Medical marketing

So, what if the solution came along?

Posted on August 1, 2011. Filed under: medical ethics, Medical marketing, Protandim, Self-deception |

Nothing here since January, 2009! Why? I’m reminded of the parents who had a child who never spoke. They took him to pediatricians, speech therapists, witch doctors: everyone they thought could help. Not a syllable came forth. They accepted that he was mute, and got on with it. One day at breakfast, when the child was six years old, he said, “This toast is burnt.” The parents almost collapsed, and with tears in her eyes, the mom said, “Johnny, you can talk!” The child responded, “Of course I can talk; I’m six years old.” Bewildered, his mom asked, “So, why haven’t you ever said anything before?” Without hesitation, the boy replied, “Up ’til now, everything’s been OK.”

So, here’s the deal. I wrote a number of posts in 2008 and 2009 about the medical profession and medical marketing.The blog generated about 10,000 hits, but not much discussion. At the time, I didn’t have anything else to say that I felt was important or revelatory. Now I do. If you have ever read my posts, you know that I am searching, and that I am a student of bias. I rejoice in learning how things work: not how they seem to work, nor how we would like for them to work, nor what the majority thinks about how things work, but how the evidence describes how things work.

Enter Nrf2. Nrf2 is an abbreviation for Nuclear factor (erythroid-derived 2)-like 2, also known as NFE2L2. Your doctor knows this, right? Wrong! When we matriculate into medical school, our teachers typically are not medical doctors, but PhD’s, who have extensive, up-to-the-minute knowledge of their niche. Among the first things they teach us are these two:

  • a vocabulary that is the equivalent of a foreign language, and like any foreign language, it is mastered when the words themselves cause concepts to appear in the brain without translation.
  • basic medical sciences.

Your doctor (and I) have mastered the vocablulary.We can read the peer-reviewed articles, and we have at least the potential to understand what they say. But the basic sciences? There are few practicing physicians who could pass a current freshman medical school test on any of the basic sciences, and the  information is changing at an almost exponential rate. Nrf2 is one of those things that basic scientists, in this case, biochemists, know about that your doctor does not.

Here’s the story. Did you know that oxygen is the source of our ultimate demise? We have to have it to survive, and to create the energy we use daily. But, in producing that energy, one of the products is a nefarious substance called “reactive oxygen species” (ROS). ROS will kill any oxygen-dependent organism. So, it is not surprising that all aerobes have evolved a method for dealing with these destructive ROS “free radicals”. The 25,000 or so genes in the human genome include 4-6 thousand genes that have evolved specifically to deal with ROS. That’s about a quarter of all the instructions that make us who and what we are. How do they do this? By up-regulation of protective enzymes that neutralize ROS, and by down-regulation of associated inflammatory and fibrotic processes stimulated by ROS. This is important. For me, it is revelatory. For your doctor? Maybe not so much.

It was a biochemist who first discovered the protective enzyme, SOD (superoxide dismutase). His name is Joe McCord. Your doctor has his own Wikipedia page, right? As Dr. McCord puts it, the discovery of SOD was the beginning of the solution, but no one knew the problem it solved. And what is the problem? Aging and degeneration itself! What is aging? Surprisingly, to a biochemist/medical school professor like Joe McCord, aging is defined as a ratio. The numerator is the level of protective antioxidant enzymes one’s genes produce, and the denominator is the amount of oxygen one consumes. Up until about the age of 18 -20 years, that ratio in genetically “normal” folks is such that very little degeneration occurs. You’ll starve if you are a doctor specializing in teen-age heart attacks, strokes, hypertension, osteoarthritis, type 2 diabetes, Alzheimer’s, Parkinson’s Disease, coronary bypasses and stents (continue the list to include almost everything non-infectious that eventually gets us), but you’ll be overworked with the same disorders if your field is geriatrics. Why? The ratio of protective enzymes to destructive ROS declines as we age, and oxygen gradually destroys us all.

What if we could stimulate our genes to rev up the protective enzyme levels to what they were when we were young? It would make front-page headlines! Fox News and PBS would find common ground featuring it! Your doctor would be calling YOU to make sure you were aware of this wellness breakthrough! NOT!!

Nrf2 was described and isolated in 1994. It’s role as the key activator for all the “survival genes” has been known to biochemists for over 10 years. There are 2088 peer-reviewed articles about it (as of today) listed on the National Institutes of Health website, Researchers in both independent university roles and as employees of pharmaceutical companies have been frantically searching for methods to activate Nrf2 safely, both to prevent and to treat the ravages of human physical degeneration. It could play a major role in reducing our runaway healthcare costs. EVERYONE’S TALKING ABOUT IT.

Well, maybe not. In fact, among all my physician friends to whom I have mentioned Nrf2, only one has ever heard of it. Furthermore, that one physician is the only one of my doctor friends who seems remotely interested in the concept. What’s going on here?! Artificial-intelligence researcher Eliezer Yudkowsky has observed: You know better than to think that a random doctor will have extraordinary clarity of mind and the power to find truth within confusion. Our medical education system stops teaching science and the scientific method after the early years of medical school; from then on, we learn and memorize prescribed solutions for various problematic scenarios.The system eschews independent thought and investigation. In fact, we are held legally liable for employing methods that deviate from the accepted norms. Those norms come down to practicing physicians through established channels, as I’ve previously mentioned here, herehere, and here. Currently, none of the established channels involves Nrf2 nor its activation, and few doctors make the effort to search for the truth within the confusion.

Enter what I will call a form of “intellectual attribution bias”. According to Michael Shermer in his book, Why People Believe Weird Things, because of this cognitive bias, smart people are about nine times more likely to attribute their own position on a given subject to rational reasons than they are other people’s position, which they will attribute to emotional reasons. Although major pharmaceutical companies are trying to develop synthetic Nrf2 activators as prescription drugs, the only currently available clinically effective Nrf2 activator is a compound of natural phytonutrients called Protandim. It is classified by the FDA not as a drug, but as a dietary supplement, and it is available not by prescription or in pharmacies, but only through network marketing.

In spite of peer-reviewed studies listed on documenting the compound’s ability to raise Nrf2 activation to unprecedented levels, and subsequently lower oxidative stress to unprecedented levels, practicing physicians are not likely to give it any credence because it doesn’t fit in the mold of their established channels of information. Their position seems to be: “I am an expert, and I haven’t heard of Nrf2 activation. Now you’re telling me that a network marketed supplement could be the most important advancement yet in my own specialty, and I don’t know about it? It’s bulls**t.”

UPDATE: Biogen’s synthetic Nrf2-activator drug Tecfidera was approved in the Spring of 2013 for the treatment of Multiple Sclerosis. Available by prescription only at a cost of about $50,000 annually. Biogen’s research shows that Tecfidera has about 50% of the Nrf2 activation of the natural-ingredient compound, Protandim, which costs $40/month, without Tecfidera’s side-effects.

Here’s an exercise your doctor hasn’t done: go to, and in the search box enter “Nrf2” followed by the name of any disorder that interests you, e.g., “Nrf2 diabetes”. As one enters disorder after disorder, and sees the scientifically documented correlation with levels of Nrf2 activity, one comes to realize that we have evolved to deal with oxygen consumption in a healthy way until we reach the years of reproduction, and then our Nrf2 activity drops off and we begin to die. We can begin to control that now by controlling Nrf2 activation. Doctors treat symptoms and the results of disease. Nrf2 activation removes the cause. The solution, or the beginning of it, has come along: Nrf2 activation. Your doctor doesn’t know about it. Tell him/her. He’ll tell you it’s bulls**t.

If you want to know more, click on “contact retired urologist” at the top of the page and send me a message.

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It’s Big Business!

Posted on January 5, 2009. Filed under: medical ethics, Medical marketing, Sexual issues |

On his blog, Science-Based Medicine, Dr. David Gorski posted about the pharmaceutical marketing technique of “seeding trials”. I had participated in one such ruse, although I was unaware that it had its own official name. As I commented to Dr. Gorski:

Fascinating article. I had never heard the term, “seed trial”, but the one in which I participated was similar to Merck’s.

My practice was exclusively limited to male sexual dysfunction for over 20 years, so when Pfizer came to me to participate in the VIGOR pre-market “clinical research” on Viagra, I assumed it was related to my expertise. Their final application for FDA approval had already been submitted, but the release date was pending the FDA’s action. By regulation, they could not detail the drug to doctors, nor even discuss it, unless the doctor was conducting “clinical research” in a pre-market trial. I was assigned only 10 patients (”to eliminate biases”), paid $1000 each for my inconvenience and expertise, and assigned an “FDA compliance consultant” who flew to my office several times, supervising every word that my “study director” (my nurse wife) entered into the forms. Both being participants, my wife and I were sent to “The Dolphin” hotel at Disney World to discuss the “research” with the other “investigators”. Airport-to-hotel limo, etc., plus an honorarium for attending. I expected some sort of round-table arrangement for the discussion; in actuality, it was held in the completely-filled grand ballroom. Other “investigator meetings” were being held around the country, and there were many others both before and after the one I attended. The only thing the investigators had in common was an American license to practice medicine. Criteria for patient enrollment were: male under 65, no anti-hypertensives, no diabetes, no hx of CAD or PVD, no physically-detectable penile abnormalities, and no previous evaluation for ED (a more pleasant term the Pfizer CEO commissioned to replace “impotence”). In other words, it was designed for 100% positive response. Before the study actually ended, Viagra was released. I never heard anything further about the study, and I don’t find much when I Google “VIGOR Viagra”, except ads.

At the time (I was told), the marketing branch of Pfizer estimated that the first-year Viagra market was $3 billion (it wasn’t, but that was their best data). That’s $8.2 million per day (counting only work days, it’s $13.6 million). By having a fully-detailed prescription-writing corps of doctors on release day, they could readily afford the costs of the elaborate “pre-market trial”, versus the months of non-productive days by having reps come around and detail “cold” docs after the release. They couldn’t afford not to have the “trials”.

My ethics in the issue are suspect, to be sure. I justified it by saying that I already knew all about the drug, there were no competitors, it filled a necessary niche (previously unaddressed) for my patients, and I was going to prescribe it anyway. Mea culpa.

But I was misled, right? Do I have to give back the money?

This fits right in with economist David J. Balan’s recent post on Overcoming Bias entitled “It is Simply No Longer Possible to Believe”. The basis for his post was this article by Dr. Marcia Angell, fomer editor-in-chief of the New England Journal of Medicine. If you have bothered to read this far, you owe it to yourself to read Dr. Angell’s treatise. I did, and I am so embarrassed for my profession.



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Doctor education #2… more real-life drama

Posted on October 7, 2008. Filed under: Everything you wanted to know about doctors, medical ethics, Medical marketing, Self-deception |

I got a call from a pharm rep for a company that markets one of the three well-known pills for treating erectile dysfunction one day about five years ago. She lived and worked in the alluvial plain area of the Mississippi delta. If you have never listened to a woman from “the delta”, as they say, you owe it to yourself to call someone in that area. The female version of the accent is melodiously syrupy; a conversation about anything is musical entertainment. “Yankees” seem to think the drawl is an indicator of ignorance or low intelligence. I assure you, that is not the case. There is a reason that William Faulkner spent most of his time in Oxford (Mississippi, not England), and it wasn’t because it was full of “hicks”. 

She sought me out because I was a “consultant” for her company. At the time, I justified that position by using what I now know is “confirmation bias”. I distinguished myself from the “medical whores” I have previously discussed by reasoning that I never consulted for competing products; that I promoted the one I actually used with my patients; and that I truly believed the product was the best in its field. I saw no conflict of interest, because I was only saying what I would have said anyway, pay or no pay. I should have considered things this way (as told by Kenny Tilton):

Once upon a time my sleazebag ward politician buddy and I were cruising the singles bars back when they had such things and he got nicely eviscerated by a woman we were chatting up. My buddy had said something cynical and she had challenged him on it.

“Oh, I have compromised my principles a few times,” he conceded with a sly grin.

“You can only compromise your principles once,” she replied. “After that you don’t have any.” (more…)

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The truth will set you free… but first, it will piss you off.

Posted on September 25, 2008. Filed under: Everything you wanted to know about doctors, Medical marketing, Personal philosophy, Self-deception |

David J. Balan, on Overcoming Bias, writes about the difficulty of responding honestly when people say, “Give it to me straight.” Generally, it’s such a bad idea that the Cajuns in my neighborhood have a story to illustrate:

Boudreaux was a widower whose most valued possession was his cat, Felix. Boudreaux won a trip to Europe, and he asked his friend Thibodeaux to look after the cat in his absence. “Thib,” he said, “I’ll call you from England to check on Felix.” Three days into the trip, Boudreaux indeed called Thibodeaux and asked, “How’s my cat doin’?” Thibodeaux replied, “Mai, Boudreaux, your cat died.” Boudreaux was beside himself, first with grief, then with anger. “Thib,” he wailed, “You don’t just tell somebody flat out that their cat died. You got no sensitivity. You should ease into it. Like, you should say, ‘Boudreaux, your cat’s on the roof, but I’m pretty sure we can get him down.’ Then when I call the next day, you say, ‘We got your cat down, but he caught pneumonia. The vet’s pretty sure he’ll be OK.’ Then on the next call, you say, ‘The cat took a turn for the worse, but the vet’s giving him some powerful medicine.’ Then the next day, you finally say,’Boudreaux, we did all we could, but your cat passed on.’ That’s the way you handle bad news like this.”

Thibodeaux expressed his remorse for his insensitivity and vowed to be more thoughtful. Two days later, Boudreaux called again. “Thib, how’s my mother?” Thibodeaux replied in his kindest voice, “Boudreaux, your mother’s on the roof.” (more…)

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Penile undermarketing

Posted on September 6, 2008. Filed under: Everything you wanted to know about doctors, Medical marketing, Sexual issues |

Alert blog-reader Moshe has asked the question: “If these penile implants you’ve talked about are so wonderful, how come I haven’t heard much about them?” You know, Moshe, I’ve been asking that same question since 1975, when I scrubbed in for my first inflatable penile prosthesis (IPP) operation. The result was so impressive that the female scrub nurse (unmarried) remarked, “Can you get me a list of men who have these things?” She wasn’t referring to size; the finished product was no bigger than the original. What she saw was control: comes up when you want it to (no matter how drunk the guy, nor how ugly the girl), stays up ’til everybody’s happy (or at least finished). The most urgently anxious patient I ever had was a widower in his 70’s who had just married a similar-aged widow. “Doc,” he begged, “I just got to get me one of those transplants (sic) right away: I just found out her late husband had one!” Ah yes, tough competition there. (more…)

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Rise and shine!

Posted on September 5, 2008. Filed under: Medical marketing, Sexual issues |

MIT computer scientist Dr. Scott Aaronson, in a post at Overcoming Bias, asked: Why do we, as a society, provide food stamps for the hungry but not sex stamps for the celibate?

Exhibiting a version of Godwin’s Law, the reader comments eventually deteriorated into a discussion of rape. Two anonymous commenters, the first an (I would guess) outraged feminist calling herself “Noir”, and the second a male chauvinist pig (as they were called in my day) using the clever nom de plume of “Anon”, argued over the plausibility of female-on-male rape. Anon’s eloquent pronouncement was: A woman forcing a man into sex is nigh-on physically impossible. She could of course violate him in various ways, but these mostly don’t even resemble sex. Retired urologist happened to be passing, and his shock at such ignorant effrontery caused him to wade in with the last comment in the thread. Alas, he was casting pearls before swine, as the readers showed no interest in his erudite remarks. Hence, the necessity for this fascinating post.   (more…)

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“How ya like me now?” he asked stiffly …

Posted on August 26, 2008. Filed under: Medical marketing, Sexual issues |

Since the “little blue pill”, the question that seems to be on everyone’s lips is, “What about these phosphodiesterase-5 inhibitors?” Right? Here’s someone inquiring, even as we speak. PDE-5’s inactivate one of the chemicals that makes erections go away (yeah, I know it seems that the verb should be “make” instead of “makes”, but that’s because the subject “one” is hidden by the prepositional clause “of the chemicals”; trust me: I went to school on an English scholarship). Male sexual arousal produces a chemical to initiate erection, and unless opposed, erection is maintained. Eventually, the almost non-flowing blood in the erect penis would clot (priapism), and without rapid treatment, probably no other erections would ever occur. Clearly, animals whose penises worked in this fashion were eliminated by natural selection. In those of us who have evolved long enough to be reading this blog, male arousal produces, along with the “get it up” chemical, a “get it down” chemical. When arousal is adequate, the former exceeds the latter. Eventually, e.g., after ejaculation, or when boredom replaces curiosity, or when the kid says, “What are you doing to Mommy?”, or when the prolonged friction has produced near-toxic levels of latex vapor emanating from the girlfriend’s woo-woo, or the Super Bowl is starting, the production of the “up” chemical slows, and the “down” chemical takes over. In the case of ejaculation, epinephrine production hastens the decline. If you want to know the exact technical aspects, check this summary.

But that’s not what I’m here to talk about. I want to explore the marketing of these miracle pills (more…)

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How do you like this education, doctor?

Posted on August 16, 2008. Filed under: Everything you wanted to know about doctors, medical ethics, Medical marketing, Self-deception |

Chances are, if your doctor seems quite successful, he is a drug rep. He may not even know it. He surely won’t admit it, especially not to himself. It probably started out as a part of his continuing education.

I wrote: In my next post, I’ll talk about the real leaders in doctor “education”; they weren’t included in this one because it’s not official CME. I’ll also throw in some first-hand, saw-it-with-my-own-eyes anecdotes. Here it is; I know you’ve been waiting with bait on your breath.

You’re sitting in your doctor’s waiting room. You have the first appointment of the afternoon, yet there are five others waiting as well. They are all relatively young women in very nice outfits. They’ve got some cleavage working, and they’re shod in FMP’s, the good kind, maybe Jimmy Choo’s. They don’t seem to be ill. They’re pharmaceutical reps. (NOTE: if your doctor is a woman, these people will instead be athletic-looking youngish men, or perhaps an occasional older, plainer chick, no cleavage. Nothing suggesting competition). They are waiting to help your doctor with his continuing medical education. In fact, statistically, they are the major source of your doctor’s new knowledge about medicines. You will be ushered to an examining room and told, “The doctor will be with you shortly.” One or two of them will see him in his private office before he comes to see you. And so the day will go. (more…)

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    The director of the Sexual Medicine Center leaves penile implants behind, and launches a quest for knowledge about Artificial Intelligence, extended life, and the issues inside the health-care industry.


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