Response to the "everyone over 50 should be on a statin story"

I have been alerted by a few people to a story emanating from the UK that everyone over the age of fifty should be prescribed statin drugs to prevent "thousands of heart attacks and strokes".

The story is about an analysis of some statin trials that apparently showed that as cholesterol levels were lowered then heart disease and stroke levels were decreased. The thrust of the argument by one of the researchers, professor Colin Baigent, is that whatever your cholesterol level, reducing it further is beneficial.  

As anyone who reads this blog will realise, lower cholesterol levels are NOT beneficial to health.

However for arguments sake lets pretend that statin trials are not paid for by the pharmaceutical companies that manufacture the statins.

Lets pretend that many of the statin trials are not conducted by personnel that have financial ties with the companies that manufacture the statins.

Lets pretend that the trials are not designed in such a way as to seriously skew the results to show statins in a favourable light.

Lets pretend that the researchers don't just accentuate the very minor positive aspects of statin drugs in the summaries of the trials, whilst completely ignoring the vast deleterious side-effects they cause.

After all that "lets pretending", lets examine figures from the British Heart Foundation statistics database and the World Health Organisation Global Health Atlas 2005.

In both graphs data was extracted from 86 countries.

Figure 1 shows that life expectancy increases quite sharply as cholesterol levels increase, and even the data regarding cardiovascular diseases in figure 2 shows that as cholesterol levels increase, then death rates from cardiovascular diseases decrease.

Lets stop pretending.

The hard data shows the opposite of what the pharmaceutical industry backed advisers tell us.

I suggest that as well as listening to advice about data gathered from "drug company industry paid for, drug company industry personnel conducted, drug company industry designed and drug company industry biased results" trials, people should conduct their own research and come to their own conclusions.

Who would you listen to and trust?

Professor Colin Baigent heads a university department which received funding from Merck Sharpe & Dohme Ltd; who just happen to be the pharmaceutical company linked to the parent company (Merck & Co) in the USA who first brought Lovastatin to market.

Would you trust someone who trots out figures that are backed by the $29 billion statin industry, or someone who just shows unbiased data of actual life expectancies, actual cardiovascular death rates and actual cholesterol levels?

If you would like another opinion of Baigent's study go to Dr Briffa's site here.

JUPITER statin trial a biased sham

This paper was published in the Archives of Internal Medicine 2010;170(12):1032-1036

Study title and authors:
Cholesterol Lowering, Cardiovascular Diseases, and the Rosuvastatin-JUPITER Controversy
A Critical Reappraisal
Michel de Lorgeril, MD; Patricia Salen, BSc; John Abramson, MD; Sylvie Dodin, MD; Tomohito Hamazaki, PhD; Willy Kostucki, MD; Harumi Okuyama, PhD; Bruno Pavy, MD; Mikael Rabaeus, MD


This paper can be accessed at: http://archinte.ama-assn.org/cgi/content/full/170/12/1032#REF-IOI05093-1


Dr. de Lorgeril notes that the results of cholesterol-lowering drug trials show no evidence that statin drugs lower the disease rates or death rates of people with or without coronary heart disease with one exception, and that is the JUPITER (Justification for the Use of Statins in Primary Prevention) trial. JUPITER reports a substantial decrease in the risk of cardiovascular diseases among patients without coronary heart disease and with normal or low cholesterol levels. 


The results of the JUPITER study were met with a massive media fanfare proclaiming the benefits of statin drugs. This enthusiastic recommendation has no doubt persuaded many people with normal cholesterol levels to start long term statin treatment.


The JUPITER trial tested the effects of rosuvastatin in patients without heart disease and with normal or low cholesterol levels but relatively high levels of C-reactive protein, a marker of inflammation. The study spanned 1,315 sites in 26 countries and included 17,802 people who were assigned either 20 mg/d of rosuvastatin or placebo.


3 recent trials with rosuvastatin (with the acronyms CORONA, GISSI-HF and AURORA) had been conducted, and all had failed to provide evidence that rosuvastatin therapy reduces heart disease complications.


The JUPITER trial was prematurely terminated on the grounds that it had generated evidence that the statin treatment had definitely reduced heart disease rates.


However the evidence shows otherwise:
(a) If you include people who had fatal and nonfatal heart attack and stroke - the trial was stopped after only 240 incidents. 
(b) There was no difference in the incidence of serious adverse events (total hospitalizations, prolongations of hospitalizations, cancer, and permanent disability) between the 2 groups.
(c) There was hardly any difference in death rates when the trial was ended, and the trend was showing that the statin groups death rate was increasing compared to the placebo group.


An "unequivocal reduction in cardiovascular mortality" was announced in March 2008 as the main justification for the premature trial termination.


However the actual facts again beg to differ:
(d) Fatal heart attacks were 9 in the statin group and 6 in the placebo group.
(e) Stroke death was 3 in the statin group compared to 6 taking the placebo.
So there was 12 cardiovascular deaths in each group. Hardly an "unequivocal reduction in cardiovascular mortality" as the JUPITER study authors concluded.


So why was the trial stopped early?


As stated earlier JUPITER was hailed in the media as a ringing endorsement for us all to start statin therapy. This was achieved by the authors of the study only highlighting some results of the trial and completely ignoring other, less favourable data. It also raises the suspicion that if the trial had continued then the results would have shown statins in an even more unfavourable light.


Rosuvastatin (sold under the brand name Crestor) is marketed and distributed by AstraZeneca Pharmaceuticals.


The JUPITER trial involved multiple conflicts of interest: 
(f) It was conducted by Astra Zeneca  with their obvious commercial interests. 
(g) Nine of 14 authors of the JUPITER article have financial ties to the Astra Zeneca. 
(h) The principal investigator has a personal conflict of interest as a co-holder of the patent for the C-reactive protein test.
(i) Astra Zenecas own investigators controlled and managed the raw data which increases the chance of bias appearing in the data.


Dr. de Lorgeril concludes:
(i) The results of the JUPITER trial are clinically inconsistent and therefore should not influence medical practice or clinical guidelines. 
(ii) The results of the JUPITER trial show that commercially sponsored clinical trials are at risk of poor quality and bias. 
(iii) The failure of the JUPITER trial to demonstrate a protective effect of rosuvastatin confirms the results of  more than 12 other cholesterol-lowering trials published in recent years, which all provided no evidence of protection against heart disease by cholesterol lowering. 
(iv) These failed trials strongly suggest that the presumed preventive effects of cholesterol-lowering drugs have been considerably exaggerated.


Dr.de Lorgeril ends by saying that the time has come for a critical reappraisal of cholesterol-lowering and statin treatments for the prevention of heart disease, and the emphasis on pharmaceuticals for the prevention of heart disease has diverted individual and public health attention away from other proven methods of prevention such as a healthy lifestyle, exercise and diet. 

How doctors in the US actually get paid more for writing more statin prescriptions

This post features an article by Catherine Shanahan, a medical Doctor from Kalaheo, Hawaii

The following article by Catherine Shanahan describes how doctors actually get paid more for writing more statin prescriptions.

Statin Payments
Catherine Shanahan

You may have read that doctors receive payment or bonuses for prescribing statins, the cholesterol-lowering drugs. I'm a chapter leader in Kauai, and a family physician, so I'm in a good position to fill in some details about how doctors actually get paid more for writing more statin prescriptions. The mechanism is a little cumbersome to describe clearly, but I'll take a stab at it.

Books:

We have a series of "quality measures" that are tracked by the insurance company. One quality measure is the number of mammograms we do on our patients between ages 40 and 69, another is that we send our diabetic patients to the eye doctor once a year for retinal exams. For our patients who carry a diagnosis of "coronary artery disease," we have to write them a prescription for a cholesterol-lowering drug. If any one doctor doesn't follow any one of these imperatives, he loses points toward a cash bonus, and the entire group is similarly penalized. As you can imagine, there is lots of peer pressure to prescribe!

Actually, we don't get our bonus unless the patient goes and buys the drug or gets the test or sees the eye doctor and so on, so it's not enough just to write the prescription, we have to talk up the drug enough to get them to go out and buy it. Currently, there are only a few means by which a person can be labeled as a patient with coronary artery disease. Having a heart attack is one, and having abnormal results on heart tests (like angiograms) is another. Diabetes is now considered a "coronary artery disease equivalent" and so, in the near future, doctors may be required to get all our patients who have type one or type two diabetes to take their statins, or lose more money.

These HMOs are insurance companies like Blue Cross, which offer their clients (employers and patients) HMO programs. The HMO plan we have is offered by HMSA (Hawaii Medical Something Something). For whatever reason, HMSA wants to offer an HMO program for people, and doctors who participate as providers must comply with the rules of the program and accept payments according to the rules. There are clear benefits to pharmaceutical companies in this structure but no obvious reason why HMSA would want to encourage people to buy expensive drugs that HMSA must pay for. One might speculate that there are some quid-pro-quo relationships between the insurance companies and the pharmaceutical companies, but I have no idea what they are. However the ties are structured, I feel, as do many other scientists, that these kinds of business relationships lead to behaviors that pose real threats to patient care, and to human health in general. Because industrial connections like this fund most research, they distort the scientific process and are far more insidious, invisible, and totalitarianistic than expensive dinners and trips to Hawaii, which are what the media would have us believe is the sum total of the problem.

By the way, the bonus is actually not a bonus at all. This is where it gets Orwellian. We give up a certain percentage of the payment for accepting HMO patients, and we get it all back, in theory, if we meet all of our quality measures. We never do because of computer glitches which continually fail to track our prescribing, testing, and referring patterns accurately. Nobody can explain why we've agreed to accept HMO insurance plans, but we seem to feel we have no choice. And we will have less choice before long; Medicare is planning to begin similar programs. Each of these programs takes more money away from the doctors and gives it to middle managers, ensures that drug companies get more money, and that expensive tests of limited value are done more often.

These are some reasons why savvy business people are going into "alternative" medicine where they benefit from cash payments and total autonomy. Several here on Kauai are making millions.

Catherine Shanahan MD

Kalaheo, Hawaii

This article can be accessed at: http://www.westonaprice.org/letters/754-letters-winter-2006?qh=YTozOntpOjA7czo5OiJjYXRoZXJpbmUiO2k6MTtzOjg6InNoYW5haGFuIjtpOjI7czoxODoiY2F0aGVyaW5lIHNoYW5haGFuIjt9

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Professor says the adverse effects of the cholesterol campaign on health, quality of life, the economy and medical research are inestimable

This post features a summary of a paper published in the Scandinavian Cardiovascular Journal 2008 Aug;42(4):244-9 and a recipe for barbecued steak.

Study title and author:
Cholesterol does not cause coronary heart disease in contrast to stress.
Rosch PJ.
Department of Medicine and Psychiatry, New York Medical College, Valhalla, New York, USA. stress124@optonline.net

This paper can be accessed at: http://www.ncbi.nlm.nih.gov/pubmed/18609060
 

Books:

PAUL ROSCH, MD, is a clinical professor of medicine and psychiatry at New York Medical College.

Professor Rosch reviewed the evidence on cholesterol and heart disease.

He found:
(a) The belief that coronary atherosclerosis is due to high cholesterol from increased saturated fat intake originated from experiments in herbivorous animals. It was reinforced by reports allegedly demonstrating this sequence of events in various populations but ignoring contradictory data.
(b) The idea has been perpetuated by powerful forces using similar tactics to preserve the profit and the reputations of those who promote this doctrine.
(c) Opponents find it difficult to publish their scientifically supported opinions.
(d) The advent of statins has further fuelled this fallacious lipid hypothesis, despite compelling evidence that their effect is not due to cholesterol lowering and that serious side effects have been suppressed and alleged benefits have been hyped.

Professor Rosch concludes that The adverse effects of the cholesterol campaign on health, quality of life, the economy and medical research are inestimable. It is imperative that public health officials, physicians and patients are apprised of proof that it is misguided, malicious and malignant.

 
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Recipe of the day

Barbecued Steak

Ingredients:

Food Mall: Rib Eye Steak

4 sirloin, rump, rib-eye or goose skirt steaks

For the spicy marinade:

2 garlic cloves, peeled and finely chopped

Grated zest and juice of 1 lemon

2 fresh bay leaves, crushed

15ml/1tbsp freshly chopped thyme leaves

Salt and freshly milled black pepper

15ml/1tbsp olive oil

Method:

1.Mix the marinade ingredients together. Place the steaks in a shallow dish, spoon over the marinade mixture and coat on both sides. Cover and marinate in the refrigerator for up to 2 hours.

2.Cook the steaks according to your preference on a prepared barbecue or preheated grill.

Are all the early statin trials a sham?

This post includes a summary of a paper published in the Journal of Lipid Nutrition Vol. 19 (2010) , No. 1 pp.65-92

Study title and authors:
Recent cholesterol-lowering drug trials: New data, new questions
Michel de Lorgeri and Patricia Salen
Laboratoire Cœur & Nutrition, Université Joseph Fourier

This paper can be accessed at: http://www.jstage.jst.go.jp/article/jln/19/1/19_65/_article

Books:

The french cardiologist Dr Michel de Lorgeril investigated the outcome of recent cholesterol-lowering drugs trials.

He found:
(a) The cholesterol-lowering drug trials published in 2008-2009 were either negative (ENHANCE, SEAS, GISSI-HF, AURORA) or obviously biased and therefore not credible (JUPITER).
(b) It is also noteworthy that most cholesterol-lowering drug trials published between 2005 (the year of the Vioxx affair and of enforcement of new clinical trial regulations) and 2007 were also negative or ambiguous.
(c) Taken together, these trials strongly suggest that the results of previous, highly positive trials with statins - particularly in the secondary prevention of coronary heart disease - published between 1994 and 2004 and that were used to issue guidelines for medical practitioners should be carefully re examined by experts independent from the pharmaceutical industry.
(d) The positive results from trials published between 1994 and 2004 were before the Vioxx affair and of enforcement of new clinical trial regulations. (Vioxx was a drug that was supposed to greatly relieve the pains of arthritis sufferers, the problem was that it caused heart attacks and strokes and three-fold increase in death rates. The company that manufactured the drug (Merck) tried to hide these side effects by manipulating data. Eventually the drug was withdrawn and now, in an attempt to prevent pharmaceutical companies hiding or manipulating evidence, the US Food and Drug Administration require that all pharmaceutical companies file any and all trial results to a federal registry within one year of the completion of the trial).

Dr de Lorgeril concludes: "The next question would be whether it is not time for a full reappraisal of the theory according to which cholesterol-lowering results in a significant protection against cardiovascular morbidity and mortality".

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Why drugs are not as effective - or safe - as the pharmaceutical industry are telling us

Published in the Annals of Internal Medicine October 18, 2010 vol. 153 no. 8 532-535

What's in Placebos: Who Knows? Analysis of Randomized, Controlled Trials
Beatrice A. Golomb, MD, PhD; Laura C. Erickson, BS; Sabrina Koperski, BS; Deanna Sack, BS; Murray Enkin, MD; and Jeremy Howick, PhD
University of California, San Diego, School of Medicine, San Diego, California

This paper can be accessed at: http://www.annals.org/content/153/8/532.abstract

How do you know a drug is safe and effective? Because it’s tested against a placebo, or sugar pill, and you know it works if it significantly outperforms the dummy pill. But suppose the sugar pill isn’t as benign as we think – suppose it contains a chemical that makes even a bad drug such as a statin look good?

This study looks at the placebo, a method used in countless drug trials over the years. The researchers studied four of the major medical journals published in 2008 and 2009 – and discovered that hardly any trials listed the ingredients of the placebo.

As the composition of the placebo can have a big effect on a drug trial’s results, the researchers concluded its ingredients should be listed every time.

AMAZON UK $29 Billion Reasons to Lie About Cholesterol: Making Profit by Turning Healthy People into Patients
AMAZON USA $29 Billion Reasons to Lie About Cholesterol: Making Profit by Turning Healthy People into Patients

Direct-to-Consumer Drug Advertising causes public harm

Published in the Public Library of Science Medicine

What Are the Public Health Effects of Direct-to-Consumer Drug Advertising?
Elizabeth A. Almasi, Randall S. Stafford, Richard L. Kravitz, Peter R. Mansfield

This paper can be accessed at: http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0030145

Almasi concludes: "There are two root causes of the problems with Direct-to-Consumer Drug Advertising (DTCA). The first is payment systems that reward drug companies for increasing sales of expensive drugs regardless of the impact on health. These systems should be redesigned. The second root cause is normal human vulnerability to being mislead. Few people have the time and advanced skills in drug evaluation, psychology, logic, economics, and semiotics, etc., required to evaluate drug promotion. Advertising can sneak in under the radar to influence even skeptical people without their awareness. Ideas that would be rejected if given attention get reinforced by repetition.

Almost all government, health professional, and consumer inquiries into DTCA have concluded that it causes net public harm. It is too difficult to regulate DTCA, so I believe that the logical conclusion from the evidence is that the best option for improving overall health and wealth is to ban all types of DTCA, including “disease awareness” advertising.

The public would benefit from reliable information and health promotion focused on public health priorities. Such information can be provided at no extra cost by copying, improving, and expanding policies and programs that are already successful in many countries. Governments and insurance companies who subsidize drugs currently pay for biased promotion indirectly via high drug prices. Instead, these agencies could fund information, education, and promotional services focused on public health needs. Such investments pay for themselves by reducing health-care costs. Universities and nonprofit organizations are well placed to compete for this funding. These organizations are more trustworthy than drug companies because they don't gain from drug sales. Where behavior-change promotion is justified, these organizations could collaborate with advertising agencies. This collaborative approach has already been successful for many health-promotion campaigns—for example, promoting smoking cessation. These improvements would not achieve utopia, but would improve health and increase wealth overall".

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AMAZON USA $29 Billion Reasons to Lie About Cholesterol: Making Profit by Turning Healthy People into Patients

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All pharmaceutical drug promotion should be banned

Published in the Journal of Bioethical Inquiry Volume 2, Number 2, 75-81, DOI: 10.1007/BF02448846

Banning all drug promotion is the best option pending major reforms
Peter R. Mansfield

This paper can be accessed at: http://www.springerlink.com/content/p65282x577681p44/

Mansfield concludes: "Drug promotion should be evaluated according to its impact on health, access to information, informed consent, and wealth. Drug promotion currently does more harm than good to each of these objectives because it is usually misleading. This is a systemic problem. Whilst improved regulation and education will address it to some degree, major reforms to payment systems for drug companies and doctors are also required. Until all these systemic reforms can be put in place, the best policy option is to ban the promotion of drugs to doctors and the public. Consequently, pending major reforms, it is appropriate for governments to restrict drug promotion as much as is politically achievable".

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Harvard Medical School find that doctors increase the prescription of their sponsors drugs by 300%

Published in Circulation. 2010;121:2228-2234

Controversies in Cardiovascular Medicine. Is There a Role for Industry-Sponsored Education in Cardiology? Funding for Medical Education: Maintaining a Healthy Separation From Industry
Jerry Avorn, MD; Niteesh K. Choudhry, MD, PhD
From the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Mass.

This paper can be accessed at: http://circ.ahajournals.org/cgi/content/full/121/20/2228#R5-869636
 
The most direct form of industry-supported education is through funding for continuing medical education (CME) activities. Support from pharmaceutical and medical device manufacturers for CME, which has quadrupled over the past decade, accounts for more than half of the $2.4 billion that is spent annually on CME.
 
Manufacturer-sponsored CME is associated with increases in prescription rates of the sponsor’s medication, perhaps because of the added attention paid to it during these sessions. In one study, the positive effects of the sponsor’s drug were mentioned 2.5 to 3 times more often than those of competitor’s drugs. Interactions with pharmaceutical representatives increase the likelihood that a physician requests to add the company’s drug to hospital formularies by more than 300%, and the receipt of honoraria to discuss a company’s new drug is associated with even larger effects on formulary requests. Interactions with detailers have been linked to more frequent prescribing of the marketed drug, as well as prescribing that is more expensive and less evidence-based.
 
There are other equally important but less visible forms of industry-funded education. "Speakers’ bureaus," in which prominent physicians are paid to lecture about a company’s products, constitute another common form of industry involvement in teaching. Manufacturers may exert substantial influence over the content of these lectures and frequently provide the slides to be used; some physicians earn more than $50 000 per year from these talks alone. Other "key opinion leaders" (known in industry marketing language as KOLs) can earn up to $10 000 from a corporate sponsor for chairing a single educational symposium.
 
The sales representative, or "detailer," is a major source of drug information for many physicians. This is especially true for new products, for which there may be little or no information available in the medical literature. On average, cardiologists meet with pharmaceutical sales representatives 9 times per month. Unfortunately, many of these salespeople may have limited scientific training and are paid on a commission basis, depending on how much of their company’s products are prescribed by the clinicians they target. There is also growing evidence of companies’ use of such communication to persuade physicians to prescribe products without a given Food and Drug Administration indication and, more importantly, without adequate evidence of efficacy or safety. Several of the nation’s largest drug companies have in recent years paid enormous sums in legal settlements mandated by state attorneys general for such off-label marketing of Neurontin (gabapentin, Pfizer: $430 million settlement), olanzapine (Zyprexa, Lilly: $1.3 billion settlement), and valdecoxib (Bextra, Pfizer: $2.3 billion settlement).

The author concludes: "We believe that the wealthiest nation on earth should be able to provide neutral, evidence-based educational messages about medications to physicians and patients without having to accept the trade-off that industrial sponsorship of such education inevitably requires...Because the clinical stakes for our patients are so high, and because the healthcare system of the coming decade will have to expend its constrained resources in the most cost-effective manner, cardiology and the rest of medicine will need to move beyond having vendors provide or pay for the education of its practitioners. The transition will be challenging for a time, but our patients, the healthcare system, and we as professionals will be better off for it".

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Only 6% of drug advertising material sent to doctors is supported by evidence

Published in the BMJ 2004; 328 : 485 27 February 2004)

Only 6% of drug advertising material is supported by evidence
Annette Tuffs
Institute for Evidence-Based Medicine Heidelberg

This paper can be accessed at: http://www.bmj.com/content/328/7438/485.2.full
 
This study, about advertising material and marketing brochures sent out by drug companies to GPs in Germany, has shown that about 94% of the information in them has no basis in scientific evidence.
 
About 15% of the brochures did not contain any citations, while the citations listed in another 22% could not be found. In the remaining 63% the information was mostly correctly connected with the relevant research articles but did not reflect their results. Only 6% of the brochures contained statements that were scientifically supported by identifiable literature.
 
The authors warn that such a high amount of misinformation puts patients' health at risk.

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GPs decision to initiate a new drug is heavily influenced by ‘who says what’, in particular the pharmaceutical industry

Published in Family PracticeVolume20, Issue1Pp. 61-68

Influences on GPs’ decision to prescribe new drugs—the importance of who says what
Helen Prosser, Solomon Almonda and Tom Walley

This paper can be accessed at: http://fampra.oxfordjournals.org/content/20/1/61.abstract
 
Prosser reports GPs rarely searched for information themselves and the decision to initiate a new drug is heavily influenced by ‘who says what’, in particular the pharmaceutical industry.

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Doctors prescription habits affected by pharmaceutical representatives

Published in JAMA. 2000;283:373-380.

Physicians and the Pharmaceutical Industry. Is a Gift Ever Just a Gift?
Ashley Wazana, MD

This paper can be accessed at: http://jama.ama-assn.org/cgi/content/abstract/283/3/373
 
Wazana found that physician interactions with pharmaceutical representatives were generally endorsed, began in medical school, and continued at a rate of about 4 times per month. This led to:
 
(a) Meetings with pharmaceutical representatives were associated with requests by physicians for adding the drugs to the hospital formulary and changes in prescribing practice.
 
(b) Drug company–sponsored continuing medical education (CME) preferentially highlighted the sponsor's drug(s) compared with other CME programs.
 
(c) Attending sponsored CME events and accepting funding for travel or lodging for educational symposia were associated with increased prescription rates of the sponsor's medication.
 
(d) Attending presentations given by pharmaceutical representative speakers was also associated with nonrational prescribing.
 
Wazana concludes the present extent of physician-industry interactions appears to affect prescribing and professional behavior and should be further addressed at the level of policy and education.
 
In a nutshell: You are likely to be prescribed whatever the pharmaceutical representativetells your doctor to prescribe.

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Lipitor (a statin), the cholesterol-lowering drug, has become the bestselling pharmaceutical in history. Here's how Pfizer did it

This post features an article published in Forbes magazine January 6th 2003 and a recipe for lemon and garlic scallops.

Pfizer's sales campaign in doctors' offices has been very aggressive

Books:

Every year, drug companies spend billions of dollars teaching their sales reps how to 'persuade' doctors to prescribe their particular products.

Pfizer have 13,000 salespeople. The trainees go through weeks of simulated sales calls in a mock physician's office, built like a movie set on one of Pfizer's upstate New York campuses. On the simulation stage, former sales reps play harried and irritable doctors. Trainees are timed and judged on their ability to deliver a pitch for a Pfizer drug.

This begs the question: Should patients be given particular drugs based on how good the sales reps are at their job?

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Recipe of the day

Lemon and Garlic Scallops
 
Serves 6
 
Ingredients:

Food Mall: Scallops

•3 tbsp garlic, minced;

•2 tbsp lemon juice;

•3/4 cup butter (or Ghee);
•2 pounds large scallops;
•Salt and pepper to taste.

Technique:
1.Heat a pan over a medium heat and melt the butter or ghee. Add the minced garlic for a minute, until fragrant;

2.Add the scallops and cook for a few minutes on the first side so they are about halfway cooked. Turn the scallops and finish cooking until they are firm and opaque.

3.Put the scallops aside to a plate and add the lemon juice to the hot butter and garlic in the pan. Season to taste;

4.Serve the scallops on a bed of steamed or roasted vegetables with the lemon and garlic butter sauce on top. Spinach and asparagus go very well with scallops. Additionally, sprinkle some fresh parsley or chives on top if available.