Monday, November 09, 2009

Paging (and Paying) "Dr Coca-Cola"

A few weeks ago, the Los Angeles Times Booster Shots blog announced that "Dr. Coca-Cola will see you now," noting opposition to the recently revealed alliance between the Coca-Cola Company and the American Academy of Family Physicians:
[in] a sharply worded letter sent Wednesday to Dr. Douglas E. Henley, the academy’s chief executive.

'We urge the AAFP to regain its credibility by rejecting the deal with Coca-Cola,' the letter stated. 'If the AAFP declines to do that, we urge your organization to reassert its support for the public health (and its own independence) by supporting a warning label on caloric sugar-sweetened beverages and a federal tax on soft drinks to support health promotion or health insurance programs.'

The letter was signed by 22 doctors, nutritionists and health advocates,

Dr Henley was not moved:
Henley told Food that the academy was aware of the letter. But he stood by the partnership with Coke.

'We will move forward with this commitment together by providing educational materials on sweeteners and how to maintain a healthy, active lifestyle while still enjoying many of the foods and beverages consumers love,' he said in a statement.

Nonetheless, criticism of the deal has continued. A Kansas City Star editorial said:
the Leawood-based American Academy of Family Physicians has set a poor example when it comes to resisting the lure of the soft drink industry.

The academy has accepted a grant from Coca-Cola, reportedly in the neighborhood of $500,000. It will use the money for educational materials about drinks and sweeteners for its consumer Web site, Leftover funds will go into the academy’s general budget.

In return, Coca-Cola gets what? Legitimacy, for one thing. Consumers are less likely to consider a product unhealthy if it’s listed as a partner with a leading physicians’ alliance.

In a more shameful scenario, the soft drink manufacturer would succeed in muting the message that the academy puts out to its consumers.

The editorial did not buy Dr Henley's assurances:
Academy leaders say they won’t allow the hefty corporate grant to compromise the organization’s integrity.

'We have total editorial control, as we always have, of,' said Executive Vice President Douglas Henley.

Henley added, 'I would hope folks won’t rush to judgment but hold us to the content we’re going to put on'

But consumers accessing that information will soon be informed that information about soft drinks is being sponsored in part by Coca-Cola, 'a proud partner of'

That’s a mixed message, regardless of the content.

Meanwhile, family physician and AAFP member Dr Howard Brody noted on his Hooked: Ethics, Medicine and Pharma blog how AAFP leaders continued to obfuscate:
AAFP President Dr. Lori Heim: obesity is more complex and that 'there's no one evil out there.'

Why does the question of whether it's a good idea for AAFP to take money from Coke so quickly segue into the question of whether Coke is 'evil'? (For our blogger colleague who likes logical fallacies, Roy Poses, this sounds like "straw man." [It sure does - Editor]) Why does it have to be: either they are evil or else it's just fine for us to take their money? What cannot it simply be that they have different interests--they are trying to make a buck selling beverages (some of which I enjoy drinking myself, I am pleased to report, if they don't have calories in them) while AAFP is trying to protect the public interest through credible health education? What part of conflict of interest don't you understand?

Some AAFP members went beyond criticism, as reported by the AP:
Dr. William Walker, public health officer for Contra Costa County near San Francisco, likened the alliance with ads decades ago in which physicians said mild cigarettes are safe,

Walker has been a member of the academy for 25 years but quit last week. He said 20 other doctors who work with his local medical practice also quit because of the Coke deal.

Nonetheless, as Dr Brody later posted,
Sadly, if the responses to this news report from AAFP leadership are accurate, the AAFP still does not get it. '[AAFP CEO Dr. Douglas] Henley said the academy regrets the resignations and hopes other members will not 'rush to judgment' before seeing the new content." News flash: we don't need to see the content to know there's something rotten in Denmark. The deal itself raises concerns about the credibility of anything AAFP posts about diet and obesity from now on.

So here we have the latest variant on institutional conflicts of interest affecting medical associations. We have noted (e.g., here) how professional societies have blithely accepted substantial funding from corporations which sell products physicians may prescribe for or implant in patients. This raises concerns that professional societies have become drug and device marketers. This conflicts with physicians' prime directive, to put the interests of individual patients ahead of their own, and hence to base decisions on which drugs to prescribe, tests to order, and procedures to do on maximizing benefits and minimizing harms for individual patients, not maximizing financial gain for physicians, or their organizations.

Family physicians are a respected source not only of decisions about tests and treatments, but about diet. Having the main family physician organization humming "things go better with Coke" suggests that professional advice could be co-opted by marketing. As Dr Brody noted above, the issue is not whether the product is good or bad, but is whether physicians are giving each patient the best possible advice.

One question implied by the "Dr Coca-Cola" story is why the leadership of the AAFP seems so oblivious to the conflict of interest issues it raises.  As Dr Brody wrote:
What's even more depressing is that with the whole world telling them that they mishandled this affair, the AAFP still seems to think that the problem is someone else's.

I appreciate Dr Brody's depression, but note that this is not the first time that AAFP leadership has seemed tone deaf to the issue of the organization's institutional conflict of interest. In 2005, we posted how the AAFP had banned the "No Free Lunch" organization, which opposes most pharmaceutical marketing to physicians, from appearing in the exhibit hall of its annual meeting. The exhibit hall was otherwise populated by lavish exhibits by pharmaceutical and other health care corporation marketers.

The abstract for a 2006 article in Family Medicine [Standridge JB. Of doctor conventions and drug companies. Fam Med 2006; 38(7):518-20. Link here] began:
Pharmaceutical companies provide the majority of financial support for staging the American Academy of Family Physicians (AAFP) Annual Scientific Assembly. In return they are allowed to dominate the physical and mental environment.

The current web-site for the AAFP Foundation boasts of its corporate partners, which include many of the biggest pharmaceutical and biotechnology companies (at the "Pinnacle" level, Amgen, AstraZeneca, Lilly, Purdue Pharma.

So adding Coca-Cola to the list of corporate sponsors does not seem like such a big step.  In fact, being "Dr Coca-Cola" does not seem intrinsically more questionable than being "Dr Amgen," "Dr AstraZeneca," etc.

Nonetheless, one would think that the latest round of criticism would make the top leaders of this august professional society less comfortable about the organization's financial relationships with pharmaceutical, biotechnology, and now beverage corporations.  I fear, though, that they may live too much in the sort of bubble that now protects top executives of most large health care organizations to really question their corporate ties.  After all, according to the most recent (2007, covering 6/2007-5/2008) US Internal Revenue Service form 990 filed by the AAFP (via Guidestar), its leaders get sufficient compensation to put them into such a bubble.  For example, Dr "Coca-Cola" Hensley received $441,027 regular compensation and $108,930 in benefits and deferred compensation, compared with a median compensation for family physicians in 2008 reported as $159,000 from one survey.  Presumably "voluntary" officers got five- and six-figure "expense accounts and other allowances," maxing out at $195,648 for then President Dr James B King.  It may be hard for leaders who are so comfortably recompensed by the organization to become uncomfortable about the financial relationships that make the largesse they receive seem less of a burden for members who may not be so well-paid.  The leaders' comfort with the current arrangement, however, makes their organization more liable to be viewed as a drug, device, and now beverage marketer rather than a defender of physicians' professionalism.  Maybe the leaders should accept more austere compensation, perhaps similar to what working family doctors get paid, as the price they need to pay to remove questions about their organization's real commitment to professionalism.


insider said...

Surely it's Dr Pepper!

Red Sphynx said...

Don't worry. Years ago, I had a conversation with my family doc about low carb. After that, I tuned out whatever he had to say about carbohydrates, sugars and fats.

And that was long before Coca-Cola bought into AAFP. So I can confidently say that this will make no difference at all with my relationship with my doc.

Anonymous said...

I keep turning back to my undergraduate program so many decades ago. During the 1970’s there was a great push into behavioral science, and we in our business program were introduced to the ideas of group behavior, and how to modify this behavior to suit our desires.

In a class I have referenced often, taught by the sales manager of a drug wholesale, we discussed not only how to motivate sales people, but how to motivate our customer base. One concept covered in a number of classes was: everybody is doing it. Translated into business speak as: this is the way we do business.

What I have seen in the ensuing years is the adoption of pharma’s corporate culture into the practice of medicine. There is a subtle unspoken current of sales and marketing pervading front line medicine. In the past one of the first people young medical students will meet is a drug rep with a coffee mug and donuts. As they move forward in their training device companies become a part of the day to day background. Finally, they will be asked to join a specialty society and support the goals and sponsors of that society.

The end result is a mindset that is focused on selling products, not necessarily a specific product, but simply product. Doctors do more test “just to be sure.” “I need these test for defensive medicine purposes” is spoken by a doctor who has never been sued. The list goes on, but at there core these are sales tools.

My most recent doctor, nice guy, and I were discussing the web and the now very professionally written blogs. He short circuited the conversation with the statement that he got his information from drug reps and peer reviewed articles. This, I am sure, gave him in his mind professional cover for the large bags of Vytorin leaving the office and the staff gushing over a drug rep about the last gourmet lunch brought in for their benefit.

The AAFP leadership has only followed a pattern started decades ago. This is how we do business. This is how I justify how we do business. This is what a successful business does.

All driven and supported by a system put in place decades ago to sell product.

Steve Lucas

InformaticsMD said...


You should direct your doc to my post about how the practice of ghostwriting has contaminated the "peer reviewed" literature, thus making that literature potentially untrustworthy and "expert's knowledge" perhaps involuntarily defective.

Has Ghostwriting Infected The "Experts" With Tainted Knowledge, Creating Vectors for Further Spread and Mutation of the Scientific Knowledge Base?

As to my posting not itself being peer reviewed, well, the Soviet Union's publications on treatment of psychiatric illness (i.e., ofthose who disagreed with the regime) were "peer reviewed" as well.

Peer review is important, but it is not the sine qua non for truth nor transparency in today's incarnation. Critical thinking and logical consistency (perhaps I should ssy avoidance of logical fallacy) are another matter - they are timeless.

-- SS

Anonymous said...


Good point. One goal f a sales manager is to control what their salespeople read. You do not want to introduce any questions on their part into their presentations. Transferring this to the customer base your goal is to control both time and the material available to your customer. The easiest way to do this is to bury them in paper.

Translating this to the medical field we see doctors given “unpublished” reports with “additional” data. As you point out, ghostwritten by someone in the marketing department.

One of the many disappointments of my graduate program was the total lack of discussion of ethics, or responsibility, in my marketing class. The whole focus was on selling more product, needed or not. From this it is easy to see that a small change in “standards” creates a very large market potential for many drugs.

As you state: “Critical thinking and logical consistency (perhaps I should say avoidance of logical fallacy) are another matter - they are timeless.”

What I find frustrating is the lack of critical debate on the part of front line doctors about the medications they are prescribing to their patients. Instead we have this blind adherence to a belief that if it is in writing it must be true.

Steve Lucas