Latest / CareTalk: Healthcare. Unfiltered. / The Ethics of Social Media Medicine

Transcript

The Ethics of Social Media Medicine · CareTalk: Healthcare. Unfiltered.

• 0:00
  Why do some doctors tweet endorsements of drugs and medical devices on X?
• 0:04
  Could it be for the same reason celebrities tweet about shoes and snacks?
• 0:09
  In other words, are they paid to do it?
• 0:18
  Welcome to Care Talk, America's home for incisive debate about healthcare business and policy.
• 0:22
  I'm David Williams, president of Health Business Group.
• 0:25
  And I'm John Driscollith, senior advisor to Walgreens.
• 0:28
  Join the fast growing Care Talk community on LinkedIn, where you can dig deep into healthcare business and policy topics, access Care Talk content, and interact with the hosts, and maybe leave an endorsement, which we will not pay anybody for.
• 0:40
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• 0:44
  David, you sound like you're stumbling over the care talk content.
• 0:48
  It's not that it's early on Monday morning.
• 0:50
  You're already challenged by the script.
• 0:53
  John, I was thinking about whether to call it care talk or cash talk, given our topic.
• 0:57
  That's what was and or and then that rhymes with trash talk.
• 0:59
  So that's what was.
• 1:01
  So David, we are we are going to, I would say, dive deeply, but probably thinly into the issue of can you buy a doctor's endorsement?
• 1:11
  Yeah.
• 1:11
  And the issue of conflict of interest.
• 1:14
  I am shocked, shocked that there is some element of corruption suggested by the payment of doctors.
• 1:22
  Now, this is a little bit of a complicated issue because of course we want doctors paid to do research and development around drugs and devices.
• 1:32
  So what's the issue here?
• 1:36
  Well, John, there's a recent research letter in the Journal of the American Medical Association that drew my interest to this topic.
• 1:43
  The esteemed journal of the American Medical Association.
• 1:47
  It is esteemed, John.
• 1:48
  I will note they also take advertising from manufacturers.
• 1:52
  It's actually a very interesting topic about how much drug companies may control some of the medical journals, because then people know about the advertising, but also the subscriptions and reprints.
• 2:04
  A lot of those are also from pharma.
• 2:06
  So there's a whole very interesting topic of how the pharmaceutical industry influences.
• 2:12
  the medical profession, and that's part of it.
• 2:14
  The specific interest that I have for today is a research letter that was published by several researchers, it was written by several researchers from Memorial Sloan Kettering, and they're looking at a new type of peer -to -peer influencing.
• 2:28
  John, a lot of times the pharma companies are interested in having physicians influence one another.
• 2:33
  That's why they hire them to give talks at dinners.
• 2:39
  and things like that where it's paid promotion.
• 2:40
  Like the Bahamas or Hawaii or the Four Seasons.
• 2:44
  I mean, let's be honest here.
• 2:46
  Pharma should be doing its job to promote its drugs.
• 2:49
  And obviously, they're going to try to entice doctors who control prescribing to at least think favorably about the drugs they're producing, regardless of whether they should be favorably considered.
• 3:03
  I mean, that's the job of Pharma.
• 3:04
  So what's wrong here?
• 3:07
  Well, I mean, I would argue this actually in general, less wrong than people may think overall.
• 3:13
  I speak with physicians and they are interested in learning about drugs and they are interested in learning about them from their peers, you know, other prescribers as opposed to a marketing person or even, you know, from some other source, the sales rep.
• 3:27
  But the challenge is that, you know, whether the issue, whether the collaborative, whether there's a disclosure of payments.
• 3:36
  And then also whether the person is actually qualified, you know, who's giving the talk.
• 3:41
  So that's the old style sort of the giving the talk, but presumably, you know, the physicians can evaluate one another that way.
• 3:46
  This new research letter is talking about endorsements of drugs and medical devices on what was then called Twitter in 2022.
• 3:55
  Well, before you get there, go there, Dave, I think there is this pretty established research that even though.
• 4:03
  the payments are largely to doctors around conversations and presentations that, and I was joking about them being in really nice places, but historically they've been some pretty nice places, which has driven the concern about disclosure because there is a pattern of increased spending on these sorts of activities, driving increasing prescription of brand name drugs over generics of expensive over low cost drugs and of.
• 4:32
  increased, not surprisingly, prescription, regardless of whether the data was there of the people who were paying for the speeches and the outings of their drugs.
• 4:46
  I mean, there's the interesting influence of influence, that it isn't always just a pay to play thing, that there is actually a bit of a long shadow where to promotion has not always been driven by science.
• 5:07
  It's driven by the pharma companies again, you know, free market desire to influence prescribing behavior.
• 5:13
  And there's research that suggests that even if it's just a simple presentation, that it does change behavior, regardless of the facts.
• 5:22
  John, that's right.
• 5:23
  I mean, there, if we take a comprehensive look at all the influences here, the pharma companies are definitely using, you know, very advanced and scientific methods in order to have influence.
• 5:35
  There's the countering side too, right?
• 5:37
  Which is the rules that the insurance companies have, that employers may have, incentives that are in plan design and so on.
• 5:45
  So there's a lot of back and forth.
• 5:46
  It is also true that sometimes even small payments or even non -monetary gifts have an impact.
• 5:53
  That's why sometimes a pharmaceutical rep will hand out just a pen to somebody because when you do something for somebody, even if it's small, there's a sort of a feeling that, I should, I now I need to return the gift in some way.
• 6:06
  It's a deep human desire for that call and response of influence.
• 6:14
  And that goes back to Cialdini's book.
• 6:16
  I mean, there's plenty of psychological research that's used.
• 6:20
  And yet we appropriately look at doctors as the arbiters of choice and recommendation for drugs.
• 6:29
  And so, Is this situation, which was now well documented and now there are, as part of the Affordable Care Act, there's actually databases you can go to to kind of look at who's paying who for what.
• 6:43
  Is this situation getting any better?
• 6:45
  Because obviously we want pharmaceutical companies to pay doctors to collaborate on development, but perhaps we don't really want them to be influenced by, you know, an excess marketing dollars and a dinner here and a trip there.
• 7:00
  Yeah.
• 7:01
  So, I mean, those are I don't I can't say for sure if it's getting better or not.
• 7:05
  It appears that, you know, some analysis has been done of this open payments database seems that.
• 7:13
  It hasn't necessarily changed what's going on.
• 7:16
  Maybe some of the more egregious sort of examples are there.
• 7:19
  Physicians certainly look at it themselves, at least to make sure that their own information is accurate.
• 7:25
  and others may as well.
• 7:27
  What's interesting now is that the new media, you know, what happens?
• 7:31
  And so a dinner is a well -established kind of an approach, but talking about a drug on X is a new thing.
• 7:41
  And especially paying someone to do so is new.
• 7:44
  And just the way that we're looking at how social media is affecting all sorts of things from, you know, mental health to elections to consumer choice, it's worth understanding.
• 7:55
  the impact here.
• 7:57
  And you can expect that pharma is going to be fairly, if not sophisticated, they're at least going to experiment with using this medium.
• 8:05
  And they are paying physicians to endorse drugs on on on X.
• 8:12
  Well, I think I think the rules around disclosure have gotten better around speeches.
• 8:18
  And certainly most companies and hospitals have become much more thoughtful about Disclosure and conflict of interest policies, but as usual in social media, there's there there are no guardrails, right?
• 8:31
  And so what's sort of surprising to me is that anyone would care if a doctor tweeted out something about a drug or a condition but more sir, but perhaps not surprising.
• 8:44
  Although I was surprised that farmers paying.
• 8:47
  Yeah, the for it.
• 8:50
  They're kind of tweets for their their.
• 8:53
  tweets and tweets for hire.
• 8:54
  I mean, it's sort of wild.
• 8:56
  And I'd like to believe that, I'd like to hope that doctors aren't influenced by other doctors, but everybody's influenced by peers.
• 9:07
  For sure.
• 9:07
  John, what would you rather have the doctors reading about on X?
• 9:11
  You know, it's going to be in their stream with whatever else.
• 9:13
  Maybe it's good that they're reading about drugs.
• 9:15
  Well, I just think, look, there's enough of a history of bad behavior of...
• 9:21
  NPR did a study a bunch of years ago on how a lot of the spokespeople for pharma companies had already been accused of misconduct.
• 9:35
  There have been investigations of doctors assuming that they were being invited for their expertise and opinions to particular conferences, but they were really just the influence sessions on the part of some pharma companies.
• 9:49
  But I think we should assume...
• 9:51
  goodwill on both sides, but we just need a lot of more disclosure.
• 9:55
  So in the same way that you every possible negative condition is disclosed on these direct to consumer ads, even though the more bizarre, the more notable, I think it's total.
• 10:06
  I think I think pharma companies should be able to hire doctors as long as they brand the doctors as bought and paid for or supported by those companies that are marketing either the device or the prescription.
• 10:18
  As long as you know, there's a conflict of interest.
• 10:19
  I think there's less of a concern.
• 10:21
  of a conflict.
• 10:23
  Maybe John, it's interesting back in the day of like around the dot com boom, and there was a lot of concern about analysts, financial analysts that had, you know, an interest to the firm had an interest in the company they were promoting.
• 10:36
  You know, they disclosed that.
• 10:38
  But what they found is that like, well, sort of like once it's disclosed, then people are like, okay, well, that's fine.
• 10:42
  So that now this disclosed, maybe they must be being honest about it somehow.
• 10:45
  And so it didn't seem to disclosure does not necessarily have that much of an impact.
• 10:51
  on whether people filter the data.
• 10:54
  you're breaking my heart.
• 10:56
  Sorry, John.
• 10:57
  But it's got it.
• 10:57
  It's got I disagree with you.
• 10:59
  There's got to be some.
• 11:01
  If I have as a doctor know that you're being paid by Pfizer, I'm going to be a little bit more skeptical of whether you're convinced trying to convince me not to use the Merck drug or the generic because you're paid, paid for by Pfizer.
• 11:13
  I mean, I don't think we can restrict doctors first amendment rights and frankly, the.
• 11:18
  the engagement of great minds in having these conversations.
• 11:21
  I just want to know that the great minds are being subsidized by someone who's got a complete conflict, like one of the large manufacturers.
• 11:29
  I think that the scary part here, David, is like in so many other parts of our life, there's just no precedent and sort of a working system that anticipates the potential perversions of social media.
• 11:47
  Yeah, where we don't really we're still getting our arms around.
• 11:50
  I think how influential they are as a group.
• 11:54
  And there are no guardrails.
• 11:56
  And so where there are guardrails around, you know, literature, there are guardrails around presentations.
• 12:01
  There's guardrails around, you know, what what hospitals and companies will allow doctors to do.
• 12:06
  There really aren't any on social media.
• 12:08
  And so the risk is that some AI generated version of Dr.
• 12:12
  David Williams.
• 12:14
  is going to be bought and paid for by someone who's going to put out something that actually doesn't help me.
• 12:21
  It might hurt me.
• 12:22
  I mean, I think, frankly, it's kind of scary.
• 12:26
  What was interesting, John, about this research letter was when they looked at the physicians who were making the endorsements, there were half of them had no publications that were related to the drug or device they were endorsing.
• 12:41
  Which means they've neither done the research or the work.
• 12:44
  put themselves in the position of being an expert, presumably.
• 12:47
  Yeah.
• 12:47
  And then two thirds of the researchers had what they call an H index of less than 20.
• 12:54
  And if you've got a 20 or more, you're considered to be an accomplished researcher.
• 12:57
  David, what is an H index?
• 12:59
  It sounds like something I should avoid because it might hurt me.
• 13:01
  It's like it probably is like preparation H index.
• 13:05
  Let's just not go there.
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  But what is it?
• 13:08
  What is the H index?
• 13:09
  It's a measure of the impact.
• 13:13
  that your research has so it's a it's a way of looking at what journals that you're published in and you know if you if you consider to have been you know sort of cross the bar or not of your peer review it's it's a measure of the breadth and and and reach of your actual research content related to you David come on you can't bring up this stuff without being able to explain it the H John everyone knows the H you know i know a guy named H once actually it's kind of a weird name but Yeah, so these are not like your top docs in general, and they're not the top docs in the field.
• 13:45
  So maybe we should feel good that actually the physicians in general are holding themselves back from tweeting these kind of topics.
• 13:56
  Maybe they have a certain amount of shame or self -respect.
• 13:58
  I think the other thing that sort of surprised me about it, David, is they didn't work for much.
• 14:03
  I mean, I think the study found that the average for a payment to the doctors was like $27 ,000.
• 14:13
  I mean, it's kind of like for putting your name out there, that strikes me as a pretty low bar.
• 14:19
  Yeah.
• 14:19
  Well, you won't be able to buy much H with that.
• 14:22
  And that actually, they don't have a way to say exactly how much were they paid for a given tweet.
• 14:28
  So it's much less than that on average for a tweet.
• 14:31
  That's all the payments they had.
• 14:33
  John, I know I brought up this sort of narrow focus on X and doctors tweeting about endorsements of drugs.
• 14:40
  But more broadly, is transparency in health care?
• 14:44
  Has it been helpful?
• 14:45
  Open payments?
• 14:46
  And you know, more broadly, is transparency a good idea?
• 14:50
  I think transparency is absolutely essential, David.
• 14:52
  I mean, in the same way that there are all kinds of subtle ways that that really smart, magician, psychologist, psychiatrist and marketers can manipulate you.
• 15:04
  through taking advantage of people's natural wiring for things like fairness and for, you know, the give and take.
• 15:11
  Someone does a favor for you, do a favor for them.
• 15:13
  I think there's the flip side of that is with disclosure comes a much more clear-eyed realism about what's going on in these situations of potential and real manipulation and corruption.
• 15:32
  It puts you in a position to actually be empowered to frame up.
• 15:36
  Is this a situation where someone has actually paid been paid a quarter of a million dollars to do critical research and they are really in a position to be an expert and they published on it.
• 15:45
  They they've not been accused or convicted of any form of misconduct, but they're really credible experts.
• 15:51
  Or whether you're just being influenced by some sham AI generated good looking.
• 15:59
  doctor in a white jacket, what looks like a good looking doctor in a white jacket and a stethoscope that gets no use.
• 16:07
  I mean, there's a, that's just being a shill for a particular marketer.
• 16:14
  I think it empowers patients, it empowers doctors, and it gives back the power of an honest conversation because these are...
• 16:25
  These are tricky issues.
• 16:26
  We want doctors to be involved in research.
• 16:28
  We want them to be advocates for the care and the devices and the drugs that they believe in.
• 16:38
  But I think that it's super important.
• 16:40
  And the flip side is that I think we're blind and disempowered if we don't have that disclosure.
• 16:46
  I think transparency is a good idea, John.
• 16:48
  I like it.
• 16:49
  And it does give an opportunity to look up your own physician or people that you're considering working with.
• 16:56
  So it does provide that opportunity.
• 16:58
  There's some, I think, policymakers who put too much of an emphasis on what transparency is going to do.
• 17:04
  And if you just disclose things or make people disclose it, including beyond payments from pharma, but also things like disclosing prices and other contractual agreements, they think that that's then the free market is going to take care of everything from there.
• 17:20
  And I think it's limited.
• 17:22
  It's important.
• 17:23
  I like to have it.
• 17:24
  but the impact is actually fairly limited.
• 17:27
  But it's a start, David.
• 17:28
  I mean, let's start with being honest and transparent, even if there are certain situations where we have to put up even bigger guardrails.
• 17:37
  And I think that there is a, sometimes doctors honestly have been pilloried for really important critical work that they're doing at the edge just because they happen to be paid by the people with the resources to support that research.
• 17:49
  But more often than not, we are one tick, behind as patients the undue influence of marketing over real progress and research.
• 18:03
  Good.
• 18:04
  Well, we wouldn't want to do any care talking under the influence.
• 18:07
  So with that, we'll say that's it for yet another episode of Care Talk.
• 18:10
  We've been talking today about transparency, tweeting, X -ing, and so on.
• 18:16
  I'm David Williams, president of Health Business Group.
• 18:18
  And I'm John Driscoll, senior advisor at Walgreens.
• 18:20
  If you liked what you heard or you didn't, we'd really love to hear from you.
• 18:23
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