Swayed By Lunch Money: A Grotesque Insult to Doctors

Here at the American Council, hardly a day goes by when we don't write about, or at the very least encounter, bad studies. They are often published in journals that have few or even no standards. This is business as usual.

What is not business as usual is a recent paper that somehow found its way into JAMA Internal Medicine and has been infuriating physicians (and rightly so) since its publication last week. This paper, courtesy of Dr. R. Adams Dudley from University of California San Francisco (1) is profoundly flawed and biased.

Maybe even evil. The premise of this paper, as well as its implied conclusion, is that doctors are so corrupt and greedy that buying them a hamburger will make them prescribe more expensive drugs for their patients.

The JAMA Editorial Board Photo credit: Shutterstock

The group examined the relationship between physician prescription practices in 2013 and whether a doctor was given a free, cheap ($20 or less) meal at a presentation about a particular drug. The study's message — which I'm betting was predetermined, regardless of data — was that doctors are such whores that they will write prescriptions for more expensive drugs simply because they got a free cheeseburger.

"Receipt of industry-sponsored meals," wrote the authors of the study, "was associated with an increased rate of prescribing the brand-name medication that was being promoted."

What a load of crap. The flaws and biases in this study are blatantly obvious to anyone who has ever debunked garbage studies. In case you haven't, this might help:

• The dataset consisted of 279,669 physicians who attended presentations where a newer, more expensive drug in one of four classes was discussed
• Of this group, 63,524 were reimbursed for meals (average cost was less than $20)
• The physicians who were reimbursed were more likely to change from a cheaper and/or generic drug to a newer, more expensive version, for example Crestor instead of Lipitor (2)
• Therefore,"Receipt of industry-sponsored meals was associated with an increased rate of prescribing the brand-name medication that was being promoted."

Here are the problems: Of the nearly 280,000 doctors who attended these presentations, only 23 percent bothered to submit receipts for reimbursement of the meal. This alone shows that they were more interested in the lecture than the money. These physicians wanted to improve their knowledge, not save a few bucks on lunch. This is not mentioned.

And, what about the 77 percent of doctors who did not turn in receipts? Did they also write prescriptions for newer, more expensive drugs? Did they do this more, less, or the same as the 23 percent? Not a word.

Four classes of drugs were chosen for this study. Why these four? Are there other classes of drugs where this effect is not seen? Or reversed? Not a word. How about the possibility that the doctors who went to the seminars actually learned something, and that it was this that changed their prescription choices? For example, Crestor is more potent than Lipitor (2). Perhaps some cardiologists were convinced that Crestor would be a better choice for some of their patients. Not a word.

Food is routinely provided by hosts of seminars. How is this different?

To do this study correctly (and good luck with this), four groups of physicians would be needed (3):

1.  A group of doctors who neither attended a lecture nor got lunch

2.  A group of doctors who got no lunch but did attend a lecture

3.  A  group of doctors who got lunch but did not attend a lecture

4.  A group of doctors who got lunch and did attend a lecture

The UCSF group had only #4. Coincidence? You tell me. But, in the absence of the other three groups, no meaningful conclusion can be drawn. But, is it unlikely that the authors wanted a meaningful conclusion. They wanted to get their biased study into the news.

And, it worked. Go to Google News. Type in "doctors prescribing free meals." You'll see 120,000 hits. The ones I saw all had the same basic message. Congratulations, guys. Your cheap shot paper made doctors look bad, even though they are not.

But, you made yourselves look even worse (4).

Notes:

(1) Other affiliations: University of Hawaii, Pacific Health Research and Education.

(2) In the SATURN trial, Crestor modestly outperformed Lipitor in disease regression and lowering of LDL.

(3) Thanks to Dr. Stan Young for help with this analysis.

(4) The JAMA editorial board ain't looking so hot right now either.