From Love and Other Drugs
Categories: Ethics
Formats: Articles

Groundhog Day

18 minutes

Question

Should whistleblowers be protected?

Becoming a Whistleblower can sound easy. Then comes the realization that you are putting your career on the line.

This is the final installment of a three part series about my adventures with the multinational pharmaceutical corporation Pfizer. In “Fool Me Once, Shame on You” I described how I got conned into serving as a “hired gun” promoting Pfizer’s efforts to get doctors to relax about prescribing deadly painkillers. In “Fool Me Twice, Shame on Me” I described how I was duped into joining the ranks of Pfizer’s target audience – health professionals who just love a free lunch. In the following article, I describe how my naïve efforts to right those wrongs helped me lose my job, and then get it back.

 

The Gathering Storm

It is April 1, 2009. I’m standing at the doorway to the Royal City Ballroom at the Delta Hotel and Conference Centre in the city of Guelph, Ontario. Despite the air-conditioned comfort of the facility, I’m sweating profusely. My shoulder is aching from the weight of a satchel stuffed with the literary equivalent of an IED – actually, a stack of posters and petitions. The room is bustling with the sound of over 200 people as they network before breakfast. I’m sweating not because my satchel is heavy from the weight of the posters, but because I’m just beginning to recognize that the only casualty of my actions will likely be me. It’s the morning of April Fools Day and instead of being amused I’m terrified. What was I thinking when I planned this fiasco?

 

It has been more than a year since this all started. During that time I have made a vain effort to complain about a Family Health Team Forum organized jointly by the private multinational pharmaceutical corporation Pfizer and the publicly funded Ministry of Health in Ontario. This was comprised of a carefully worded missive that explained all about drug marketing, professional education sessions, and conflicts of interest. I had hoped that my efforts to draw attention to the issues would result in the Ontario Ministry of Health withdrawing its support for this kind of event. Instead, it turned out my words fell on deaf ears. Just two months before I found myself standing in the doorway of the ballroom with my satchel, I had discovered that the executive director in one of my own FHT’s was organizing a second Forum.

 

I was thunderstruck. This was my boss and someone with whom I’d shared my views on the issue of drug manufacturers’ efforts to influence the prescribing practices of health professionals. She had seemed sympathetic to my perspective at the time. I had even sent her a copy of some constructive criticism of the event that I’d sent off to various government officials. Naively, I had assumed that the concerns I had raised had been quietly dealt with. Instead, a year later I learned that the same deceptive email invitations were distributed to allied health professionals working for FHT’s throughout southwestern Ontario. Once again, they were mailed under the letterhead of FHT executive directors along with the banner for the MOH, with nary a hint of the involvement of Pfizer, the pharmaceutical giant. In a fit of ethical overenthusiasm and with the self-confidence of David as he stepped into the arena with Goliath, I decided to mount a protest. But what could I do? My efforts to raise awareness in my local area had only succeeded in demonstrating that most people were unaware of the issues and had no interest in changing things. As for my bosses, it seemed that they were included amongst some of the key people organizing the event, so I could hardly count on them to support me.

 

I decided that the most powerful way to address the issue would be to provide some education for the participants attending the event. To accomplish this, I needed accurate information that was empirically based, clear and concise. I dusted off the research papers that I had unearthed following the previous year’s event when I had composed my initial complaint. Over the ensuing weeks, I developed a simple plan and spent most of my free time working on the project. I decided that to carry off my plan I would need to attend the event. However, rather than being a keen participant, I would be the lone protestor. Recalling the old adage that the pen is mightier than the sword, I crafted a single page Poster outlining the concerns about drug companies’ sponsorship of education events in health care and the research that had been conducted suggesting the potential harms to consumers. Attached was a petition offering participants the chance to protest the use of publicly funded educational events to help companies like Pfizer sell their products to health providers. It was titled “No Free Lunch”

 

Tempest in a Teapot

Someone brushes past me, then turns and extends his hand in greeting. Based on the research that I’ve done I know that he is the key account manager for Pfizer in this area. This means that he oversees the entire force of drug reps and handles the budget that pays for the perks they offer to health care providers. He also has managed to insert himself into the board of the Local Health Integration Network overseeing the distribution of public funds to pay for health services distributed over a large area covering several hundreds of thousand patients, and sits on the same committees as many of my bosses – the executive directors managing the staff and accounts for the various Family Health Teams that I work at. Although I’ve never actually met this fellow before, he seems to know who I am and warmly introduces himself. I’m slightly psyched out as I realize I’m not the only person who has been doing their homework. Now I am really nervous. Here I am with a satchel full of protest forms being greeted by the local rep for the company whom my protest is targeting. Could he possibly know what I am about to do? I try to be polite and hope he doesn’t notice how clammy my palms are as we shake hands. Fortunately, he is in a rush so I barely get a chance to congratulate him on the attendance for the event before he says goodbye. Relief momentarily washes over me as I watch him weave his way among the tables of participants to a small cluster of speakers gathered at the front of the Ballroom.

 

The relief is short-lived. I realize that with the speeches about to begin, it’s time to act or I will miss my opportunity. Little did I know how stressful it would be to stick my neck out in this way in the midst of my peers. My stomach is lurching and my heart is pounding in my chest. Is this what a panic attack feels like? I do my best to take some deep breaths in a vain effort to relax and then force my rubbery legs to help guide me to the nearest table, where a dozen people are enthusiastically talking and exchanging business cards. I awkwardly introduce myself and begin handing out my posters while I provide a brief explanation of my motive. People are initially curious, friendly, and polite – until they read the poster I’m handing out, at which point they fall silent and begin to fidget. I move from table to table repeating my message, and notice that as I progress the room is getting quieter.

 

The first sign that I may have gravely overstepped my boundaries comes when I arrive at a table full of physicians in business suits. This is an anomaly, as the mental health workers making up the audience are mostly women, and along with their male counterparts most are dressed casually. One of doctors glares at me. He is bristling with anger, having apparently had some forewarning of what I am up to. I notice that he can hardly contain himself as he introduces himself as one of the conference organizers. He mentions that he is faculty at a prominent university that is co-sponsoring the event. He does not need to explain to me that he is incensed over my actions. He reminds me that without the generous support of companies like Pfizer events like this would never happen. He reminds me that education is precious and valuable to professionals, and challenges me with a question: “How are we supposed to fund large and expensive conferences like this without the generous financial assistance of companies like Pfizer?” The implication is that without Pfizer these events could not take place. I store this notion for future reference and like any good psychologist, instead of reflecting his anger and defensiveness I reassure him that his efforts to organize the event are appreciated. He is too angry to respond, and instead tosses my poster across the table and turns away from me.

 

I hastily move on to distribute the last of my posters, then retreat to the side of the room and seat myself at an empty table as the opening speeches commence. A prominent civil servant with the Ontario Ministry of Health steps up to the lectern and heaps praise on the partnership between universities, the province, and Pfizer in organizing the event. As she is speaking three handsome men in suits saunter into the room and casually make their way over to my table. They sit down and flash me with broad smiles, then lean back in their chairs and make a pathetic effort to feign interest in the keynote speaker. I realize with a sinking feeling in my stomach that they are all Pfizer reps. It would appear that someone is worried that I might make a scene, and I’m not sure whether to feel flattered or concerned. I briefly imagine standing up and ranting about the dangers of “Big Pharma” as they drag me out of the room kicking and screaming. I can’t help but smile at the absurdity of the idea. The fact of the matter is that I’m just really anxious to come up with an excuse to leave. I shuffle through my papers, keenly aware that I’m being studiously avoided by everyone in the room as the networking resumes before the morning sessions commence.

 

The day drags on interminably. On several occasions I am taken aside and politely reprimanded for my actions by different executive directors of local Family Health Teams. They are unanimous in expressing their disapproval of my actions. Each has their own take on how my behavior has been rude and my expectations unreasonable. I am told by one that the Pfizer representatives at the conference are upset, and have held an emergency meeting to decide whether to withdraw from the event. As the day goes on I realize that my own executive director is ignoring me. My heart sinks. Though I don’t know it at the time, she has already been speaking with a ministry of health official who is not happy with my behavior.

 

Rather than mounting a successful protest of a just cause, I’m feeling like I’ve spoiled my best friend’s birthday party, and that everyone is anxious to see me leave. Worse yet, despite having successfully distributed over 150 letters and petitions, my satchel contains only two that have been signed and returned to me. That’s below even the worst predictions of chance alone. Am I just a voice in the wilderness or have I pushed my supporters into hiding their heads further into the sand?

 

I’m beginning to think that I’ve made one of the biggest mistakes of my career, and worse yet, made a public spectacle of it. Now the wheels are really turning in my head. I recall that my clinic is always worrying about funding its programs. My colleagues have been using quick screens for depression designed by Pfizer, who also “donates” manuals for our pain management program. All the doctors in my clinic enjoy regular drug lunches sponsored by an assortment of companies. Then there is my own position, funded by the Ministry of Health and under the budget of the local LHIN, who I have just accused of conspiring with the enemy. April 1st is drawing to a close, but contrary to my noble plans to poke the villain in the ribs, it would seem that I am the fool.

 

I leave early from the Forum. The Pfizer reps stop shadowing me as I walk out to the parking lot. My phone immediately buzzes with a message from my son who is checking in on me to find out how things went. I reply with a lame joke about being thrown in jail for my actions, and needing a loan from him to make bail. Judging from the emoticons I get in response, I realize he thinks I’m serious, and I end up having to calm him down. April Fools day is supposed to be over by now, but I can’t face the fact that things might just have become very serious.

 

The Retreat

It did not take long for the knives to come out once I returned home. The executive director at the FHT in my home community was deeply hurt by my actions. We had enjoyed a good working relationship until now. She pressed me to explain my decision to mount a protest without letting her know my plans. She described a recent conversation with the area manager for the Ministry of Health, and my heart sank even further. As all of our funding came from the Ministry, there were worries about fallout. Our clinic had just submitted an application for additional funding for some staff and programs. There were concerns that this was now in jeopardy. Some of my colleagues were less than amused. Things were rapidly spinning out of control.

 

I thought that things could not get much worse, but they did. As chief of medical staff my wife was required to report to the monthly meeting of the board of directors for our clinic the week after the conference. She came home from the meeting very upset. It seemed that my protest had been the main topic of discussion. Board members had been less than flattering in their assessment of my actions. Fear was expressed that the Family Health Team would see funding cut or even terminated entirely. This was no idle concern, as the teams were highly politicized and fresh. Anything seemed possible. Worse yet, a major faction on the board wanted my head on a platter. They had been working on a proposal for a new research centre in our community, and unbeknownst to me Pfizer was already involved in supporting the venture with grants and resources. Apparently the funding was now at risk of being pulled. My wife was furious. At first I thought she was angry with me over my actions, but as we discussed the situation it became apparent that she was upset that the board would ignore the facts of the case and show the very behavior that my protest was designed to draw attention to.

 

My next meeting with my boss at the clinic dashed any hopes that I had of rescuing the situation. I learned that while the chair of the board supported me, the majority of its members remained upset and worried. I was being asked to write a letter reassuring the ministry of health and LHIN that my actions did not represent the philosophy of our team, and that I acted independently and without their approval. I was to apologize for my actions. Pfizer was also “deeply hurt”, but recognized that my behavior reflected my own “bad judgment”. They were to be sent a copy of my letter of apology. I left the meeting feeling a mix of humiliation and anger. When I arrived home I was dealt the final blow. My inbox contained letter from one of the Forum participants who had signed my petition, asking that I please remove her name from my list. She explained that she was worried about losing her job, as her clinic had regular drug lunches and her executive director enjoyed close ties with the drug reps in her area. That left only 1 out of close to 200 people at the Forum who were willing to publicly support my concerns.

 

Within the next couple of days I composed a terse letter absolving everyone of any responsibility for my views. I then spent a day writing a letter of resignation from my team. It was the modern equivalent of the Roman falling on his sword, save that the effect was bloodless and I got to attend my own funeral. Over the ensuing weeks I negotiated the termination of my contract and began the task of breaking the news to my clients. All of concern with “Big Pharma” and the politics of health care were forgotten by this point. My boss was torn between her feelings of hurt and betrayal and concern that she was losing a valued colleague and friend. I was simply bummed out to be walking away from my dream job, and nursing my wounds over the public nature of the debacle. Any dreams about being a heroic whistleblower were buried by now, and I was just glad not to have been tarred and feathered before being chased out of my home town.

 

The Fallout

In hindsight, I’m still proud of myself for making the effort to bring attention to a serious problem in health care, despite the small scale of my actions and its apparent failure to accomplish anything but make me appear to be the bad guy. My resignation did not create unusual hardship in my life, as I was overworked at the time and had plenty of contracts to keep me busy over the ensuing year. In the meantime my ex-boss worked behind the scenes to bring in new conflict of interest policies at my former workplace. Upset over losing their primary mental health clinician, the medical staff at the clinic voted to put in a symbol of support for me by putting an end to drug lunches. As news began to hit the press (1) (2) about the large class action lawsuit over Pfizer’s criminal behavior in promoting some of its products, the Family Health Team’s board of directors reopened their debate about what had happened and began to review their policies. Though it took several months to transpire, several key members who had pressed for my ousting were so upset by the changes being contemplated that they resigned. My contract had been left unfilled for the year, so when my boss explained the many positive changes that had taken place since my departure and asked for me to reapply for the position, I happily agreed.

 

As for the larger powers to be in this process, I’m happy to say that despite the fact that my protest likely had nothing to do with it, all traces of Pfizer’s remarkable pact with the Ministry of Health vanished. In fact, there would never be any further mention of the FHT forums. In the meantime my local therapist-networking group decided to take on the challenge of providing some continuing education among our peers, and we spearheaded a new event. From the start, it was stipulated that we would be self-funding and the speakers at the event would all volunteer their time and service. The first FHT Networking event was a resounding success, and has become an annual occurrence.

 

I’d like to say that my actions were responsible for some very significant changes in the relationship between big pharmaceutical corporations and those who are trusted to provide health care in our communities. Like Phil in the classic comedy film Groundhog Day, I lived and relived the same old script of my life until I finally got it right. Only instead of getting the girl like Phil did, in my dance with pharmaceutical manufacturers over the years I managed to find my principles and stick to them. Fortunately, in the bigger picture of the world many people have been lobbying to address this problem and over the years have managed to achieve limited success towards their goals. In many jurisdictions, there are now clear policies in place to limit the extent to which companies can buy influence over doctor’s prescribing practices. Prominent journals have begun to demand that authors disclose any conflicts of interest, and any respectable review article or meta-analysis of past studies is careful to identify results tainted by drug company sponsorship of any sort. Over the same period of time, companies have won the right to market their products directly to consumers, and have been granted broader protections for their patents. While they boast about their commitment to research, on the whole they devote the majority of their investment into marketing efforts. Furthermore, efforts to get doctors to prescribe drugs “off label” continue, even when the research support is weak and the risks of harm are well known (see my article on ketamine for more on this). The truth of the matter is that while modern medicine and psychiatry cannot survive without good pharmacotherapy, we can’t benefit from it without good oversight and careful regulation of the industry. My own experience suggests that this is much easier said than done. As the great American satirist Mark Twain once said, “How easy it is to make people believe a lie, and how hard it is to undo that work again!” (3).

References

1

Harris, G. (2009) Pfizer Pays $2.3 Billion to Settle Marketing Case. New York Times. Sept. 2

2

The United States Department of Justice (2009). Justice Department Announces Largest Health Care Fraud Settlement in its History.

3

Autobiography of Mark Twain, Volume 2 (2013) University of California Press

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