. . .But is that enough?

Merck recently published a list of payments made to doctors who speak or consult about its medicines. Eli Lilly & Co.'s list was published in July. GlaxoSmithKline says it, too, has one, although we have to wait to get it. In the meantime, here is GSK's statement about marketing practices, including the $150,000 cap it will pay physician-consultants to talk about their products. All are part of an agreement with the justice department.

Deconstructing disclosures
Campaigns for transparency have brought about disclosures and these lists are the first step. But what do we do with them? Is disclosure of doctor-industry relationships like the fine print on a credit card agreement, or the tedious contract for renting a car? Lots of information, but who bothers to read it?

There are several ways to parse the information that companies such as Lilly or Merck are making available as a result of agreements to settle law suits, public pressure, or Congressional investigations. Lilly's list includes the names of itinerant physicians who have been paid up front to educate other doctors and advise the company about their drugs. What do we learn about the 3,971 (mostly) physicians who have repped for the company not in the manner of a traditional sales force but cast as educators, consultants and advisors?

For the first six months of 2009, according to Lilly spokesperson Carole Puls, these physicians averaged $11,231 for 12 engagements, or roughly $900 per event. Lilly spent a total of $44.5 million. In broad strokes, just for the first three months of the year, The Boston Globe calculated that Lilly "paid at least 60 doctors in Massachusetts" more than half-a-million dollars.

Top of the list for the number of presentations, (not the top earner) was Dr. Robert Busch, an endocrinologist in Albany, New York, who lectured 164 times, more than one talk a day for a five-day week. His company, Brilor, was paid $74,950.

Psychiatry
All aspects of medicine are involved, but psychiatrists, and mental health advocacy organizations, have come under klieg lights as disclosures about new drugs, and new diagnosis, go hand in hand. Why psychiatry? The reasons are many: It's a field with a surge of new drugs. After decades of relying on a few medicines with inconsistent results, in the 1990s the industry filled a gap, often at the urging of desperate families or skilled clinicians wanting better treatment choices. Treating mental illnesses as fundamentally biological disorders is relatively new to medicine, and poly-pharmacy - mixing drugs to achieve specific outcomes - can be subjective with guidelines open to individual interpretation. The profitably of these drugs has already put them at the top of the earnings profile.

Even if the majority of psychiatrists do not rep for pharma, they appear in disproportionate numbers on various lists. In states like Vermont, which requires public reporting, psychiatrists were the top recipients of industry cash and gifts in 2008.

A similar cluster appears on the Eli Lilly list. A review of the nearly 4,000 names finds psychiatrists in all areas of expertise -- general, child and adolescent, geriatric, forensic, mood disorders, anxiety disorders, or schizophrenia - and all types of practices, paid educational consultants. Eli Lilly's speakers come from individual offices, from groups made up of two or more, they are academics in nationally respected medical schools and research departments, where they teach, and train young psychiatrists in continuing medical education programs. In other words, there is no single niche.

The nation's 38,000 psychiatrists are only 5.4 percent of the 700,000 practicing doctors. But as a specialty, it dominates the upper brackets of paid speakers. Of the 26 doctors earning consultants fees ranging between $70,000 and $79,000, nearly one-quarter were psychiatrists. Six of the nine doctors earning $70,000-$71,000 were psychiatrists, as were three of the five paid by Lilly in the $73,000-$74,000 bracket.

Some consider repping for pharma a professional asset. Dr. Charles Shelton, of the Lexington Psychiatric Group, must. Named author of articles about anxiety disorders, Dr. Shelton's resume includes poster sessions at professional meetings where he speaks about the benefits of Wyeth's Venlafaxine XR (Effexor). For Eli Lilly, Dr. Shelton gave 40 talks and was paid $58,650. His resume identifies consulting for six additional drug companies with speaker bureaus as part of his qualifications as a psychiatrist. Dr. Christopher Douglas Bojrab (president and founder of the Indiana Health Group), was paid $68,300 for 42 events. Dr. Bojrab's resume lists similar work for 12 other companies. Dr. Craig Donnelly, faculty in child psychiatry at Dartmouth-Hitchcock's Medical School, received $52,000, of which $18,975 came from 19 seminars. He, too, has a pattern of similar work for at least six drug companies.

As a result of press and blog exposure of prominent academic psychiatrists at schools such as (Stanford, Emory, and Harvard, many have, or are now drafting, policies about industry-faculty relations. But how they are enforced is unclear. According to an email from Jason Aldous, spokesperson for the Dartmouth-Hitchcock Medical Center's policy, there is :

"Acceptance of Fees by Individuals for Professional Services to the Medical Industry", which includes pharmaceutical companies, but also medical devices and related equipment manufacturers as well. It specifies an upper limit of $30,000 or 10% of a person's salary. Exceptions can be made in consultation with the person's department chair.

A spokesperson for the psychiatry department declined to comment on the apparent discrepancy between policy and the Lilly registry, or even to confirm Dr. Donnelly's current appointment (which is listed on their web site).

What goes on in these educational settings, including grand rounds, courses at professional conferences, or continuing education programs that pharma spends billions of dollars underwriting. Dr. Daniel Carlat described what the process is like for the lunch seminars he provided for Wyeth before he became a whistleblower to alert the public. In an article in the New York Times, he describes what he assumed were luncheon seminars for primary-care physicians. Initially flattered, later Carlat winced to hear himself greeted as part of the "drug lunch" using hand-outs he prepared from Wyeth's materials. Later he realized his honest opinions were being monitored for adherence to marketing goals. Carlat terminated the relationship reaping handsome reimbursement, and now writes a blog about pharma's role in continuing medical education, research, and he has become one of the medicine's watchdogs for conflicts-of-interests.

Consequences
It is naïve and optimistic to think that current efforts to shine light on the process will cleanse it. Two measures to limit pharma were incorporated in the health reform bill passed by the House and are expected to become part of the Senate's bill. One measure includes provisions of Sen. Charles Grassley's Physician Sunshine Law that (S. 301).

"Requires any manufacturer of a covered drug, device, biological, or medical supply that makes a payment or another transfer of value to a physician, a physician medical practice, or a physician group practice to report annually, in electronic form, specified information on such transactions to the Secretary of Health and Human Services."

Commendable as they are, they should the viewed as the start, not the end of needed change.

Disclosure is essential for transparency, but why tolerate what we see? Simply stating it doesn't make it right. Perhaps the best way to inoculate the medical profession is to decontaminate the culture with prohibitions to restore trust and eliminate conflicts-of-interest. PharmedOut has asked NIH to do this in a letter signed by 100 physicians. That would truly become a mark of health reform.