As a “thought leader” in gastroenterology, Dr. Brian K. Dieckgraefe has received some of the highest speaker fees paid by drugmakers to St. Louis area physicians in recent years.
Dieckgraefe — a physician scientist affiliated with Washington University — earned $150,500 in speaking fees from Pfizer Inc. in 2011 and $143,500 in speaking fees from Pfizer in 2010. He also received more than $15,000 from the drugmaker for travel and meals in those two years.
The payments, found in the nationwide ”Dollars for Docs” database compiled by ProPublica, an independent, nonprofit investigative news organization, are based on disclosures made by some of the nation’s leading pharmaceutical companies.
Hundreds of St. Louis area physicians are included in the database as having received payments from drugmakers.
Such fees underscore the generosity of “Big Pharma” in courting those doctors who speak on behalf of a drugmaker’s interests. The disclosures also include the dollar amounts of payments made to physicians for research, consulting, travel and meals.
It’s unclear why Pfizer placed such a high value on Dieckgraefe’s remarks in 2010 and 2011. In other years, he received smaller speaker fees from Pfizer: $10,000 in 2009 and $6,000 in 2012.
Dieckgraefe, an associate professor of medicine at Washington University and chief of gastroenterology at St. Louis Veterans Administration Medical Centers, declined to comment.
According to industry experts, pharmaceutical companies often hire trusted medical experts to inform other physicians of a new drug’s potential uses.
Those business ties, however, can raise red flags.
“Probably the most ethically problematic of all the activities you can do in the industry is be part of sending out the pharmaceutical industry’s message for hire,” said Art Caplan, who heads the Division of Medical Ethics at New York University’s Langone Medical Center.
“You don’t want to be hired to be a paid messenger for the industry,” he said. “It just creates a huge conflict of interest because they’re shaping the message. You’re promoting their product or service without giving a fully balanced presentation about other options, and they gain prestige from your prominence that has nothing to do with the product.”
Pfizer officials declined to discuss the company’s business ties to Dieckgraefe, whose areas of clinical interest are Crohn’s disease and inflammatory bowel disease. He has also written about colorectal cancer.
“Pfizer is committed to fairly compensating health-care professionals, clinical investigators and institutions for the work they do with Pfizer,” spokesman Dean Mastrojohn said in an email. “We continue to partner with physicians to educate peers about important safety and effectiveness information for our medicines and constantly evaluate our communication approaches to ensure that we meet the information needs of healthcare professionals and patients.”
Joni Westerhouse, a spokeswoman for Washington University School of Medicine, said in an email that Dieckgraefe had received payments from Pfizer in past years to give lectures to physicians “to increase awareness of adverse effects of nonsteroidal anti-inflammatory medicines (often used to treat arthritic pain) and potential strategies to reduce them.”
Pfizer drugs in this category include Celebrex, Ansaid, Arthrotec, Daypro, Feldene and non-prescription Advil.
“Though Pfizer drugs are rarely used in his practice, in situations where he did prescribe a Pfizer medication while receiving funding from the company, his financial relationship was fully disclosed to the patient,” Westerhouse wrote. “He also disclosed funding from Pfizer in compliance with the university’s conflict of interest policies.”
Academic medical centers such as Washington University generally allow their faculty to receive payments from drugmakers for providing advice on product design or for speaking about the use of drugs, devices, equipment or procedures.
Dr. Jim Crane, an associate vice chancellor for clinical affairs at Washington University School of Medicine, said the institution sought to maintain a balance in “academic-industry collaboration” with the aim of “bringing new medical discoveries to the bedside (while) maintaining professional integrity and preserving public trust.”
One of the goals, he said, is to ensure objectivity in medical decision-making.
“Our faculty who participate in this are sought out because of their subject matter expertise,” Crane said. “We don’t allow them to promote specific products. They are allowed to talk about certain medical conditions and procedures in a broad and balanced matter, but not to focus on a particular company’s product.”
He said it was important for these paid speakers “to give a fair and balanced assessment of therapeutic options that are based on scientific evidence. ... Our faculty have to have final editorial control over lecture content and materials.”
When asked if these lectures were promotional in nature, he responded: “We wouldn’t permit a faculty member to promote a specific product or to promote one drug over another drug.”
Asked whether the university was concerned that the acceptance of speaking fees from pharmaceutical companies might create an appearance of impropriety, he declined to comment.
Dieckgraefe is only one example of Big Pharma’s largess to St. Louis area physicians. Other top recipients of speaking fees include:
• Dr. John Lasala, a cardiologist at Barnes-Jewish Hospital, received $70,075 in speaker fees from Eli Lilly and Co. in 2012, and $73,800 in Lilly speaker fees in 2011.
• Dr. Gordon H. Robinson, a psychiatrist on the staff of Mercy Hospital St. Louis and a principal of Gateway Psychological Partners LLC, received $97,250 in speaker fees from Forest Laboratories in 2012.
• Dr. Gregory Mattingly, a psychiatrist and a principal of St. Charles Psychiatric Associates, in 2012 received $90,300 in speaker fees from Forest Laboratories and also $26,440 in speaker fees from Novartis International AG. Mattingly and members of his medical practice at CenterPointe Hospital also received a total of $190,150 in speaker fees from Eli Lilly in 2009 and 2010.
• Dr. Hari Thanigaraj Srihari, a cardiologist at SSM Heart Institute, received $98,250 in speaker fees from AstraZeneca plc in 2012 and $39,600 from the drugmaker in 2010. He joined SSM Health Care in December 2012.
“I am asked to do these programs because of my expertise in teaching and cardiovascular care, especially heart attacks,” Thanigaraj said in an email. “My goal is to improve patient care, and these programs provide me an opportunity to educate health care professionals about treatment options that can help improve the cardiovascular care of their patients.”
Mattingly and Robinson did not return phone calls requesting comment.
“The perception is that ‘Big Time Pharmaceutical’ is playing a heavy hand in getting a drug through,” said Lasala, who spends much of his time doing procedures in Barnes-Jewish Hospital’s catheterization lab. “But those things are very heavily scrutinized by the FDA, both in the pre-trial approvals, the trials themselves and what comes after.”
Lasala, who holds a Ph.D. in biochemistry, said he was retained in 2011 by Eli Lilly to speak about the drug Prasugrel (also called Effient), the first in its class of drugs to prevent strokes and heart attacks among patients who are undergoing a heart procedure called a percutaneous coronary intervention, or PCI.
Lasala was not a primary investigator of Prasugrel, whose clinical trials occurred locally and in other areas. He did not recruit patients for these trials, and does not normally prescribe drugs.
“As a university professor, my job is to train and educate (and) to take care of patients. ... The bottom line is, we do what’s best for our patients,” he said. “The data is what the data is. We’re not here to deceive or suggest that there’s something there that isn’t.”
Lasala said he gave about 25 lectures a year for Eli Lilly to physicians, nurses and physician assistants nationwide.
“There is a need for those who can’t get to meetings or can’t get on the Internet as easily to understand the data and what the significance of the data is,” he said. “It’s a relay of data, and describing what the options are. ... In general, physicians want to hear from other physicians.”
Lasala said he designed his lectures by choosing from Lilly’s pool of hundreds of slides approved by the Food and Drug Administration.
“It’s a restricted, FDA-approved set of slides that includes data from the (clinical) trial itself,” he said. “It’s non-commercial. It’s relatively narrow in scope — for informational purposes only.”
Forest Laboratories, for whom Robinson and Mattingly gave promotional talks, got into trouble in recent years via its Forest Pharmaceuticals subsidiary in Earth City.
In 2010, Forest Pharmaceuticals pleaded guilty to criminal charges that it illegally marketed certain antidepressants, including Lexapro, to children and adolescents even though that usage was not approved by the FDA.
It is unclear which Forest products, if any, Robinson and Mattingly — both psychiatrists — spoke about to other physicians during their lectures for Forest.
“Forest complies with all laws and regulations governing our company and industry regarding interactions with health care professionals,” Forest spokeswoman Mandy Kaufman said in an email. “This includes publicly disclosing information about payments and transfers of value to physicians.”
In conjunction with a “corporate integrity agreement” between Forest Laboratories and the U.S. Department of Health and Human Services, Forest has published a statement on its website regarding payments to doctors.
“Forest works hard to ensure that all aspects of our interactions with healthcare professionals, including the provision of payments or other transfers of value, are conducted with the highest legal and ethical standards, and solely for bona fide business and educational purposes,” the statement says.
According to Pfizer’s website, its speaker fees are for “expert led forums” — professional, peer-to-peer exchanges.
“Pfizer’s speakers are health care professionals who spend years building expertise in their fields,” the website says. “They work with us to help educate and inform their peers about areas such as the treatment uses, risks and benefits of our medicines; a specific health condition or disease state; (and) patient care and treatment options.”
According to Pfizer, its speakers present only content that is “grounded in science and free of any misleading information.” All of its sponsored lectures “must be consistent with FDA-approved product labeling and must fairly balance the benefit and risk information relating to any Pfizer product discussed.”
Pfizer speakers are paid according to their fair market value, which is based on the speaker’s qualifications and the time needed to provide the service, the website says.
Some physicians receive speaker fees from multiple drugmakers in the same year.
For example, Dr. George T. Griffing, a St. Louis endocrinologist, former professor of medicine at St. Louis University School of Medicine, and chief editor of a journal on internal medicine, earned a total of $57,500 in speaker fees from Novartis from 2010 through 2012, the latest year for which disclosures are available.
Griffing, who declined to comment, also earned $40,750 in speaker fees from AstraZeneca from 2010 through 2012; $9,099 in speaker fees from Eli Lilly from 2011 through 2012; and $1,500 in speaker fees from Glaxo in 2009.
Steve Rothenberg, a consultant at Numerof & Associates Inc., a Creve Coeur firm with expertise in health care, said drugmakers’ speaker fees were at times controversial.
“Questions arise. Doctors are highly educated and trained, but why is the company hiring them? Is it for an appropriate educational reason or is it to induce them to use their product?” he said. “This is a very regulated area.”
Even if the rules are followed, he said, such payments may raise eyebrows.
“Paying a doctor a large fee to give an hour talk obviously raises questions,” he said. “Sometimes it may be necessary. If the product is complicated, new or unique, then you may need a physician to speak about this product in an environment where they can provide an hour’s worth of education.”
But such fees can be “problematic for a number of reasons,” he said, “not the least of which is that doctors get paid a whole lot of money and their credibility and objectivity gets called into question.”
NYU’s Caplan said physicians’ business ties to drugmakers called for scrutiny. “Ethically, I think there can be legitimate academic-industry and physician-industry relationships,” he said, “but when your independence, your message and your objectivity come into question due to big paydays, that’s where the ethical problems begin.”
©2014 the St. Louis Post-Dispatch
Visit the St. Louis Post-Dispatch at www.stltoday.com
Distributed by MCT Information Services