your suggested alternative source of funding for CME?

The Heart Rhythm Society is corrupt. Witness the evolution of catheter ablation for atrial fibrillation, a risky and unproven procedure that is now front line therapy, being touted as a “cure” for afib: http://collateral-damage.net

Larry Grossman:

Two weeks ago, OMSJ deposed one of your “highly educated and intelligent” medical doctors - a self-described expert who prosecutors called to testify as their expert witness.

http://www.wishtv.com/dpp/news/local/marion_county/alleged-predators-hiv-diagnosis-in-doubt

After our first hour of questioning, this top director of the Indiana State Dept. of Health was compelled to admit on the record that she is not really the expert she said she was.  Had OMSJ not been there to challenge her, her incompetent opinions would have sent a factually-innocent man to prison for 27 years.

The failings of this board-certified physician are either connected to her lapse in analytical skills or her lack of integrity.  Either way, she oversees the implementation of healthcare policy for millions of Indiana residents.
 
And while former Marine Corps-helicopter pilot-scuba divemaster-LA cop-investigators like me may not have spent a decade in college, one does not require a PhD to recognize character flaws or criminal behavior.  If I had probable cause to arrest that dangerous charlatan, she would not be the first practicing doctor I put in prison for making bad decisions that threatened the lives of others..

Medicine is not theology.  Doctors are not gods.  Although the drug industry wants us to believe the doctors they bribe (and those who acquiesce) are worthy of our faith, physicians are subject to the same vices and weaknesses that the rest of us succumb to.

The fact that the drug industry has paid $9 billion since 2004 to settle thousands of criminal and civil complaints related to the illegal marketing (and bribery of physicians) of drugs that kill or injure a million Americans annually is well-documented in the peer-reviewed medical literature.

Preventable medical errors and complications kill thousands of Americans annually:

http://www.wkyc.com/news/story.aspx?storyid=35109

Infectious disease became statistically irrelevant in the US by 1955 – years before mandatory vaccination schedules were imposed:

http://jama.ama-assn.org/cgi/content/full/281/1/61

Infectious disease is widely spread throughout US hospitals.  But if we consider that that infectious disease is ranked somewhere around the twentieth leading cause of death in the US, why would we push drugs and vaccines that (if tracked like real diseases) would rank between the fourth- to sixth-leading cause of death in the US?

http://jama.ama-assn.org/cgi/content/full/279/15/1200

Although your arguments might make sense to “intellectuals,” I don’t get it.  Then again, I never understood eugenics, Tuskegee, death camps or any of the other intellectual schemes of 20th century medicine.  While some advances have improved life expectancy, no one seriously considers that a crime family deserves clemency simply because some of their proceeds are directed to the local orphanage.

All of this is best summed up by the father of virology when he said, “Unless the law winks occasionally, you have no progress in medicine.”

I guess it depends upon one’s definition of progress - and who profits from it.

If the public would just get off its collective dead ass and learn about the heart as a vital organ/muscle of the body they would know that all the gadgets in the world won’t really help.  We must help ourselves BEFORE it gets to the point where you go to a cardiologist.  Magnesium, magnesium, magnesium.  Mostly magnesium oil.  This is the most important thing you can do for heart rhythm.  But—it doesn’t cost an arm and three legs, so hey, it can’t possibly work.  Also, it’s from that boogey-man broom closet called natural therapy, so that makes it even more criticized in the allopathic world.  Hemlock, CoQ10, B complex and good fats will go a lot farther to prevent problems and protect heart health than any doctor on the face of this good earth, I don’t care how much “knowledge” he thinks he has or how many hours of CME he has.

As we continue to see everything is for sale nowadays. The mistake i made was i trusted my doctor. Silly me. Let’s stop thinking they are gods.

“Physicians are highly educated and intelligent people who clearly can make distinctions about proper therapies that you clearly cannot.  The term is “learned intermediaries” and they should have the analytical skills to make informed decisions. Marketing = education about product benefits with the predetermined expectation that it is self-serving.  Come out of your Ivory Tower and recognize reality.  Grow up intellectually.  And what is your suggested alternative source of funding for CME?”

Larry Grossman, in your post you do not disclose that you have ties to the CME Group. Don’t you think you should have disclosed this in your post?
 
CME Group Special Executive Report

http://www.cmegroup.com/rulebook/files/20100726S_5343.pdf

Obvioulsy not everyone knows what CME stands for.

@ C: Well, enlighten us. 

I thought CME stood for continued (or continuing) medical education.

Good job… does the link above or it’s members listed have anything to do with continuing medical education - or does it have more to do with Futures trading and that someone did a google search of CME, clicked the first link that popped up - then did a name search on their search tool - then clicked the first link that popped up.

I must admit, I wondered what the Chicago Mercantile Exchange had to do with continuing medical education, but I didn’t have time to look through the entire link and thought maybe it was, in some way, correspondent to the marketing or sales of the medical equipment or something of that nature.  Otherwise, I don’t know.

@ Dan Walter:  Thank you so much for sharing the link for the book on collateral damage.  I have mitral valve prolapse (insignificant for now) so I like to stay current.  I didn’t have a lot of time to read at the link yet, but I’ll look into it later.

My apologies.  The link has nothing to do with Continuing Medical Education but I would still like to know if Larry Grossman is biased as I found his name on a CME course. 

Disclosure: I was poisoned by a medical product that is still being marketed and used and I suffer from mental impairment.  I have bad days and good days.  Today is a bad day.

No sweat, Sharon.  It’s nice to see C & D found at least one little error… I’m still waiting for them to attack the JAMA links I posted…

I wasn’t attacking anyone.  I was just answering a question from C.  I don’t get a lot of time to look around at all the different links, and you’re all free to post any sources, even JAMA.  It’s usually the .gov links I don’t trust much.

NeedlestickSafety.org

May 11, 2011, 4:41 p.m.

The medical device companies are in bed with the purchasing groups like Premier, Inc. as reported over the years.

Beware of dangerous needles in the US. Stop this menace that harms nurses and patients.  Medical device manufacturers are selling defective needles.  See proof at:  http://tinyurl.com/dangerousneedles

Headline:
Annual convention for industry, physicians, dominated by industry, physicians.

This is followed by a widely misinterpreted study published in JAMA claiming that 1 in 5 devices were implanted in patients who did not need them, a statement which has been recanted by the authors, in print, after confronted with established guidelines and obvious clerical errors in the registries used for the study, among other things.

Lastly, one commenter wished there were a “link” that could be posted to support the contention that medical therapy and devices have improved the public health. Well, there are no “links,” but consider the following verified numbers driven from non-industry sources, such as CMS and Medicare:

Cardiac deaths have decreased by ~25% in the US over the past ten years.

Hospitalizations for cardiac causes have decreased by 30% over the same time period.

Or you could ask a sudden cardiac death survivor how their day was. I have a panel of about 1000 of them in my clinic.

Does there need to be total transparency between the public and industry? Yes, in all sectors. And the idea that a company could put any professional society logo on their business card is obscene. But overall, this is just another lopsided story. Big yawn.

Its a free country - if you don’t trust the “healthcare-industrail complex” you don’t have to use it. When you collapse with your heart attack or develop a cancer, you can stay at home, sing songs around a fire, and treat yourself “holistically”. No one is forcing you to go to a hospital. Stop whining.

America’s freedom to be better than the past, to achieve better lives for our society than what other nations’ call normal, to advocate for what is known to be right and just even when society is at odds with what is right and just, is what the discussion is about. 

Thinking such as, “If you don’t like us, if you don’t accept dung as it it were gold…”—it is this kind of mind that embraces ignorance over wisdom.  Propublica’s research and reporting on realities in healthcare in the end will improve healthcare…for all, even those who chose to be ignorant.

Free Country:

We are not as free as you think.

Aside from the billions of tax dollars that American taxpayers (you and me) squander with useless NIH research and through the unnecessary prescriptions and kickbacks that bilk Medicaid and Medicare, some of OMSJ’s clients include:

* Doctors whose careers were ended when hospitals retaliate against them for not abiding by iatrogenic “standards of care.”

* Career military parents, who are forced to vaccinate their children with known pathogens under threat of dismissal.

* Parents who are forced to administer deadly “black box” drugs to their children or have them reassigned by child services functionaries to foster parents who will.

* Professionals who are ordered by health department officials to surrender the names of their friends, associates and lovers under threat of their personal lives being exposed to employers.

* Healthy law-abiding taxpaying citizens who are serving life in prison after junk scientists and doctors testified against them in court.  During the past 20 months, OMSJ has forced prosecutors and courts to drop all HIV-related criminal charges in 19 cases by simply forcing these so-called experts to testify in court under oath, in our presence.  Last month, OMSJ forced a top director of the Indiana Department of Health to admit on the record that she wasn’t really the expert she claimed she was.  Without OMSJ, he would likely serve the rest of his life in prison.

The so-called “anti-vaccine movement” doesn’t care if parents choose to vaccinate their children – they just want to be able to make those choices without being threatened.  I find it bizarre that government officials who say women can CHOOSE to kill their unborn babies have no choice regarding vaccines and drugs if they allow their children to live.  Is THAT freedom?  And while pharmaceutical “researchers” insist that there is “no evidence” that vaccines cause autism, you don’t need Sherlock Holmes to explain why evidence doesn’t exist WHEN YOU ARE PAID NOT TO LOOK FOR IT.

As a former Marine and retired LA cop, I appreciate freedom as well.  The problem is that the CDC, NIH and HHS generate fear and hysteria to justify the imposition of Stasi tactics to enforce drug industry pseudoscience.  That industry has paid $9 billion since 2004 to settle thousands of criminal and civil complaints related to the illegal marketing of drugs that kill or injure a million Americans every year. 

That’s a lot of altered freedoms – a success rate that al Qaeda could envy.  Except for their white coats, these companies are criminal enterprises.

For those who insist that the industry does a lot of good, the fact that the Gambino, Gotti, Rockefeller and Kaiser families give to local orphanages doesn’t make their enterprises virtuous.

Like air, most people don’t think about freedom until it’s interrupted for a little while.  OMSJ defends freedoms that most of us take for granted.

Clark Baker
Principal Investigator
http://www.OMSJ.org

Clark, the work you are doing to expose the cancers in society stemming from greed and nefarious medical practices perpetuated on people in the name of humanity, is very important.  Please advise how to reach you, as OMSJ has no contact information. Thank you.

You’re correct Steve - I need to update some of our links for clarity. 
http://www.omsj.org/action

You can also look up the OMSJ by Googling “Clark Baker and LA Times.”

The world is not black and white. A few bad outcomes in medicine doesn’t mean the entire industry is corrupt, just as an AIDS denying cop who beats up a handcuffed JAYWALKER can’t be all bad, or mean that the LAPD is a corrupt entity. Or does it?

The entire medical industry has been pretty much corrupt ever since the Rockefeller’s and the Rothschild’s, amongst others, started mandating and paying for all the cirriculum studies at all the medical schools.  Even then they saw a future bright with $$ signs because they saw the potential for pills, invented diseases, and a society awed by all the hoopla of “medical machines” - making the doctor’s and hospitals seem like Gods.

Now we pay for the corruption.

I say vote with your feet then. Just say no to those corrupt docs and hospitals, throw your pills down the drain, and forget about those phony invented diseases.

This article is part of an ongoing investigation:
Dollars for Doctors

Dollars for Doctors: How Industry Money Reaches Physicians

ProPublica is tracking the financial ties between doctors and medical companies.

The Story So Far

ProPublica is investigating the financial ties between the medical community and the drug and device industry. In October 2010, ProPublica compiled the list of payments that drug companies make to physicians and built a publicly searchable database so that patients could look up their doctors.

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