THE CHRONICLE REVIEW

The Secret Lives of Big Pharma’s‘Thought Leaders’

By Carl Elliott

SEPTEMBER 12, 2010

MICHAEL MORGENSTERN FOR THE CHRONICLE REVIEW

In the early 1970s, a group of medical researchers decided to study an unusual question. How

would a medical audience respond to a lecture that was completely devoid of content, yet

delivered with authority by a convincing phony? To find out, the authors hired a distinguished-

looking actor and gave him the name Dr. Myron L. Fox. They fabricated an impressive CV for

Dr. Fox and billed him as an expert in mathematics and human behavior. Finally, they provided

him with a fake lecture composed largely of impressive-sounding gibberish, and had him deliver

the lecture wearing a white coat to three medical audiences under the title “Mathematical Game

Theory as Applied to Physician Education.” At the end of the lecture, the audience members

filled out a questionnaire.

The responses were overwhelmingly positive. The audience members described Dr. Fox as

“extremely articulate” and “captivating.” One said he delivered “a very dramatic presentation.”

After one lecture, 90 percent of the audience members said they had found the lecture by Dr. Fox

“stimulating.” Over all, almost every member of every audience loved Dr. Fox’s lecture, despite

the fact that, as the authors write, it was delivered by an actor “programmed to teach

charismatically and nonsubstantively on a topic about which he knew nothing.”

It is tempting to imagine that the Dr. Fox study reveals a deep flaw in the structure of medicine

—for example, that health-care workers are too trusting of authority, or that Continuing Medical

Education (CME) lectures are a sham. But what the study actually reveals may be something

closer to the opposite. If medicine were simple and transparent, pretending to be a medical

expert would be very difficult. An audience could spot incompetence right away. Pretending to

be a medical expert is possible precisely because medical knowledge is so specialized and

opaque. These days an ordinary doctor can no more expect to understand the intricacies of

specialized medical research than the driveway mechanic who tinkered with his Volkswagen in

1962 can expect to fully understand the complex, computerized automobiles on the road today.

Those who have tried to sit through a medical lecture in a field other than their own will secretly

admit that they could have been fooled by Dr. Fox as well.

Since the 1950s, marketers have been taken with the idea that when it comes to spreading the

word about unfamiliar products or ideas, some people are far more important than others. The

phrase “opinion leader” was made familiar by the sociologists Paul Lazarsfeld and Elihu Katz in

their 1955 book, Personal Influence, where they used the term to explain the way that media

messages were filtered and spread by personal, face-to-face contact with influential people. It is

not hard to see why marketers liked this idea. Mass-media advertising can be expensive. What if

there were a way to avoid the masses and simply concentrate on the special people? Today the

pharmaceutical industry uses the terms “thought leader” or “key opinion leader"—KOL for short

—to refer to influential physicians, often academic researchers, who are especially effective at

transmitting messages to their peers. Pharmaceutical companies hire KOL’s to consult for them,

to give lectures, to conduct clinical trials, and occasionally to make presentations on their behalf

at regulatory meetings or hearings.

The KOL is a combination of celebrity spokesperson, neighborhood gossip, and the popular kid

in high school. KOL’s do not exactly endorse drugs, at least not in ways that are too obvious, but

their opinions can be used to market them—sometimes by word of mouth, but more often by

quasi-academic activities, such as grand-rounds lectures, sponsored symposia, or articles in

medical journals (which may be ghostwritten by hired medical writers). While pharmaceutical

companies seek out high-status KOL’s with impressive academic appointments, status is only

one determinant of a KOL’s influence. Just as important is the fact that a KOL is, at least in

theory, independent. Medical audiences trusted Dr. Fox partly because he played the part of an

expert so convincingly: white coat, gray hair, and a complicated lecture, delivered with authority.

But they also trusted him because they had no reason not to trust him. Dr. Fox was not selling a

product or pitching an idea. The very implausibility of his charade is part of what made it so

persuasive. Dr. Fox appeared to be impartial.

It is not hard to see why pharmaceutical companies would like to have a Dr. Fox speaking on

their behalf. Most marketers would like to have a convincing, influential, and apparently

independent expert who will deliver the text that they give him. The more interesting question is:

Why do so many academic physicians want to be Dr. Fox?

“It strokes your narcissism,” says Erick Turner, a psychiatrist at the Oregon Health and Science

University. There is the money, of course, which is no small matter. Some high-level KOL’s

make more money consulting for the pharmaceutical industry than they get from their academic

institutions. But the real appeal of being a KOL is that of being acknowledged as important. That

feeling of importance comes not so much from the pharmaceutical companies themselves, but

from associating with other academic luminaries that the companies have recruited. Academic

physicians talk about the experience of being a KOL the way others might talk about being

admitted to a selective fraternity or an exclusive New York dance club. No longer are you

standing outside the rope trying to catch the doorman’s eye, waiting hungrily to be admitted. You

are one of the chosen. “You get to hobnob with these mega-thought leaders and these aspiring

thought leaders,” Turner says. “They make you feel like you’re special.”

Turner is a former drug reviewer for the Food and Drug Administration. He worked at the FDA

for three years, after six years as a fellow at the National Institute of Mental Health. In 2003,

after taking an academic position at Oregon, he began giving talks on behalf of pharmaceutical

companies—Eli Lilly, AstraZeneca, and Bristol-Myers Squibb. “I left the FDA, and I felt kind of

frustrated that I had all this knowledge about how clinical trials work, and I felt there wasn’t

much of anything I could do with it,” he says. “It felt like a demotion going from bossing big

pharma around, where you tell them to jump and they ask how high, and then suddenly you are

way on the other end of the food chain. You’re begging to be a site investigator, and they say,

‘Nah, I don’t think so. You might have trouble recruiting,’ or ‘Your IRB is too slow.’”

Actually doing clinical trials for drug companies is often boring and mechanical, Turner says.

But if you are involved with the rollout of a company’s new drug, you are really in on the action.

“The first thing they do is ferry you to a really nice hotel. And sometimes they pick you up in a

limo, and you feel very important, and they have really, really good food. And they make you

sign a confidentiality agreement and say you need to sign this if you want to get paid.” The

meetings Turner attended featured what he calls the “mega-thought leaders,” the recognized

leaders in the field, who gave presentations to a group of people like him—the second-tier “little

thought leaders.” (“It was kind of like the farm team,” he says.) The companies will also offer

these aspiring thought leaders media training and advice on public speaking. “They give you

slides that you will probably be speaking from, and you’ll be in a room with about a dozen other

people,” Turner says. “You get up there, and you have your pointer, and then you stand off to the

side when you’re done. And the facilitator will say, ‘So what did you think of his voice? What

did you think of his body language? Did he project well?’”

It is an article of faith among pharmaceutical executives that KOL’s are a critical part of any

marketing plan. According to a 2004 study of the 15 largest pharmaceutical companies, the

industry spends just under a third of its total marketing expenditures on KOL’s. So important are

KOL’s that new businesses have emerged solely to recruit, train, and manage them. The reason

they are so important is their role in managing the discourse around a given product. Equal parts

scientific study, commercial hype, and academic buzz, this discourse will begin years before a

drug or device is brought onto the market, and will usually continue at least until the patent

expires. If a company can manage the discourse effectively, it can establish the desperate need

for its drug, spin clinical-trial results to its advantage, downplay the side effects of a drug,

neutralize its critics, and play up the drug’s off-label uses. (Drug companies are prohibited from

promoting a drug for conditions other than the ones for which the FDA has approved it, but

because these off-label uses are often highly profitable, many companies have found creative

ways of getting around the prohibition.) Virtually all physicians are on the receiving end of this

communication, but only a relatively few deliver it. If the industry can influence those few, then

it can also influence the rest.

Naturally, some lower-level pharmaceutical employees resent the KOL’s they are expected to

flatter and serve. A medical writer I spoke with compares thought leadership to a cult, or maybe

the priesthood. “At meetings they get big fancy badges, like generals with their medals,” he says.

Michael Oldani, an assistant professor of medical anthropology at the University of Wisconsin at

Whitewater, worked for nine years as a drug rep for Pfizer before beginning his academic career.

Once he flew in a surgeon KOL from Texas to talk about an antibiotic at a German restaurant in

Milwaukee. Unfortunately, the restaurant seated them in the basement, which was sweltering

hot. “It’s a sweat pit down there!” Oldani said to the manager, but there was no other place for

them to go. The evening was a disaster. “A lady passed out into her strudel, face down,” says

Oldani. “And it’s an emergency, with an ambulance, and picture me: I’m like, ‘Christ, just throw

some water on her and get her outside! She’s ruining this program!’” The surgeon’s talk was

fragmented and disorganized, and when it finally ended, at 10 p.m., Oldani was ready to go

home and sleep. But to Oldani’s astonishment, the surgeon was not finished. “He tells me he

needs some kind of alcohol to clean his mouse pad. And I’m like, ‘Really? I was just going to

drop you off.’ We drove around town for like an hour and a half until we finally found an all-

night Walgreen’s.”

Perhaps the most remarkable recent exchange with a KOL emerged in an investigation of Joseph

Biederman, a child psychiatrist at Harvard University. In a lawsuit against Johnson & Johnson,

Biederman was accused of promising positive research results to the company in exchange for

funding. A hint of Biederman’s self-opinion emerged in a deposition, where a lawyer asked him

about his academic ranking.

Biederman: “To move in the ranks from one rank, for example, at Harvard, there is instructor,

from instructor you move to assistant professor, from assistant professor you move to associate

professor, from associate professor you move to full professor.”

Lawyer: “Full professor?”

Biederman: “Mm-hmm.”

Lawyer: “What rank are you?”

Biederman: “Full professor.”

Lawyer: “What’s after that?”

Biederman: “God.”

Lawyer: “Did you say God?”

Biederman: “Yeah.”

The status of being a KOL carries a certain irony. It is a hunger for status that motivates many

academic physicians to work for industry, yet in order to preserve their status, those physicians

must also cultivate the perception of independence. If Dr. Fox were unmasked as an actor,

merely reading his lines, nobody would pay any attention. And of course, most academics do not

especially like to think of themselves as figures like Dr. Fox. As Erick Turner asks, “Is it worth

it, feeling like you are a robot, just speaking from a prefab slide set?”

For the past several years, Sen. Charles E. Grassley of Iowa, the ranking minority member of the

Senate Finance Committee, has made it his mission to investigate and expose the conflicts of

interest generated when KOL’s work for the pharmaceutical and medical-device industries. His

investigations have targeted prominent academic physicians at Harvard, Stanford, Emory,

Wisconsin, and Minnesota, among other universities. Last year, in a little-noticed section of the

health-care-reform legislation, Congress passed the Physician Payments Sunshine Act, which

will require drug and device companies to disclose payments to doctors and teaching hospitals to

the Department of Health and Human Services. Disclosure of conflicts is widely seen as a “win-

win” solution to the KOL problem. Doctors get to keep accepting industry money; the drug

companies get to keep giving it; and anyone else who might be affected can be reassured by the

knowledge that the transactions are no longer secret.

Mere disclosure is unlikely to fix the problem, however. Minnesota, where some of the most

egregious offenses have occurred, has had a similar “sunshine law” since the mid-90s, to little

effect. What is more, empirical research in psychology suggests that, contrary to conventional

wisdom, people who disclose their conflicts of interest make judgments that are more biased, not

less. If the aim of disclosure is to shame KOL’s into giving up their industry relationships, it is

based on a faulty premise; the most prominent KOL’s often announce their industry relationships

with something close to pride. And why shouldn’t they? If the very reason scholars work with

industry is the status confirmed by the relationship, then asking KOL’s to reveal their industry

ties is not much different from asking them to reveal their honors and prizes.

Universities could easily clean up the problem, simply by banning or capping industry payments

to faculty members, but that is unlikely to happen. Not just because academic physicians would

object, but also because many high-level university administrators have lucrative corporate

relationships of their own. (For instance, the president of the University of Michigan sits on the

Board of Directors of Johnson & Johnson, while the president of Brown University sat on the

boards of Pfizer and Goldman Sachs.) As universities have come to look more like businesses,

competing for funding and prestige in a consumer marketplace, industry relationships have

become a lucrative perk of many university jobs.

David Healy, a psychiatrist at Cardiff University, in Wales, and a prominent industry critic,

worked for many years as a KOL before his industry relationships began to go sour. Healy says

he was never impressed with the intellectual accomplishments of KOL’s: “If you look at the

opinion leaders, the guys in the field are not stellar geniuses. The field moves forward by virtue

of the fact that people cooperate. It’s not that anybody has a particularly brilliant insight, or that

these guys are really awfully bright, but the opinion leaders who work with pharma are actually

the least bright. These guys get made by industry. They get money, they get status, and they

knew they wouldn’t be anything if it weren’t for this.”

My brother Hal, a psychiatrist at Wake Forest University, used to work as a KOL for

GlaxoSmithKline. The event that drove him away from the business came one day when he was

giving a lunch lecture at a local primary-care clinic. To his irritation, none of the doctors in

attendance paid any attention to the lecture. They were answering pages, talking loudly with one

another, helping themselves to the lunch that Glaxo had brought in—anything, it seemed, to

avoid listening to him talk. Eventually Hal got so frustrated that he cut the lecture short. As he

was packing up his laptop to leave, however, the Glaxo rep asked him a favor. The director of

the clinic had been unable to attend the lecture. Would Hal mind sticking around a few more

minutes to say hello? Reluctantly, Hal agreed, and the rep took him to a small room adjoining

the clinic, where he said they would wait until the director appeared.

“There was a line on the floor,” Hal says. He had never seen such a thing before. “The rep told

me that we weren’t supposed to step past that line unless a doctor said it was okay.” They stood

behind the line, waiting patiently. After a few minutes, the director walked down the hall toward

them. “I sort of looked at him hoping to make eye contact and speak, but he wouldn’t even look

1255 23rd Street, N.W. Washington, D.C. 20037© 2020 The Chronicle of Higher Education

at us,” Hal says. “This rep just stood there with a big smile on his face, and the doctor stopped in

front of the treatment room five feet away from us, and stood there for several minutes reading a

chart. Then he walked away into the treatment room like we were not even there.”

Hal calls this his moment of understanding, after which he never gave another industry-funded

talk. Up to that point, he had imagined himself as a high-powered academic physician bringing

the latest university research to doctors out in the community. Standing next to the drug rep,

however, Hal understood how the community of doctors saw him. To them, Hal was a drug-

company shill. “I was literally standing in the drug-rep spot begging for a minute of this doctor’s

time, like a cocker spaniel begging for a leftover piece of meat from the table,” he says. It was

no wonder the doctors saw little difference between Hal and the rep. “It was like I had become a

psychiatric call boy,” he says. “I might as well have just said, ‘Hi, I’m Hal. The company sent

me to make sure you all have a good time.’”

If you have questions or concerns about this article, please email the editors or submit a letter

for publication.

OPINION