Food Over Medicine: The Conversation That Could Save Your Life

5. THE DIETARY ESTABLISHMENT

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GM: Pam, I just went on the website of the Academy of Nutrition and Dietetics (AND). I clicked on “nutrition for growing bodies” and saw that they recommend whole grains, fruits, and veggies, including 100 percent juice, low-fat dairy foods, and then a protein group that is lean meat, poultry, fish, eggs, beans, and nuts.

PP: Right. Hey, it’s the dietary recommendations of the United States Department of Agriculture (USDA). If the USDA issued recommendations tomorrow for everyone to drink ten ounces of arsenic before breakfast, it’d be posted on AND’s website by noon.

GM: Ha!

PP: I’m not kidding! And this stuff is important because these are the people providing the dietary guidelines that are being used to design school lunches.

GM: I read in the New York Times about a study that showed that children who eat school lunches are 29 percent more likely to be obese than kids who bring their own lunches to school.1

PP: And since their own lunches probably aren’t so great, that gives you an idea of just how awful the school lunches are. The Physicians Committee for Responsible Medicine (PCRM) filed a lawsuit against the USDA over the latest dietary guidelines because they’re so horrific. Not only does AND not say that the guidelines are terrible but its president issued a press release gushing about what a great job the USDA committee did and how hard it worked to sort through all this science to come up with this wonderful recommendation. The president also reminded us, by the way, that AND is the group of people you want to look to for dietary information.2 It’s almost like the USDA has put AND on the payroll, which wouldn’t be surprising because everyone else has. If the USDA isn’t paying AND, then that would be the one group that has somehow been exempted.

GM: What do you mean by that? Who’s paying AND?

PP: They’re heavily funded by sponsors. Millions of dollars a year.

GM: The dairy industry?

PP: Oh, there aren’t any that are missed. The dairy industry, the beef industry, food manufacturers like Wrigley and Hershey’s and Kellogg’s—there’s no discernment. If you own a food company and you want to sponsor AND, just step up to the plate with your wallet open. There’s no filtering that says you have to qualify based on promoting a healthful food.3 So the American Distillers Association, the lamb industry, there’s nobody exempt from their endorsement, provided they show up with a check.

GM: Is there no group of critics within AND, no group of dietitians, that fights this system and calls it corrupt?

PP: Not within AND. You have the same thing going on with dietitians that you have going on with medical doctors. When we talk about how bad health care is and how corrupt the medical system is, it all starts with corrupt professional organizations. Just as Dr. John McDougall is not representative of the medical profession, there are great dietitians out there, some of whom are close friends of mine, who have gone to dietetics school and held their noses in order to get their degrees. They’ve reengineered themselves to practice completely differently, to oppose within their own practice the guidelines of their umbrella organization. But there’s no force within AND that is trying to change the system. Of course, AND’s public stance is that it can’t function without this type of money. How would the organization operate, after all? Of course, my response is that we’ve found a way to operate here and not take money from any corporate sponsors. If AND sends representatives, I’ll show them how to do it with something interesting called earned income.

GM: Why couldn’t AND function just on the dues of practicing members, rather than funds from corporate sponsors?

PP: Or selling services. There’s no reason why AND couldn’t actually market services in some ways directly to the public, but it’s easier just to take the corporate bucks. I don’t mean to pick on AND, because the American Academy of Pediatrics, the American Medical Association (AMA), and the American Diabetes Association (ADA) all do it. They’re all on the take. They’re all taking money. It’s pervasive in the health care business. So we have terrible recommendations that come from the federal government, and all of these organizations are corrupted by the same monetary influence.

GM: Who gives money, for example, to the AMA?

PP: The drug industry, mainly in the form of advertising in its journal. The American Psychiatric Association sends its journal free to its members. Guess how it gets to do that? Drug ads. Most of what psychiatrists are seeing is material promoted by the drug companies. I’d like to think that the average psychiatrist is smart enough to know that. Are they smart enough to say, “Maybe I should automatically be skeptical of anything these ads say that are printed in these journals?” I don’t know. Psychiatrists are pretty drug-happy these days.

GM: Who gives money to the ADA?

PP: Well, the “health tip of the day” on the website was sponsored by Eskimo Pie for about eighteen months. Because if you’re diabetic, you can never get enough Eskimo Pie.

The artificial sweetener companies contribute a lot. Cadbury Schweppes gave the ADA $1.5 million a few years ago. Cadbury is the third-largest maker of soft drinks in the world and also makes those crème eggs available at Easter. Those are some great items for diabetics also!

GM: Let me try to wrap my head around this. You’re a manufacturer of soft drinks and you say, “Uh-oh, millions of people in America have become diabetic. That’s not good for us because, after all, we’re selling flavored sugar water. Here’s an idea. Let’s give money to the American Diabetes Association so that doctors won’t tell their patients that soft drinks are bad for them?” Is that really conceivable?

PP: Well, they basically want the ADA to make mushy, meaningless pronouncements, which it faithfully does, as does the Academy of Nutrition and Dietetics. The party line that AND proudly announces to the general public is that there is room for everything in a healthy diet; that everything in moderation is fine; that there aren’t any good and bad foods; that there aren’t any good and bad dietary patterns; and that different things are appropriate for different people. And essentially it promotes this whole idea that sure, you can go ahead and have that soft drink with that Eskimo Pie.

I did a television interview recently in which this was a big topic of conversation. The promotion of this idea that you can just eat whatever you want without consequences. “You maybe want to do a little less of that and a little bit more of this, but nothing you eat is clearly right or wrong.” You’ll see a lot of statements from the American Diabetes Association, for example, to the effect that it’s important to look at the whole range of products available to diabetics. Look at all the sugar-free drink products you can have, for example, if you’re a little more sugar sensitive than somebody else. And the beverage industry is doing a great job by developing artificially sweetened soft drinks so that diabetics can enjoy these products, too. Yay! Now, of course, my employees here at The Wellness Forum joke that they’ve got guaranteed lifetime employment as long as this nonsense is going on, but I don’t really think that’s our objective here. I’d be happy to find something else to do with myself if we could fix the country’s health problems.

GM: Let’s talk about AND’s recommendation to eat lean meat and poultry and fish and eggs. What is AND’s factual basis for this? I know that you make your dietary recommendations based on science. Maybe it’s asking too much to expect AND to do the same, but is there any medical literature anywhere that suggests that there’s anything healthy about poultry? Has there ever been a study done that if you eat poultry, it’s good for any of your organs or has a positive effect on longevity? Is there any study in the world that suggests that poultry has health benefits?

PP: No.

GM: So no study has ever been done that eating poultry is any better for you than eating rice or beans or lentils or broccoli?

PP: No. We have studies that show the contrary.4

First, chicken contains just about as much fat as beef. Even chicken breast with the skin removed, and is broiled rather than fried, derives 23 percent of its calories from fat. And four ounces of chicken contains almost one hundred milligrams of cholesterol, about the same as four ounces of beef. And a study conducted by the Physicians Committee for Responsible Medicine determined that almost half of chicken sold in grocery stores was contaminated with feces.5 Yet Americans have been told that chicken is better for them than beef and pork. This has caused chicken consumption to more than quadruple between 1950 and 2007, while beef consumption increased by only 50 percent and pork consumption went down.6 Of course, Americans have continued to get fatter and sicker all the time.

GM: Well, is there any study that makes any positive case at all for poultry? Is there any study that shows that eating poultry is at least better for you than eating lizards, horses, chipmunks, or rats?

PP: No.

GM: So they’re just pulling these recommendations out of their ass?

PP: They would clearly recommend the nutritional benefits of eating rats if there were a rat farm lobby or if people found fried rats delicious and there was a chain of Kentucky Fried Rat restaurants.

GM: Is it fair to say that a group like AND will promote some information occasionally that’s based on science, and then other information—like advising people to eat lean meat and fish and eggs and poultry—that’s just a safe way of endorsing the status quo, affirming the general culture and the standard American diet, without any science involved at all so as not to ruffle any feathers in, say, the poultry industry?

PP: Yes. And what makes this confusing to the general public is that people get on the AND website and, first of all, they have no idea how dietitians are trained and they assume the best. Then they see messages that are clearly right: eat more fruits and vegetables. I mean, who really disagrees with that? Whole grains and beans are good for you. So they see some things that are right and it makes them think this organization is probably right across the board. Even when there’s clearly a sponsorship relationship, such as in the position papers. (It’s printed in very small type in the website’s right-hand corner.) I doubt the average person knows that the paper was written specifically in response to sponsorship money. The Wrigley Science Foundation sponsored a piece that stated you could add enamel to your teeth by chewing gum. Now, I have a lot of friends who are dentists and I’ve asked all of them, “What do you think of this?” They laugh out loud and say, “Who gave you that crazy idea?” Well, it was posted on AND’s website.

The average person can’t be expected to factor in the conflicts of interest. All the average person sees is that these organizations appear to be authoritative and the experts in the field. If you know no more than that, following their advice seems like the sensible thing to do.

GM: How about the governmental organizations? Do you feel the same way about the Food and Drug Administration (FDA) as you feel about these medical associations?

PP: Oh, it’s probably worse.

GM: Then let’s talk about the FDA.

PP: There are a few different issues to discuss: drug approval and regulation, and regulation of supplements, fortified foods, and the functional foods industry. In terms of the FDA’s drug regulation, the flaw is that the drug companies make a lot of the decisions about study design, even about what’s considered a side effect; they negotiate with the FDA on what should be listed as a side effect.

GM: How do you negotiate on what should be listed as a side effect?

PP: Well, Prozac doesn’t list withdrawal symptoms as a side effect because both the manufacturer and the FDA agreed that if the list of side effects was too long, it would discourage people from taking the drug.7

GM: I’m always amazed by the TV commercials for drugs. They might be for restless leg syndrome or erectile dysfunction or something and they say, “May cause headaches, fatigue, nausea, diarrhea, dizziness, suicidal thoughts, stroke, heart failure, kidney failure, unusual bleeding, or sudden death.” And I’m thinking, how badly do you want to keep your appendages in a certain position? I mean, after hearing these warnings, who the hell is buying these things?

PP: Well, the drug ads work because there are plenty of people out there who have these conditions. They go in and ask their doctor for the drugs, and the doctors feel as if they should accommodate their patients. What they should really do is say no. It’s okay to say no to somebody. Of course, doctors worry that the patient will switch to the doctor down the street. My response would be to let them. Let them go to the doctor down the street and get the bad treatment. You don’t get it here.

Even the way that adverse events are reported is manipulated by the drug companies and the FDA, in collusion with one another. You have an institutional conflict of interest with the FDA: the organization that approves drugs should not be regulating them in the marketplace. Why? Because in order to withdraw a drug, the FDA essentially has to admit that it was wrong to approve it. One step in the right direction, in addition to posting trials online in advance, would be requiring proof that the drug is not only better than nothing but also better than other drugs on the market. That way, we avoid the “me too” drugs that do no more than mimic other drugs. We should also split the FDA into two agencies—one that approves drugs and one that monitors safety. That way, the one that monitors safety in the marketplace might not be so inclined to allow a bad drug to stay on the market.

If you go back and look at the Merck debacle with Vioxx, you will find that for many, many years before that drug was taken off the market, the FDA knew, as did Merck, that the drug was seriously dangerous. The same thing is true for Accutane and Crestor. These are dangerous, terrible drugs; they shouldn’t be taken by anybody. Yet the government didn’t do anything about Vioxx until tens of thousands of people had died.8

The FDA is no less flawed when it comes to regulating supplements, functional foods, and fortified foods. The supplement and food industries have been able to influence decisions at the FDA for years. The FDA long ago succeeded, unintentionally, at getting public sentiment on the side of the supplement makers by using tactics that were so outrageous and over the top as to provoke a backlash. Before the Dietary Supplement Health and Education Act (DSHEA) of 1994 was passed, the FDA had done things like raid the office of a doctor who was making his own vitamin C formula. They used heavily armed Alcohol, Tobacco, Firearms and Explosives agents to hold people in the office at gunpoint as the agents confiscated the office records. That’s an example of a kind of governmental overreach that breeds contempt of government. DSHEA got the FDA off the back of the supplement industry and allowed the supplement manufacturers to make generalized, unsubstantiated claims about how a given supplement may support the function of a given organ. The FDA is now toothless in dealing with the supplement industry, and given the history of the FDA, we’re probably better off that way.

GM: The FDA may be ineffective when it comes to doing things like pulling dangerous drugs off the market, but it can be remarkably effective and tenacious opposing nonconventional forms of treatment.

PP: Oh exactly, exactly, because their real client is the drug companies. If you look at most of the decisions that the FDA makes, it’s acting in the interest of the drug companies. When Andrew von Eschenbach was head of the FDA, Avastin was approved for breast cancer treatment. It does not extend the life of breast cancer patients by a single day, but signing that order resulted in billions of dollars in sales for Genentech.9

That decision benefited Genentech, but it did not benefit most of the women who took the drug. And while people love to beat up the insurance companies over these issues, consider the plight of an insurance company that was forced to pay $90,000—that’s what Avastin costs the average patient annually—for a drug that does absolutely nothing at all, because the drug companies lobby Congress to force Medicare to pay for it. Once Medicare pays, then all the insurance companies have to pay. We like to beat up the insurance companies, but they’re being mandated to pay for a lot of ineffective treatment, yet still have to make a profit, make their shareholders happy, and pay for all these unnecessary diagnostic tests and annual visits to the doctors and on and on and on. So the whole system is screwed up and the FDA is a vital cog in that very screwed-up wheel.

GM: Still, it’s the USDA, not the FDA, that comes up with the Food Pyramid, or the Happy Plate, or whatever it calls its recommendations now.

PP: That’s correct—and in conjunction with the Department of Health and Human Services.

GM: How did the USDA get involved in deciding what the healthiest diet should be? Why do we trust an agency that’s supposed to deal with farm issues to tell us what to eat?

PP: We shouldn’t. The conflict of interest stares us in the face. Its recommendations are all about promoting certain sectors of agriculture, not about what the healthiest diet should be. The most blatant example of the corruption is the “checkoff” program.

GM: Explain how that works.

PP: With the dairy checkoff, for example, for every hundred pounds of milk that dairy producers sell, they are mandated to contribute fifteen cents to the program. That money is spent on marketing dairy products to the public, like the “Got Milk?” campaign. It’s also spent on direct marketing of dairy products to schools, on promoting the use of butter, on partnering with fast-food chains to offer more cheese in their pizzas or more milk in their coffees, and on research to create new and more devastating uses of dairy.

But it’s not only dairy. There’s also a pork and a beef checkoff program. Cattle producers pay a dollar a head. Let me read to you from a website funded by the beef checkoff program a little ditty called “Feel Good about Loving Beef”:

Isn’t it great that a food you crave can be so good for you too? Beef is easy to love because it tastes so great, but it’s also a naturally nutrient-rich source of ten essential nutrients. The protein in beef helps strengthen and sustain your body. Evidence shows that protein plays an important role in maintaining healthy weight, building muscle and fueling physical activity. And when you’ve got all that going for you, you and your loved ones are one big step closer to a healthier lifestyle and at lower risk for disease.10

GM: That’s very nice. Conservatives are always saying that government should get out of the way and let private businesses run things efficiently without bureaucratic interference. But the checkoff program seems to me a good example of government and business working in complete harmony on a disinformation campaign.

PP: Yes. Working hand in hand to help make people sick and obese.

GM: Does the FDA get involved in nutrition at all?

PP: It gets involved only to the extent that it regulates, along with the Federal Trade Commission, the sale of supplements and the approval for structure/function claims that can be made about certain nutrients and the labeling of fortified functional foods. So we can thank the FDA, for example, for allowing cholesterol-lowering claims to be made for margarine products that are 100 percent fat because the companies fortify the margarine with beta sitosterol or plant sterols, which have been known to lower cholesterol.

GM: You’re kidding me? In other words, you could take pork fat, inject a little bit of niacin in it, and make a cholesterol-lowering claim for that?

PP: Basically, yeah. You’ve come up with a viable business model.

GM: But it doesn’t seem kosher.

PP: And this constant bantering back and forth that goes on between the FDA and the food companies about fortifying foods by adding omega-3s to white bread, and the health claims that can be made for that nonsense, is unconscionable. If we want to reduce the incidence of coronary artery disease, for example, that means that we’ve got to, on the federal level, start giving people the right advice. Here’s why it’s not happening. If you give the people the right advice, it means you’re going to tell them to eat more of something, less of something, and none of something. Then you’re going to tick off manufacturers and agricultural groups, something the government is unwilling to do. So whose side is the government on? It’s willing to sacrifice tens of millions of people to horrible treatments, drugs, unnecessary procedures, and even deaths every year so that it doesn’t tick off the National Dairy Council? So that it doesn’t upset Kellogg’s? That’s who the federal government is working for, not us. It does not function in the interest of the public health.

GM: Do you have a theory about whether the decision makers at the FDA—and for that matter the AND, the AMA, and so forth—believe that they’re doing the right thing? Do you think that they’re simply in the dark scientifically, but that they at least believe that the science is on their side? Or do you think that they know that what they’re promoting is untrue and evil and corrupt, but they’re just making a living?

PP: I think some of both. First of all, health care professionals in general often do not have a very good understanding of how to read and interpret research. A common issue is reporting data in relative versus absolute terms. For example, patients are told that a 50 percent reduction in the recurrence of breast cancer results from taking tamoxifen. And boy, with those results, who wouldn’t take it, right? Then you discover the recurrence rate is 1.3 percent; with tamoxifen, recurrence is reduced to 0.68 percent, which is actually a 49 percent reduction, but the real or absolute benefit to the patient taking tamoxifen is one-half of 1 percent.11 Once someone looks at the side effects, nobody in her right mind would say, “Oh, I’m willing to endure all of this to reduce my risk of a recurrence of breast cancer by half a percent; it’s an insane trade-off.” So, part of it is well intentioned but poor science, combined with a mind-set that all the solutions to our problems must be drug related. They view their findings through that filter.

And then the other side of it is just pure money. We’re not going to tick off anybody who’s in a position to hurt us. The late Senator George McGovern learned that lesson long ago, and it’s had a chilling effect that’s lasted decades.

GM: What happened to Senator McGovern?

PP: Senator McGovern chaired a Senate committee that started looking into a shift from Americans being malnourished to Americans suffering from diseases of excess. And he had Ancel Keys testify in front of his committee. Keys had done the Seven Countries Study that helped establish the role of cholesterol in cardiovascular disease. As a result, Senator McGovern and his committee issued some dietary recommendations; you and I wouldn’t like them a whole lot, but they’re a whole lot better than the guidelines at the time. They discouraged overreliance on animal foods and processed foods. The food business—the agriculture groups—were incensed by this and got together, determined to take him out. Senator McGovern lost his bid for reelection in large part because of the enormous amounts of money that came from the cattlemen’s associations and the dairy industry and the agriculture groups that said this guy’s bad for business. So all the politicians looked around and said, “You know what, it’s not profitable to stand up to the agri-foods complex.”

GM: In the end, the recommendations of the USDA and the FDA and the AND tend to get filtered through doctors, so let’s talk about medical doctors. They get how many hours, typically, of training in nutrition?

PP: Tufts University is the best and those doctors get seventeen hours; that’s not seventeen credit hours; that’s seventeen classroom hours in nutrition. They’re the best in the country.

GM: And the worst?

PP: That would be about three-fourths of them, where the subject’s not even discussed at all. And in most of the rest, a cursory review of nutrition is about the best you can hope for. I’ve had current medical students tell me that when the subject of nutrition comes up, it’s dismissed as inconsequential. Their attitude is that patients can always be referred to a dietitian or whatever. There is absolutely no awareness—and this is true for all health care professionals. Nobody is taught that diet is the cause of the diseases we battle and nobody is taught that diet will reverse them. A doctor or a dietitian or a nurse practitioner or a physician assistant who goes to school is not taught that you can reverse early-stage multiple sclerosis with diet. They’re not taught that diet causes it and they’re not taught to reverse it. In fact, none of them are taught to reverse any condition. They’re taught to treat symptoms with drugs.

GM: Now, we can assume that most med school students are highly intelligent.

PP: Undoubtedly.

GM: Is it possible that they could go to med school for four years and, even if they’re not taught anything about nutrition in med school, not see the relationship between, for example, diet and heart disease, and just focus on pharmaceutical and surgical interventions?

PP: Well, even if they see the relationship, they need to be quiet about it. Friends of mine who are physicians advocating a low-fat, plant-based diet in their medical practice have children who have applied to medical school and mentioned in their essays their interest in helping patients regain and maintain their health with diet. Their applications were met with disinterest and in sometimes open hostility; in one instance, an applicant was instructed to sanitize his application of this information in order to be considered.

GM: All the same, there are obviously many doctors who give advice about diet, even if they’ve had no formal training in the subject. I would think that most doctors who have patients with heart disease discuss with them whether hamburgers or cheeseburgers or hot dogs are a good idea. I mean, even the general public knows that cheeseburgers contribute to heart disease.

PP: There are a few things that need to be said about the advice that people do get from doctors. The first is that doctors tell patients to reduce the fat, lose a few pounds, to try to eat less red meat. They buy into the myth that if you eat chicken and fish instead of red meat, it will help you tame your coronary artery disease, which we know is not true. The second thing is that the recommendations tend to be so general that the person has no idea what to do with them. One thing that we’ve learned at The Wellness Forum is that the specificity of the instruction has a lot to do with the outcome. If I tell you, “Hey, Glen, eat a little bit less of this,” you don’t really know what that means. If I say, “Glen, do not eat this; I want you to eat that instead,” you now have a specific directive. The likelihood that you’ll know what to do and be able to follow through on all my advice is a much greater. The information from doctors tends to be vague; in the context of the short office visit, that’s about as good as it’s going to get. The third thing is that some doctors don’t even do that much. They basically say, “Okay, you have coronary heart disease and high cholesterol, but your dad had it and your grandfather had it. It runs in families, so the earlier we treat you with meds or an angioplasty, the better.” The patient is effectively told that he or she is the helpless victim of bad genetic wiring. That victim mentality shines through and sometimes precludes any advice whatsoever about diet from being dispensed, or taken to heart if it is.

GM: There’s also the problem of low expectations, isn’t there? Doctors may recognize that meat and cheese in the diet are harmful, but believe that it’s all but impossible for most people to change their eating habits.

PP: Yes, that’s a problem. The idea that either people won’t try it or they won’t stick with it—that’s taken as gospel, although there are some studies out there that suggest otherwise. You know, Dr. Neal Barnard did the original compliance study on Dr. Dean Ornish’s diet and showed that patients who made bigger changes were more compliant and happier with their diets.12 He conducted a similar study with diabetic patients who converted to a plant-based diet that showed similar results.13

GM: If doctors believe that their patients can’t possibly change their diet and they approach them with that philosophy, then that’s likely going to be self-reinforcing: patients will embrace what’s presented as the difficulty of changing one’s diet.

PP: The more insidious aspect is getting unhelpful dietary advice. Let’s say I develop high cholesterol and high blood pressure and I go to a traditional doctor. Perhaps she is even enlightened enough to have a dietitian in the office. However, that dietitian is trained on the party line, so the dietitian says I’ve got to have skim milk on the cereal, give up hamburgers and cheeseburgers and pizza, but I can have some chicken and fish. So I really work at this, I’m trying. I’m drinking the skim milk that tastes like crap and eating a lot of salmon. I do this for six months and I show back up at my doctor’s office. My cholesterol’s actually gone up and my A1C levels, a marker for diabetes, have also gone up. I had a prediabetic condition and now it looks like it’s developing into full-blown diabetes despite my best efforts for six months and you know what I say? “This dietary change doesn’t work, give me the drugs.” And so the medical skepticism about diet becomes a self-fulfilling prophecy because the dietary advice given out has no chance of helping anybody.

On the other hand, when we put people on the type of diet that actually does work, we get a different form of reinforcement. People get better, they lose weight, they get off their medications, and they don’t want to go back. We get a great deal of compliance because they actually see results from their effort. And that’s the big missing link in what’s going on in the general medical community.

Doctors need to know, and I believe most of them do, that part of their job, if they’re going to be in practice and present themselves as doing right by people, is to continue to learn. It’s the responsibility of any physician in practice to be reading and learning all the time. Now, it would be lovely if one way they would continue their learning would be by visiting, say, Dr. McDougall’s Health and Medical Center in Santa Rosa, California, or our Wellness Forum in Columbus, Ohio. But that’s not what happens. Doctors go to continuing education conferences that are largely sponsored by drug companies. The companies have doctors make presentations about the use of their drugs, many of which are off-label applications, which the drug reps can’t recommend, but doctors and continuing medical education programs effectively can.

GM: Now, doesn’t a lot of that additional education sponsored by drug companies take place at resorts in places like Maui?

PP: Oh yeah, and on cruise ships. And you get to be a presenter by being a high prescriber. There are rewards for being a high prescriber. For example, you and your spouse get an all-expenses-paid vacation for making a presentation on how to prescribe for off-label uses. So even the system of continuing education for doctors is corrupt.

GM: I didn’t know about the rewards for being a high prescriber. I’ve never seen a doctor advertise on a website, “Number-one prescriber of Fosamax.” Why is that?

PP: Professional modesty.