ST. LOUIS (KMOX) – The funneling of money between drug companies and doctors has blossomed into a nearly $1 billion industry, earning several physicians in the U.S. over one million dollars in the past several years. Locally, documents show hundreds of doctors have netted speaking fees, travel reimbursement, meals, and more.

Dr. Brian Dieckgraefe, a gastroenterologist, earned more than $331,000 for speaking on behalf of pharmaceutical giant Pfizer between 2009 and 2012. His colleague, fellow Washington University gastroenterologist Dr. Jeffrey Gordon, was paid $278,000 by the same company for consulting work. Between 2009 and 2010, another drug giant, Eli Lilly, paid Washington University cardiologist Dr. John Lasala $110,000, St. Louis psychiatrist Dr. Kevin Miller nearly $95,000, and Missouri Baptist ob-gyn Dr. David Weinstein $122,000 in speaking fees.

“There are a lot of laws that potentially apply and I’m sure the companies are very careful in knowing exactly what’s OK,” said Dr. Susan Chimonas, a research scholar at the Columbia University Center on Medicine as a Profession who has been studying ties between physicians and pharmaceutical companies for the past decade.

“When I started, it wasn’t really talked about. Everybody knew that it went on but people just didn’t really think about it or talk about it,” Chimonas said. That is changing, however, and reactions vary. “But I would say probably most physicians fall in that middle area where they feel like some of the arrangements make them feel uncomfortable and some of the arrangements are unethical and embarrassing but there are times when it’s beneficial for physicians and, therefore, for their patients.”

Renewed interest in the relationship between those who manufacture prescription drugs and those who prescribe them comes amid the release of new documents by New York-based journalism group ProPublica. The data was collected between 2009 and the first half of 2012 as changes to federal health care laws mandated the disclosure of such payouts. Still, only fifteen companies, representing 47 percent of the U.S. pharmaceutical market, have disclosed how much money they have paid physicians. As a result, the figures in this article could represent less than half of a physician’s yield.

Of the physicians who earned the most from drug companies, disproportionate amounts both in St. Louis and across the country are psychiatrists. It’s a trend that American Psychiatric Association head Dr. James H. Scully Jr. said “boggles the mind.” While noting the legality of the practice, Scully told ProPublica that “everybody needs to be clear — this is marketing.”

Locally, St. Louis psychiatrist Dr. Adam Sky made more than $343,000 total from four drug companies between 2009 and 2012. Dr. Rolando Larice, a Chesterfield psychiatrist, earned roughly $226,000 over that time span and psychiatrist Dr. Vadim Baram was paid a total of $225,000 by six companies.

At St. Charles Psychiatric Associates, documents show that founding partner Dr. Gregory Mattingly was paid nearly $400,000 from 2009 to 2012, including $143,000 in speaking fees from pharmaceutical Eli Lilly in 2009. Dr. Richard Anderson, Mattingly’s partner and SCPA’s co-founder, earned nearly $200,000 over the same span, all from Eli Lilly. Similarly, the geriatric psychiatrist team of Dr. Azfar Malik and Dr. Mohd Malik earned $180,000 and $161,000 respectively between 2009 and 2012 for speaking, travel, meals, and research.

‘Do what they’re told’

“They’re looking for someone with credibility among their peers,” Dr. Chimonas explained. Once the drug companies have recognized that credibility, a process begins. “The companies will train the physician. So, if you are selected to be on a company’s speaker’s bureau, you’ll be sent to speaker’s bureau school, more likely than not, and they will teach you exactly how to do what they want you to do.”

From there, physicians join the payroll, traveling, eating, and speaking on the company’s dime. “They’ll go to fairly nice restaurants and there will be a physician there who is an expert in the field who will deliver the presentation while everyone’s dining and then the company pays the physician who’s speaking and also picks up the tab for everyone,” Chimonas explained.

For some physicians, speaking on behalf of drug companies is a one-time event; for others, it is a multi-year partnership spanning several speaking engagements and hundreds of thousands of dollars. Regardless, Chimonas says, all doctors have a standard they must uphold.

“So, if you go to speaker bureau school and you’re selected to be on the speaker’s bureau and you are going along and doing what they want you to do but you start to feel like ‘you know, I’m not so sure about this product or this message’ and you start to challenge the company message then you’ll probably be dropped from the speaker’s bureau,” she explained. “So, they’re also looking for people who will, for lack of a better phrase, do what they’re told.”

In rare cases, Chimonas says, physicians will be asked to speak with other physicians individually and the company will pay both the speaker and listener.

Several top universities have taken steps in recent years to ban or limit their professors from accepting pharmaceutical payouts. In 2010, the Harvard Medical School issued a new conflict-of-interest policy that prohibited professors from speaking for drug companies or accepting gifts, travel, or meals. Earlier that year, Stanford went even further, banning pharmaceutical representatives from patient-care areas and prohibiting its faculty from using industry reps to ghostwrite articles. Stanford medical school dean Phillip Pizzo warned at the time that without the changes, “our reputation can be tarnished.”

In the case of Washington University in St. Louis, the School of Medicine first revised its conflict-of-interest guidelines in 2007. The policy prohibits doctors from using promotional items such as pens and magnets in clinical areas and says “meals, sporting event tickets, golf outings, gift baskets, travel, and any other free goods or services” should not be accepted from industry vendors.

The changes also ensure speakers “have final editorial discretion as to lecture content and materials.” As Chimonas explains, the move is an attempt to avoid instances in which pharmaceutical companies dictate what is said by the speakers.

“These are speaking arrangements where the companies pay the physician to speak and provide the presentation materials, the PowerPoint slides. Sometimes there will be a script,” she said. “The physician is really not contributing to the presentation; they’re really just delivering the company message.”

At the time of the change, four companies – Pfizer, Bristol-Myers Squib, AstraZeneca, and Sanofi-Aventis – refused to comply with Washington University’s new policy. Dr. James P. Crane, executive vice chancellor for clinical affairs in the School of Medicine, then advised his faculty to cut ties with the companies. Some of those companies later agreed to comply with the university’s requirements, according to Washington University School of Medicine spokesperson Joni Westerhouse.

KMOX News reached out to several physicians mentioned in this article for comment. Westerhouse explained that Dr. Jeffrey Gordon, mentioned above, does not see patients or prescribe drugs. Dr. Brian Dieckgraefe does prescribe drugs, including those made by Pfizer, but, according to Westerhouse, fully discloses to patients his financial ties to the company before doing so.

According to Chimonas, doctors who accept payments from pharmaceutical companies generally argue that their relationship does not constitute a conflict-of-interest or change the way they treat patients. “They would also say that what they’re doing is a good thing, that they’re educating other physicians about good products that are FDA approved,” she added.

The top earners

Aside from the dozen St. Louis-area physicians mentioned above, at least sixteen other local doctors were paid more than $100,000 from pharmaceutical companies between 2009 and the first half of 2012.

Dr. Anthony Guarino, an anesthesiologist and professor at Washington University, earned $216,401 directly and another $256,037 for Guarino Educational Services, Inc. by speaking and consulting on behalf of four companies. Guarino billed drug companies $35,369 in travel costs in 2010 alone.

Dr. Anthony Margherita, a physical medicine and rehabilitation physician in Creve Coeur and Washington University associate professor, earned himself and his company, TM Medical Solutions, $374,640, including over $47,000 in travel costs. $197,405 was paid by Eli Lilly.

Dr. Marin Kollef, a pulmonary and critical care physician in Manchester and Washington University professor, was paid $304,000 total by Merck and Pfizer.

Dr. David Alpers, a gastroenterologist and Washington University professor, was paid $284,584 in consulting fees by GlaxoSmithKline, an average of more than $71,000 annually.

Dr. Barry Singer, a neurologist at Missouri Baptist Medical Center, earned $272,993 total from Novartis and Pfizer.

Dr. Scott Arbaugh, a psychiatrist in O’Fallon, Missouri, earned roughly $200,000 total from Forest, Eli Lilly, and Pfizer.

Dr. Georgia Jones, a St. Louis psychiatrist, was paid more than $110,000 by Eli Lilly from 2009 to 2011 and nearly $60,000 by Merck between 2011 and 2012.

Dr. Mario Castro, a pulmonary and critical care physician and Washington University professor, received more than $160,000 total from four drug companies.

Dr. Steven Sorscher, an oncologist and Washington University professor, earned $158,000 from Eli Lilly for speaking, travel, and meals.

Dr. Bruce Bacon, a gastroenterologist and Saint Louis University professor, earned $143,456 between 2010 and 2012, $130,000 of which came from Merck.

Dr. David Holtzman, a Washington University neurologist, received nearly $141,000 from Pfizer between 2010 and 2012 for consulting, travel, and meals.

Dr. Andrey Shinyee Shaw, a Washington University pathologist and immunologist, was paid $137,500 by Pfizer for consulting work.

Dr. Gordon Robinson, a St. Louis-based psychologist, earned $115,638 from Forest.

Dr. John Mazuski, a surgeon and Washington University professor, earned more than $99,000 from Pfizer along with $14,350 from Merck.

Dr. Hari Thanigaraj Srihari, a cardiologist in Bridgeton, earned more than $110,000 in 2012, all from AstraZeneca.

Dr. Lawrence Gelb, an infectious disease specialist, received $102,526 from Merck.

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