Like thousands of physicians across the United States, Dr. Ajay Chaudhuri gets paid by

pharmaceutical companies to teach doctors and nurses about the latest medications to treat the

diseases in his field.

The $79,037 that the Buffalo specialist received from Eli Lilly & Co. to talk at 69 events

in the first three quarters of 2009 makes him one of the company's highest earners as a

speaker about its products.

Drug and medical device companies, as well as the doctors they pay to speak or consult,

consider the programs educational and the fees fair compensation for the physicians' time and

knowledge.

"I speak to people who are not in my specialty who need to know the risks and benefits, and

the appropriate use of new medications," said Chaudhuri, a specialist in diabetes.

But the fees have come under greater scrutiny, leading some pharmaceutical companies to

disclose the payments in recent months. The disclosures reflect growing concern over the

financial ties between doctors and industry — everything from gifts of branded pens to

free meals to corporate-funded continuing education to major research support.

There is mounting pressure to restrict, ban or bring out into the open questionable

industry practices among physicians, medical schools, journals and medical societies.

In December, for instance, Sen. Charles Grassley of Iowa, ranking Republican on the Senate

Finance Committee, asked 33 nonprofit medical groups that lobby government, including the

American Medical Association, for information on funding they receive from drug and medical

device corporations.

Among other signs of change:

The University at Buffalo School of Medicine and Biomedical Sciences, similar to

action taken or planned by other medical schools, has released a conflict-of-interest policy

on industry relations with teaching physicians and trainees.

Gov. David A. Paterson in January proposed a bill that would restrict pharmaceutical

companies from dispensing inappropriate gifts and misleading product information.

The health reform bills in Congress contain provisions to require reporting of

payments to doctors, as well as large industry investment interests held by doctors.

"We're seeing more transparency, but it's a first step. You need to use the information to

make improvements," said Susan Chimonas, a researcher at the Institute on Medicine as a

Profession at Columbia University.

Highest earners locally

A few companies — including

Lilly, GlaxoSmithKline, Merck and Cephalon — have begun to post on the Internet some of

the fees they pay doctors for consulting or speaking.

Among the highest earners in Buffalo were Dr. Romanth Waghmarae, an anesthesiologist who

specializes in pain management, who received $134,700 from Cephalon in 2009, according to the

manufacturer. He was one of nine doctors nationwide who received more than $130,000 in speaker

fees from Cephalon, whose products include treatments for pain and cancer.

Based on industry data for part of 2009, other local doctors here who earned high fees

included Dr. Sanjay Gupta, a psychiatrist, $70,650 from Lilly and $2,750 from GlaxoSmithKline;

Dr. Horacio Capote, a psychiatrist who specializes in imaging to study mental disorders,

$62,350 from Lilly and $9,250 from GlaxoSmithKline; and Dr. Adam Ashton, a psychiatrist,

$55,600 from Lilly and $4,500 from Cephalon.

Overall, the four drugmakers reported more than $900,000 in fees in part of 2009 to more

than 60 physicians in Western New York.

Physician-Pharma financial ties

Click on the name of a drug company to see the information that is available.

">Merck

GlaxoSmithKline

Eli Lilly

Cephalon

Congress is considering some restrictions. Click here to read more about the Physician Payments Sunshine Act.

The University at Buffalo has also released a new conflict-of-interest policy for its medical school. Click here to read it.

Chaudhuri said the speaking activities serve an important function: Doctors with expertise

educate other health care professionals about the benefits, side effects and appropriate use

of new medications.

Connections with industry have led to abuses, but such cases are exceptions, he said.

"All of us who speak have to be true to ourselves," he said. "You have to make your

presentations according to (Food and Drug Administration) regulations. You need to identify

who you are speaking for."

Waghmarae also downplayed the issue of conflicts, saying he speaks for some companies whose

products he doesn't use and refuses to speak about medications he doesn't believe in.

"The purpose is education. You are teaching people who use the products about new

medications and technology. If it was about money, I could make more seeing patients," he

said.

The other doctors declined to speak or did not return calls.

The scale of industry fees to doctors is eye-opening.

Targeting physicians

Lilly spent $62 million nationwide in

the first three-quarters of 2009 on 4,500 doctors the drugmaker refers to as "faculty." Nearly

$480,000 went to 30 doctors and two health-related groups in the Buffalo area, Buffalo Medical

Group and Health Research Inc. About 320 physicians or medical groups in the U.S. received

$50,000 or more.

GlaxoSmithKline paid 3,728 physicians and other health professionals in the United States

$14.6 million for speaking or consulting from April through June 2009, of which $190,000 went

to 31 doctors in the Buffalo area.

The largest amount in those three months, $99,375, went to a Boston, Mass., allergy and

asthma specialist.

Critics contend voluntary guidelines do little to offset the real and perceived conflicts

that arise from an industry that directs most of its annual marketing budget, estimated at

$57.5 million, at physicians.

They say the marketing raises questions about the independence of doctors' treatment

decisions, promotes the benefits of drugs while underplaying risks, and increases health care

costs by encouraging use of the newest, most expensive drugs.

High-profile cases have added to the concerns, including physicians failing to disclose

handsome industry contracts in research favorable to certain drugs, doctors signing medical

articles in journals ghostwritten by writers supplied by drug and medical device companies,

and physicians accepting huge payments that were not revealed to universities and hospitals

that employed them.

Studies show that even small gifts — everything from lunch to a golf outing —

matter by creating a sense of obligation and entitlement. To critics, speaking and consulting

may have an educational aspect, but another purpose is to boost sales.

"These are for-profit commercial organizations that exist to sell products. To ascribe to

them some sort of benevolence is wrong," said Eric Campbell, an associate professor at Harvard

Medical School who sat on a national panel that last year made recommendations to avoid

conflicts of interest.

Campbell and others also note that the industry disclosures are not entirely voluntary.

Cephalon and Lilly were required to reveal payments as part of multimillion-dollar legal

settlements over alleged off-label promotion of medications.

In addition, the drugmakers disclosed different fees over different time periods and did

not disclose all types of payments.

"We need standard reporting regulations," said Chimonas, the Columbia University

researcher.

Medical school policy

In prepared statements, industry officials described paid speakers as playing a key role in patient care.

"We've learned from experience that health care professionals often prefer to receive

information from Lilly about our products through their peers and professional colleagues,"

said John C. Lechleiter, chief executive officer of Lilly.

The concern over conflicts of interest is also forcing medical schools, such as UB's, to

examine relationships with drug and medical device makers.

A disturbing level of industry dependence exists at medical schools that threatens to

compromise medical education and research, critics say.

The industry routinely funds research projects. Its representatives have become fixtures

in schools with unfettered access, buying meals for physicians and medical students, making

promotional presentations to specialists-in-training, and providing lecturers from industry

speakers' bureaus.

Two national university organizations in 2008 called on all medical schools to devise

conflict-of-interest policies within the next two years and to refine their standards for

individual financial ties to industry.

UB had a unversitywide policy but not one solely for the medical school.

The new measures, in addition to requiring annual disclosure to the UB medical school of

conflicts worth $10,000 or more, call for physicians to reveal an industry relationship to

patients when recommending a product made by that manufacturer.

The policy also restricts faculty from using a university affiliation when speaking on

behalf of products and suggests doctors not rely on companies to write the material used in

the talks.

Allan Coukell, director of the Pew Prescription Project, gave UB's policy a mixed review,

mainly because the new regulations do not ban gifts.

"It's a step in the right direction, but there is no place for gifting in medical schools.

It doesn't have anything to do with patient care," he said.

Managing conflicts

The nonprofit Pew Prescription Project is pushing to eliminate physician conflicts of

interest.

Dr. Steven Dubovsky, head of a committee that drafted the policy, said UB sought to avoid

an extreme approach. The committee viewed industry collaboration as integral to medical

education and research, and marketing as an activity that should be controlled but allowed in

a free economy, he said.

Industry representatives now must schedule appointments instead of having unlimited access

to buildings, and support for educational activities must be in the form of unrestricted

grants to departments. The policy also calls for educating trainees about the influence of

promotional efforts.

"It made more sense to teach residents and students to recognize marketing," said Dubovsky,

UB's psychiatry chairman.

The university sought to balance the need for physicians to work with industry with

measures to assure the relationships are appropriate and transparent, said Dr. Michael Cain,

UB medical school dean.

The school's position reflects the view that industry ties have proven to be valuable in

the development of new treatments and aren't necessarily tainted.

"The thrust is to manage conflict of interest and not react as if you can turn it on or off

like a light switch," said Cain.