Is Your Endocrinologist Under the Influence of Drug Companies?

Conflicts of Interest With Drug Companies and Physicians

In almost two decades as a patient advocate, it’s no secret that I’ve made a few enemies when I’ve questioned whether the close relationship between drug companies and our doctors is in the best interest of thyroid patients.

I’ve written many articles that call attention to the influence that thyroid drug companies, and especially Synthroid -- the top-selling thyroid drug, and one of the most prescribed drugs in America, according to -- have had on thyroid doctors, their professional organizations, and even the doctors who run the various thyroid patient groups.

In 2007, I linked to the program for the 2007 Endocrine Society conference –- the conference was known as Endo 07 -- and mentioned that the conference was offering a number of thyroid-related educational sessions to endocrinologists. My blog post pointed out the apparent irony of one session, titled “Thyroid Hormone Therapy: Why Some Patients Are Unhappy," and the fact that it was sponsored by Abbott Laboratories, then the manufacturer of Synthroid. (They have since spun off a company, AbbVie, which is Synthroid's manufacturer.) The session was led by Dr. David Cooper, an endocrinologist who has had long-standing financial ties to Synthroid’s manufacturer.

Interestingly, this particular blog post drew fire not from Cooper, but rather, from University of Kentucky professor and physician Dr. Kenneth Ain, who was also a medical advisor to the Thyroid Cancer Survivors’ Association (ThyCa). Dr. Ain was leading a thyroid cancer session at Endo 07.

In an angry open letter to ThyCa’s online support group, Dr. Ain wrote about the post: “Her main interest is to slander endocrinologists and impugn their practices...” He suggested that I was “creating dissent and controversy regarding fictitious conspiracies between academic physicians and pharmaceutical companies.”

Perplexed at what prompted such a vehement response, I did a bit of digging, only to find that in addition to his medical practice and university duties, Dr. Ain had worked as a paid speaker for Abbott Laboratories. He was also a paid speaker for Genzyme, manufacturer of the drug Thyrogen, used in thyroid cancer treatment. Dr. Ain also performed research under paid contract to Celgene Corporation, manufacturer of a drug being tested for thyroid cancer treatment.

When I pointed out these potential conflicts of interest, Dr. Ain confirmed his financial ties but attempted to defend the relationships, writing: “ is NOT unethical for academic physicians and professional organizations to utilize funding from biotechnology and pharmaceutical companies for education and research, provided that they fully disclose this funding so that participants can see all...”

Dr. Ain’s comments raise an interesting question. Are doctors who have close financial ties to drug companies able to objectively gauge whether they are being influenced by those ties?

Are questionable ties between physicians and pharmaceutical companies fact -- or “fiction?” Does physician disclosure ensure that patients are getting a doctor who is not “under the influence” of pharmaceutical company marketing practices?

I decided to take a look at what the experts have to say.


In January 2006, the Journal of the American Medical Association (JAMA) released a seminal paper that explored the conflicts of interest created by pharmaceutical company influence on medical practice. Authored by academic physicians from Columbia and Harvard universities, the article revealed some startling figures about the extent of drug company marketing.

Approximately 90 percent of the $21 billion marketing budget of the pharmaceutical industry continues to be directed at physicians, despite a dramatic increase in direct-to-consumer advertising. In 2000, for example, the industry sponsored 314,000 events specifically for physicians. Moreover, industry contracted with many hundreds of physicians to serve on advisory boards or speakers bureaus. The purpose behind such industry contacts with physicians is unmistakable: drug companies are attempting to promote the use of their products.

Where was this money going? Typically, it was being spent on everything from the free pens and prescription pads handed out by drug representatives to doctors’ offices, to paid speaking opportunities for research doctors, to free continuing medical education, to lavish all-expense-paid vacations and entertainment.

But participating in these sorts of marketing practices increasingly came under fire. Dr. Marcia Angell, a senior lecturer in the Department of Social Medicine at Harvard Medical School, and former editor-in-chief of the New England Journal of Medicine, is an outspoken critic of the coziness between physicians and drug companies. Said Dr. Angell, in an article in the New York Review of Books:

Over the past two decades the pharmaceutical industry has moved very far from its original high purpose of discovering and producing useful new drugs. Now primarily a marketing machine to sell drugs of dubious benefit, this industry uses its wealth and power to co-opt every institution that might stand in its way, including the US Congress, the FDA, academic medical centers, and the medical profession itself....This is an industry that in some ways is like the Wizard of Oz -- still full of bluster but now being exposed as something far different from its image.

The fear that the federal government would enact restrictive legislation caused some drug companies to promise greater self-regulation of marketing practices, and some hospitals, universities and medical journals to call for full and better disclosure of these relationships by their physicians. But was that enough? No, said the JAMA authors, who argued for stringent guidelines limiting or even preventing most financial connections between physicians and makers of drugs and medical devices. They argued that physicians’ attempts at self-regulation of conflicts of interest, even if well-intentioned, are simply not effective.

They write:

Although physician groups, the manufacturers, and the federal government have instituted self-regulation of marketing, research in the psychology and social science of gift receipt and giving indicates that current controls will not satisfactorily protect the interests of patients. More stringent regulation is necessary, including the elimination or modification of common practices related to small gifts, pharmaceutical samples, continuing medical education, funds for physician travel, speakers bureaus, ghostwriting, and consulting and research contracts. We propose a policy under which academic medical centers would take the lead in eliminating the conflicts of interest that still characterize the relationship between physicians and the health care industry.

The JAMA authors described how many physicians seemed to believe two key -- but ultimately faulty -- assumptions: first, that small gifts or basic interactions don’t have significant influence on physician behavior, and second, that disclosure of financial conflicts is sufficient to satisfy the need to protect patients' interests.


Interestingly, the JAMA authors reported that the rate at which physicians prescribe a particular drug increases substantially after they see sales representatives, attend company-supported symposia, or accept samples of that drug. The writers cited evidence that doctors are no more immune than the general public to the psychology of gift-giving, in which one feels obligated to “give back.”

University of Pennsylvania researcher Dana Katz, writing in 2003 on the ethics of pharmaceutical industry gift-giving, found: "When a gift or gesture of any size is bestowed, it imposes on the recipient a sense of indebtedness. The obligation to directly reciprocate, whether or not the recipient is conscious of it, tends to influence behavior..Feelings of obligation are not related to the size of the initial gift or favor."

Dr. Ashley Wazana, in her January 2000 JAMA article titled “Physicians and the Pharmaceutical Industry: Is a Gift Ever Just a Gift?,” found that meetings with drug company representatives were frequently associated with requests by doctors to add those drugs to the hospital formulary, and changes in the doctors’ prescribing practices. Doctors who went to educational sessions sponsored by drug-companies preferentially highlighted the sponsor's drugs, compared to other continuing medical education (CME) programs.

And attending free educational sessions, accepting funding for travel or lodging for educational symposia were all associated with increased prescription rates of the sponsor's medication, and what Wazana refers to as “nonrational prescribing.”


One way that hospitals, universities and medical journals had tried to address the issue was by instituting policies requiring doctors to disclose these sorts of gifts, payments and financial ties with drug companies, including consulting, research funds, speaker’s bureau or speaking fees, honoraria, and travel reimbursements, among others.

The rationale of disclosure policies seemed to be the belief that in publicizing the relationship, patients, lecture attendees, or journal readers are alerted to a potential prejudice or bias, and problems are averted.

The issue of disclosure remained controversial, however. The JAMA study authors felt that there was little evidence to support the assumption that disclosure to patients was enough to resolve problems created by physicians' conflicts of interest. The authors wrote:

First, physicians differ in what they consider to be a conflict, which makes the disclosure of conflicts incomplete. Because declarations of conflict are usually unverified, their accuracy is uncertain. Second, recipients of information who are not experts in a particular field often find it impossible to identify a biased opinion that they read or hear about that subject. Third, disclosure may be used to ‘sanitize’ a problematic situation, suggesting that no ill effects will follow from the disclosed relationship. Rather than eliminate the conflict, it is easier to disclose it and then proceed as though it did not exist.

Dr. Jerome Groopman, author of the bestselling book How Doctors Think, agreed that disclosure was an easy out, and in reality, works against its purpose. Groopman writes: “...patients or readers may believe that disclosure frees the physician or scientist from potential bias associated with personal gain when in fact disclosure does no such thing.”

In his 2004 article, “Doctors and drug companies” in the New England Journal of Medicine, Dr. David Blumenthal explained why disclosure often doesn't work:

Physicians also tend to be confident that they themselves are invulnerable to any bias inherent in the educational content offered or supported by drug companies. A study of residents found that 61 percent believed that they were not influenced by the marketing efforts of pharmaceutical companies (although only 16 percent were equally confident about their colleagues)... Despite the confidence of physicians in their ability to resist efforts by drug companies to affect their behavior —- especially in ways that may serve company purposes rather than their own or those of their patients —- a substantial body of theoretical and empirical literature (as well as physicians' own concern about their colleagues) suggests that many physicians may be mistaken...

Blumenthal also found that physicians are subject to a powerful, unconscious "self-serving bias." He writes: “They have trouble seeing themselves as biased when the bias serves their needs or advances their own perceived interests.”


In the end, the groundbreaking JAMA article made a recommendation –- considered heresy by some doctors -- that in the best interests of patients, industry interactions must be controlled. They suggested eliminating or severely limiting the ability of drug and medical device makers to finance these items:

  • Gifts, ranging from small, low-value items such as pens, pads or mugs, to sports tickets and lavish vacations
  • Meals
  • Payment for attendance at lectures and conferences -- including online
  • Continuing Medical Education/CME programs for which physicians are not charged
  • Payment for time while attending meetings
  • Payment for travel to meetings
  • Scholarships to attend meetings
  • Payment for participation in speakers bureaus
  • Ghostwriting of articles for publication under the physician's byline
  • Pharmaceutical samples
  • Grants for research projects
  • Financial incentives to participate in clinical trials
  • Payment for consulting relationships


Several years later, the push for regulation and legislation won, Legislation was first introduced in 2007, and failed to pass. It was amended, and incorporated into the Affordable Care Act, and in 2010, the Physician Payments Sunshine Act (PPSA)--which is also called "section 6002 of the Affordable Care Act (ACA) of 2010"--was passed. This legislation requires medical product manufacturers to disclose any payments or disbursements of anything valuable to physicians or teaching hospitals. This information must be reported to the federal Centers for Medicare and Medicaid Services (CMS).  The legislation also requires manufacturers and other organizations to disclose physician ownership or investment interests in those companies. 

The data is published each year in an online searchable database, the CMS Open Payments Data Explorer

Under the legislation, any company that makes drugs, medical devices, and medical supplies must report payment or coverage of meals, travel reimbursement, and consulting fees.

These same companies also need to report any ownership or investment interests by physicians their family members 

Finally, any research payments need to be reported. 

The only exemptions are payments under $10 (unless individual payments exceed $100 a year), educational materials for patients, and product samples. The type and amount of samples given to physicians are, however, tracked and submitted. Payments made to subsidize accredited educational events that provide continuing medical education (CME) credits are also exempt, as long as the organization doesn't have authority to chose speakers for the event. 

You can learn more about it in this American Medical Association summary and this HealthAffairs briefing paper.


The Sunshine Act is clearly a step forward. But even with the Sunshine Act in place, you will still need to do your own "due diligence" in vetting your doctors. Most doctors will assure you that they are not influenced by their financial ties -- and, as the research shows, they may truly believe they are immune to influence -- but you can still get a sense of the extent to which your doctor is “under the influence” by doing some background research and asking questions.

Research - use the the CMS Open Payments Data Explorer to research your current or prospective doctors, and assess their financial relationships with medical manufacturers and drug companies.

Observe -- Is the doctor’s office filled with posters, prescription pads, pens, and brochures sponsored by drug companies? Do they push particular drugs, and offer you free samples? 

Ask -- Don’t hesitate to ask your doctor directly: “Do you have any financial relationships with the companies that make the drugs you are prescribing for me?” 

Read/Research -- If your doctor has been published in any medical journals, check the articles for disclosure statements or references to funding. If your doctor is affiliated with a university, search the university’s website for information on their latest research studies, grants, or trials, to see if you can determine who is funding them.

Advocate -- Find out more about No Free Lunch and its growing directory of doctors who pledge to accept no drug company freebies.

In the end, you may not be able to avoid endocrinologists who are “under the influence,” but being an informed, empowered thyroid patient will go a long way toward ensuring that you get the best possible care from your physician.


While the relationship between physicians and drug companies are now under closer scrutiny, there is no similar scrutiny for the relationship between drug companies, their legions of lobbyists and our state and federal legislators. The drug companies, medical manufacturers and their lobbyists still have virtually free rein to contribute to PACs and SuperPacs, finance junkets, meals, corporate jet flights, and other big-ticket items.  


Ain, Kenneth, MD. Faculty Disclosure, “Thyroid Cancer: Diagnosis and Clinical Management,” Online.

Ain, Kenneth. Miscellaneous posts to ThyCa support listserv. April 28-30, 2007.

Angell, Marcia, MD, “The Truth About the Drug Companies,” New York Review of Books, Volume 51, Number 12, July 15, 2004, .

Blumenthal, David M.D., M.P.P. “Doctors and drug companies.” New England Journal of Medicine, 2004;351:1885-1890, Online

Brennan, MD, MPH; Troyen A., et. al. “Health Industry Practices That Create Conflicts of Interest: A Policy Proposal for Academic Medical Centers,” Journal of the American Medical Association, 2006;295:429-433. Vol. 295 No. 4, January 25, 2006 Online.

Groopman, Jerome, MD, How Doctors Think, Houghton Mifflin Co., NY, 2007.

Katz, Dana, et. al. “All gifts large and small: toward an understanding of the ethics of pharmaceutical industry gift-giving.” American Journal of Bioethics, 2003;3:39-46., Top 300 Drugs by Prescriptions Dispensed Online

Saul, Stephanie, "Gimme an Rx! Cheerleaders Pep Up Drug Sales," New York Times. November 28, 2005, Online

Studdert DM, Mello MM, Brennan TA. “Financial conflict of interest in physician relationships with the pharmaceutical industry: self-regulation in the shadow of federal prosecution.” New England Journal of Medicine,” 2004;351:1891-1900.

Wazana, Ashley, MD “Physicians and the Pharmaceutical Industry: Is a Gift Ever Just a Gift?” Journal of the American Medical Association, 2000;283:373-380. Vol. 283 No. 3, January 19, 2000 Online

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