On the Take: How America's Complicity with Big Business Can Endanger Your Health

Thirty years ago Dr. Kassirer was my chief when I was a medical house officer in Boston. (That will serve as my disclosure of possible conflict of interest although we have had little contact since that time.) He has been a wildly successful nephorlogist/researcher, clinician and teacher. As editor of the New England Journal of Medicine, he constantly expressed concerns over possible conflict of interest and its influence on published medical literature. This book is a highly researched and extensively documented look at conflicts of interest and potential conflicts of interest in the medical literature and other closely related areas of medicine. Sometimes there are situations where potential conflict of interest has little or no influence on our decision making. As amply documented in On the Take, there are other times when conflict of interest may impact our decision making to the detriment of our patients. This book examines when and how the harmless potential conflict of interest moves into the realm of a serious, even ethical, dilemma. Amazingly, these conflicts may extend beyond the published medical literature to consensus papers and clinical guidelines increasingly embraced by the government and major medical societies and these conflicts of interest may even intrude into organizations designed to protect the consumer like the FDA (Food and Drug Administration) and the CDC (Center for Disease Control). We as physicians minimize the extent to which potential conflicts of interest influence us in our medical practice - a view not widely shared by patients or government regulatory committees. Dr. Kassirer presents a number of suggestions to improve the situation. Some of these are already being implemented by major medical journals. Others will depend on the integrity of individual practitioners. This book should be a must-read for medical students - both those planning to do medical research and those who will use the medical research to guide their medical practices. Martin G. Kistin, M.D.

I rarely write reviews, but in this case feel obligated to point out what a tremendous service Dr. Kassirer has provided. As a physician, I have always been concerned about the influence of gifts and outright payments to doctors and researchers in promoting pharmaceuticals and other healthcare. However, I had no idea how extensive and pervasive it is. Dr. Kassirer has done an outstanding job in giving us a picture of the truth. This is a very well written book. I strongly recommend that all medical students and physicians read it, and suggest that everyone interested in healthcare do so. As a minor point: Dr. Kassirer does not address the same influence which is present in alternative and complementary medicine--whose practitioners often benefit from the negative press of scientific (allopathic) medicine. In fact, it is just as bad or even worse in those types of care. Finally, I must point out that I have never met Dr. Kassirer and have no financial inducement to write this :-) Paul Gahlinger, MD, PhD

Dr. Jerome Kassirer is the former editor of the New England Journal of Medicine and a physician-educator with impeccable credentials. He has written an insightful and illuminating analysis of how big business money has harmed physicians and the patients they serve. This volume is a must read for physicians who have experienced some of the events described in the book and for patients whose interactions with their physicians may have been influenced in ways that they couldn't have appreciated. Much of the book focuses on the activities of pharmaceutical companies that spend more than $30,000 per year on each U.S. physician to promote and market products. Physicians have been exposed to a variety of marketing tactics over a period of years. The resulting changes in physician behavior, e.g. conflicts of interest, erode the core of trust that binds physicians and their patients together. These conflicts of interest also taint the information physicians rely on to treat their patients. Dr Kassirer also focuses on medical journals, professional organizations, research organizations and prestigious federal agencies that have been coopted by the insidious influence of big business money. The book provides an analysis of how this problem has developed and makes specific suggestions on treatment. Although the writing is hard-hitting, it is balanced and fair. The problem is huge. This book may do just what Dr. Kassirer requests: initiate a sustained public outcry against inappropriate practices.

Fact-dense, well referenced, yet balanced in tone and easy to read, this book is the best exposé I have ever read on the financial conflicts of the medical profession caused by the efforts of Big Pharma, which for this review will include device and test manufacturers as well as drug makers. From pens and pads to cruises and fake consulting arrangements, Big Pharma has caused financial conflicts in many physicians and others "on the take". Many of the consulting deals are to give talks, ostensibly based on good medical science, that promote a product. Much of this is shown to occur at Continuing Medical Education courses sponsored by Big Pharma in which gifts are freely dispensed, reprints of journal articles favorable to products are handed out, and financial ties of the "consultants" giving talks are minimized or concealed. Academic researchers are tainted as well. By being encouraged by their universities to obtain grants with overhead from Big Pharma, they must do research that helps in product development. Agreements may delay, prevent or pollute the publication of results. When a product possibility from a government (usually NIH) grant is seen, federal legislation passed 20 years ago allows the researcher to patent discoveries, form a company, and do clinical trials on his own potential product. While this may have led to valuable results, the potential for bias at every step due to financial conflict is clearly laid out. Journals fare little better, even the prominent JAMA, NEJM and Annals of Internal Medicine. Papers that may have been ghost-written by Big Pharma on clinical trials with selectively favorable results are published [see Joel M. Kauffman, Bias in Recent Papers on Diets and Drugs in Peer-Reviewed Medical Journals, J. Am. Physicians & Surgeons, 9(1), 11-14 (2004)]. Editors and peer-reviewers may have ties to Big Pharma. Editorials and comments in medical journals may be written by authors with financial conflicts of interest. Revealing such conflicts is mostly on the honor system at present. Clinical guidelines for physicians are promulgated by committees whose members often have close ties to Big Pharma. The products included in formularies of HMOs, Medicare and other insurers, the only products that will be paid for, are influenced by Big Pharma, whose general lobbying efforts are already legendary. Dr. Kassirer gives many specific examples of financial conflicts. Far from quitting with the devastating description of how bad things are, he goes on to make specific suggestions for reform, while being very realistic about their success without federal action for certain conflicts. He lists many desirable changes, such as no gifts from Big Pharma at all, boycotting meetings sponsored by Big Pharma, disclosure mandated for all financial ties, and selection of journal editors, officers of medical societies and leaders of medical schools who have no financial conflicts. He did not seem to indicate the degree of influen

Dr. Kassirer, Distinguished Professor in Tufts University School of Medicine and former Editor-in-Chief of the prestigious New England Journal of Medicine, is a representative of the medical profession of another era which earned and retained our confidence and respect. His book is a call to the physicians today to resist the insidious effects of subtle and not-so-subtle conflicts of interest in accepting funding from the pharmaceutical industry. Scores of examples are documented of greed, venality, laziness and ignorance which have led physicians and professional organizations to compromise their integrity in the quest for financial support. As Executive Vice-President of the American Heart Association's New York City Affiliate for thirty years I personally watched this corrosive influence tempt and occasionally even subvert this once-proud organization into compromising its intellectual standards. Dr. Kassirer indicates that in the ten years since I retired, their resistance has weakened. The book is a must-read for physicians of conscience and a warning to consumers to be careful where they place their trust.