Physician John Abramson interviewed by Brad Lemley
One Doc’s Drug Complaint
“The truth is that lifestyle is far more important than
John Abramson is a clinical instructor of primary care
at Harvard Medical School
He began his career in Appalachia, serving in the National Health
Service Corps. In 1982 he became a family physician in Hamilton,
Massachusetts, and practiced there for 20 years. He was selected by
his peers three times as one of the best family doctors in the state. After
researching his book, Overdosed America, he says health care in the
United States is becoming less effective than in other industrialized
countries while becoming much more expensive.
Q: What’s the evidence for your thinking that Americans aren’t getting
better health care for all their spending?
A: In 2000 Barbara Starfield, University Distinguished
Professor at Johns Hopkins University, wrote an article in TheJournal of
the American MedicalAssociation showing that the health of Americans
ranks second to last among 13 wealthy industrialized countries. And in 2001,
the World Health Organization looked at the 23 countries that spend the most
for health care. The United States spends by far the most in that group:
roughly $6,000 annually per capita, which is twice the average of the other
countries. But we have nearly the lowest healthy life expectancy, that is,
total life expectancy minus the number of years of illness. Only the Czech
Republic ranks lower.
Could it be that Americans
simply eat more junk food and exercise less than people
in other developed
There isn’t a clear-cut boundary between medical care and
lifestyle. For example, when a patient comes to a doctor for a physical
exam in the United States, there is a 67 percent chance the doctor and
patient will talk about cholesterol levels and less than half as much
likelihood that they will discuss lifestyle choices like diet, exercise,
and not smoking. The truth is that lifestyle is far more important than
cholesterol levels in determining the risk of heart disease for the vast
majority of people, but this is getting drowned out by the commercially
fueled cholesterol-lowering frenzy.
Why do you
say drug trials are losing credibility?
A: When President Reagan came into office in 1980, we
started to get a small-government ethos. The budget for clinical trials
funded by the National Institutes of Health shrank dramatically during those
years. The drug companies were very happy to step in and fill the vacuum.
Initially the change in funding didn’t have much impact on clinical
research. Although the drug companies were funding 70 percent of the
clinical trials by 1991,80 percent of those trials were still being done in
universities, where the checks and balances inherent in the academic
environment were still in effect. But then things started to change: By
2000, universities were doing only 34 percent of industry-sponsored
research; the rest was being done by for-profit organizations. Now we’re in
the final stage: Private research companies are being bought by large
advertising agencies. Ad agencies are now in a position to help design
studies so that the results will create the best possible marketing
opportunities for the drug companies.
any proof that
privately funded studies are biased?
A: When you look at the highest quality medical studies,
the odds that a study will favor the use of a new drug are 5.3 times higher
for commercially funded studies than for noncommercially funded studies.
Drug companies are also sponsoring about 70 percent of the continuing
education that doctors are required to participate in to keep their
licenses to practice.
Is this an
A: Absolutely. Germany is in many ways the most similar
market to us, but we spend 12 times more per capita marketing drugs than
they do. Half the statins used worldwide are used in the United States, and
that was before the 2001 and 2004 updates of the National Cholesterol
Education Program recommended more than tripling the number of Americans
taking statin therapy. Direct-to-consumer advertising exploded more than
75-fold in the United States from 1991 to the present. We now spend $4.2
billion a year on it. Only the United States and New Zealand, which has less
than 4 million people, even allow direct-to-consumer advertising.
talking about all the “ask your doctor” ads?
A: Right. They work: Turns out that when you ask your
doctor for a prescription drug, you get it between 50 and 80 percent
of the time. But a study done by researchers in British Columbia showed that
when a doctor accedes to a patient’s request for a specific drug, the
doctor is ambivalent about it being the right choice 50 percent of the time.
On the other hand, if doctors prescribe a drug that was not requested by
the patient, they are ambivalent about it just 12 percent of the time. These
ads drive a wedge between doctor and patient. For a while, I was both a
family practitioner and a researcher, and I knew as much about the real data
behind Vioxx and Celebrex as anybody. I knew they were neither safer nor
more effective than the much less expensive alternatives and would tell my
patients so. Nonetheless, many still demanded these drugs, which shows the
tremendous power of marketing.
Is it true
there is no requirement to release all the data in a privately funded study?
A: Yes. Not only that, all the authors of journal articles
don’t even get to see all the data. In 2001 the editors of the 12 leading
medical journals decried what they described as a “draconian” situation for
academic researchers, hut even that extraordinary joint statement went
largely unheeded. Now universities have been forced into what’s been called
a race to the ethical bottom. If they don’t conform, they will lose out
altogether to the for-profit research companies.
What do you
A: All the authors have to have free access to all the
data when they write a journal article. If the authors of those articles had
to sign off and say they saw all the data, and they are responsible for the
article being a hill, unbiased representation of it, I think you would see
some of this stop.
A: The most important step is that we need some
disinterested body—perhaps the Institute of Medicine working with the FDA or
maybe a new, independent body modeled after the Federal Reserve Board—that
has complete access to research design, all data, and all analyses and can
then certify the integrity of the conclusions that are drawn from that
study. Good medical journals today are very frank that they can’t certify
that the studies they publish are complete and accurate, so we need
somebody who can. Then, good medical journals might refuse to publish
articles that are not certified. This is important because a big part of
becoming a doctor is learning which sources of information to trust. During
medical training, if you make a decision that’s not based on the latest
research published in medical journals, more senior doctors are openly
critical, so you learn to follow the journals very closely. The journals
play a central role in American medicine, and they have to realize that what
they publish has real consequences.
meantime, what can patients do?
A: The first thing we have to do is become aware of
how distorted much of our medical care has become. The net effect of this
commercialization of our medical knowledge is to have created the
impression that a good and healthy life requires a lot of medicine. The fact
is, about 70 percent of our health has to do with how we live our
‘About 70 percent of our health has to do
how we live our lives. Doctors are not
keeping up with
lives. Doctors are not keeping up with this. In June 2003, the Rand
Corporation published an article in The New England Journal of Medicine
showing that when prescribing medicine, 68 percent of the time American
doctors meet objective quality standards. But when it comes to llfestyle
counseling—and this is simple stuff, like telling someone with emphysema to
stop smoking—the quality standards are met only 18 percent of the time.
Another big point is that every person needs to have a primary care
physician they trust; that’s the basic unit of good health care. We need to
get over the misconception that the best care is provided by a big
repertoire of specialists. The number of U.S. medical students choosing
careers in family practice plummeted by more than 50 percent in just the
last eight years, but ironically, the more specialists there are in a state
per capita, the lower the quality rank of medical care in that state and
the higher the cost. It’s appropriate to talk to your doctor about where he
or she gets information. I think it’s within a patient’s rights to say,
“You know) doc, I’d rather you got your continuing education from