The Pen Is Mightier Than the Scold

Pharma journalist Matt Herper, who’s generally quite savvy about these issues, argues on his Forbes blog that little things like free meals and modest speaking fees don’t really influence doctors. He says that as a journalist he avoids quoting physicians who receive tens or hundreds of thousand of dollars from industry, but small payments don’t bother him. Pharma may no longer give out free pens like in the old days but marketing will never go away. Get over it and get used to it, he argues.

But I think he misses an important point here. For many people, small things like pens or meals are a litmus test: if you’re against them then you’re an acidic pharamscold, wasting your time on the most trivial of matters; if you’re ok with them then you’re a base defender of industry.

Admittedly, there is something silly about the whole pen discussion. I certainly don’t believe that any decent doctor is going to change his or her prescribing practices because of one free pen. And that’s often the way the discussion gets framed. Doctors say that they are insulted by these sort of accusations.

But let’s face it, pens are just the entry-level drug in industry’s armamentarium, the first step of the slippery slope.

There are key chains, hotel key cards, bus head rests, free meals, journal ads, promotional talks, and websites. There are advisory panels and public relations campaigns and publication programs. And then there’s financial support for CME programs, academic medical organizations, and patient and disease advocacy groups. All these activities, and many more I haven’t mentioned, have a cumulative and nearly overwhelming effect.

Let’s ignore for a moment the studies that have demonstrated the potent effects of advertising and marketing, even in sophisticated populations like doctors. Let’s also forget that it is nearly impossible for any individual to detect the unconscious influence of advertising and marketing on his or her own thought process.

Because here’s the question I want to ask those people who blithely dismiss the free pen issue: if the pens and meals really are worthless and have no effect, then why spend so much time and effort defending them? In other words, if the best argument in defense of these things is that they simply have no effect, why even try to justify them? If only to avoid the appearance of conflict, why not get rid of such a potent symbol?


  1. Try to find a pen now to sign an EKG or script pad when E-scribing is down in my highly electronic office these days and I’ll show you why pens from pharma are still defended.

    Just sayin’

  2. Larry,

    This opinion, your’s that is, and Charlie Ornstein’s, are important. No one can deny the (negative) influence of industry. The Multaq debacle is case in point. But the thing that’s so much less discussed in the intellectual community is the other side of the coin. As a fellow (20 years ago), Medtronic flew me up to Minneapolis, put me up in a nice hotel, and even fed me unlimited M and M’s while in class. Sounds terrible, I know, but the thing is I learned a ton about pacemakers in those two days. Of course they showed me their technology, but the bottom line is most pacemakers are about the same–and good doctors know this.

    What’s more, it really rankles me that Dr Relman shoots down the Aristotle trial because it’s industry sponsored. Who does he think is going to sponsor drug trials?

    Some might even argue that his argument opposing the trial is trivial. Dr Relman makes a huge deal of the fact that the authors did not discuss one subgroup (the Euro cohort), nor did they point out that warfarin dosing was off in 1/3 of the patients. Since when is cherry-picking one subgroup allowed? And I’m not sure about in Cambridge, but here in the east end of Louisville, 65% in range with warfarin is pretty good. Is he really touting warfarin? Or worse: that developing novel new blood-thinners that compete with rat poison lies at the crux of our healthcare crisis?

    Regular doctors on the front lines deserve more credit than we get. We can see that apixaban reduced the number of strokes, lowered the risk of catastrophic bleeding in the head, and even reduced mortality–all without having to limit salad intake or check INRs. These endpoints seem hard to fudge.

    I like the debate. But I miss the pens. Some of them allowed me to right so boldly in charts, like John Hancock did. Now I have to pan-handle for low-end bics.

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