Marcia Angell, M.D., formerly Editor-In-Chief at The New England Journal of Medicine, writes in her highly acclaimed book The Truth About the Drug Companies (New York: Random House, 2004, pp. xvii-xviii):
“[The pharmaceutical industry] over the past two decades has moved very far from its original high purpose of discovering and producing useful new drugs. Now primarily a marketing machine to sell drugs of dubious benefit, this industry uses its wealth and power to co-opt every institution that might stand in its way, including the U.S. Congress, the FDA, academic medical centers, and the medical profession itself.”
Do pharmacists have serious doubts about the safety and effectiveness of many of the drugs they dispense? If so, what is the likelihood that they will speak out in criticism of pharmaceuticals and Pharma? Most people probably assume that physicians and pharmacists would blow the whistle if Pharma deviates too far from truth and reality. In this article, I hope to explain why, from the perspective of a pharmacist, that is very unlikely to occur.
Here are my 12 reasons why pharmacists don’t criticize pharmaceuticals or blow the whistle on Pharma:
[1] Pharmacists who are frequently critical of drugs risk angering their employer and jeopardizing their employment
It is quite possible that many pharmacists agree that Americans are overmedicated (or grossly overmedicated), but those pharmacists fear discussing this topic because they are afraid they could get a reputation as a pharmacist who questions the pill circus in America.
With an oversupply of pharmacists in many parts of the country, pharmacists fear that their supervisor could find out that a number of pharmacists are less than completely enthusiastic about all the pills they dispense. The district supervisor could consequently concoct some pretext to ease those pharmacists out of their job or make them want to quit.
When the district supervisor visits the store, most pharmacists don’t criticize pharmaceuticals or the pharmaceutical industry. After all, we want our supervisor to view us as a loyal team player. Pharmacists are employed by the big chains to move pills, not to question the legitimacy of basing a health care system on a tsunami of pills, and not to get involved in long discussions with our customers about the risks and benefits of pharmaceuticals. Clearly pharmacists understand that they cannot spend their days in chain drug stores using their job as platform to advocate for aggressive regulation and reform of the pharmaceutical industry.
If my district supervisor is standing nearby, it is highly unlikely that I would criticize a drug or make a non-drug recommendation.
If a customer asks me whether a particular drug is safe and my district supervisor happens to be standing nearby, it is highly unlikely that I would criticize that drug. I would almost certainly sugarcoat my answer under those circumstances. If a customer were to ask me to recommend something for a cold or cough or diarrhea or constipation or sore throat or lack of energy or insomnia, etc., it is highly unlikely that I would make a non-drug recommendation if my district supervisor is standing nearby. If a customer asks me to recommend a vitamin, there is zero chance that I would recommend a dietary or lifestyle change (rather than a vitamin) if my district supervisor is standing nearby.
Pharmacists are likely to be more frank with close friends and family when discussing the risks versus benefits of pharmaceuticals.
Many pharmacy customers believe that when they ask their pharmacist for his/her opinion on the safety of a medication, the pharmacist will be as frank and open with them as he/she is when discussing drug safety with close friends and family. In the real world, chain store pharmacists feel subtle yet powerful unspoken pressure from corporate management to be basically positive and supportive about the drugs we dispense to avoid scaring the customer and angering the prescribing physician. Moreover, with dangerously low levels of staffing at the too many chain drug stores, pharmacists simply don’t have the time to answer your questions with as much depth as those questions deserve.
[2] Pharmacists fear being ostracized by their peers for being critical of pharmaceuticals.
The views I have expressed in articles I’ve written since my retirement would have been met with tremendous disdain from other pharmacists if I were still in the workplace. Indeed, among the hundreds of pharmacists I’ve met during my career, I never encountered one with whom I felt completely comfortable discussing my preference for prevention instead of pills. I was always afraid that one of my supervisors would hear about my concerns and then devise some excuse to ease me out of my job.
[3] Pharmacists rarely if ever see critiques of Pharma or pharmaceuticals in their pharmacy magazines, pharmacy journals or at continuing education seminars, nor are pharmacists eager to read the dozens of books critical of Pharma.
It is very remarkable to me that critiques of the pharmaceutical industry are quite common in the mainstream media (The New York Times, Wall Street Journal, Bloomberg BusinessWeek, etc.) but are completely absent from the largest circulation pharmacy magazines (Drug Topics, Pharmacy Times, US Pharmacist, etc.). The major pharmacy magazines are typically very pro-industry because they receive most of their revenue from lavish Big Pharma advertising for their latest wonder drugs.
Here is a comment posted by a reader in response to one of my previous articles for The People’s Pharmacy:
“Pharmacists, like fish who live in and are dependent upon an environment of water, are as much a part of the culture, with all its ills, and therefore unaware of the extent to which they are a part of the problem. Confirmation bias found in trade publications puts blinders on their eyes so they do not see the negative impacts of the pharmaceutical industry.”
Even though there are dozens of books available on Amazon that criticize the pharmaceutical industry, pharmacists seem to be among the people least eager to read these books. I don’t recall ever seeing a discussion of any of these books in pharmacy magazines even though these books are absolutely extremely relevant to any understanding of pharmaceuticals.
For example, I do not recall seeing any mention in pharmacy magazines of the book that is possibly the most widely read expose’ of the pharmaceutical industry, “The Truth About the Drug Companies: How They Deceive Us and What To Do About It,” by Marcia Angell, M.D., formerly the editor in chief at The New England Journal of Medicine.
Here is a comment posted by a pharmacist in response to one of my previous articles for The People’s Pharmacy:
“It’s very simple why pharmacists don’t want to read books critical of the pharmaceutical industry. It’s basically burnout from a system that promotes overwork, terrible schedules, and is already burdened by the complexity of being expected to be 100% accurate, learning and retaining the extensive knowledge of what drugs are used for, when they shouldn’t be used, minor to major interactions and contraindications, plus following an extensive set of laws and regulations, and then, after a stressful work day, dealing with the rest of life’s demands in everyday living and family life.”
I practiced retail pharmacy for nearly 30 years. It becomes a nearly inescapable tyrant that invades every aspect of your life. Even if you get 3 or 4 weeks of vacation, it’s often not possible to take it when you want to. Then add Covid, politics, etc. I could continue on, but the simple answer is, after you invest large amounts of time and money getting educated, and still need to pay off those expenses, plus the everyday expenses of living, then face all the pressures of the profession, why would you want to add to your list of anxieties and problems more negative information to dog you and plant nagging doubts?
…By the way, I am NOT in the profession any longer. I watched manufacturers inflate prices for 30 years beyond any degree of necessity, while chains stomped out nearly all independent competition. I make less than 50% of what I used to, but I at least have my mental health back and can sleep at night. It wasn’t easy divorcing a profession, but it’s the best thing that ever happened to me.
[4] Pharmacists who worry excessively about possible harm from pharmaceuticals are likely to experience mental stress from the inconsistency between their beliefs and the need to be relentlessly positive about pills.
It would exact a heavy toll on the psyche of health professionals to maintain serious doubts about many of the pills they prescribe or dispense, and to have doubts about whether the quick-fix pill for every ill approach is the best one, and yet engage in that activity every hour of every workday. Thus it is easier to sublimate those unsettling views and fully embrace the pill juggernaut in America.
In psychology, cognitive dissonance is the mental stress or discomfort experienced by an individual who holds two or more contradictory beliefs at the same time. According to Wikipedia, cognitive dissonance theory is founded on the assumption that individuals seek consistency between their expectations and their reality. An individual who experiences inconsistency (dissonance) tends to become psychologically uncomfortable. Since it is impossible for a thinking person to hold two mutually exclusive beliefs simultaneously, anxiety is usually the result.
Cognitive dissonance is inevitable in every pharmacist’s life when faced with these contradictions:
—The contradictions between the glowing picture of drugs painted by direct-to-consumer advertising and the reality of a long list of potential side effects
—The contradiction between the FDA’s seal of approval and the reality that many side effects don’t appear until after a drug is on the market
—The contradiction between the fact that our health care system is based on drugs and the reality that prevention is safer and more effective than pills
Cognitive dissonance often arises when there is conflict between a pharmacist’s positive concept of himself/herself (The drugs that I dispense are safe and effective), and the reality (Some drugs do more harm than good).
Pharmacy students graduate from pharmacy school heavily invested intellectually in the concept of pills for everything. Questioning that concept can cause major emotional conflict. We studied so hard in pharmacy school and now we’re confronted with the realization that pharmaceuticals are grossly over-prescribed in a culture in which marketing is what drives pharmacy.
Adding to the emotional conflict is a concern that pharmacists don’t want to upset our parents and/or spouse by stating that we’re disillusioned with our career choice. After having spent a large sum of money to obtain our pharmacy degree, our parents and/or spouse might be very upset if we reveal discontent with the pill for every ill focus of modern medicine.
Here is an e-mail I received from a pharmacist in response to my Drug Topics commentary titled “Pharmacists and Cognitive Dissonance” (https://www.drugtopics.com/view/pharmacists-and-cognitive-dissonance):
“I can’t believe you can read my mind so perfectly! The cognitive dissonance you speak of is as familiar to me as getting out of bed in the morning, and much less palatable. How DO you reconcile what you know to be true with what you must tolerate to survive. For many years, I have felt “two-faced” or phony in my practice of pharmacy. What I really want to do is tell my customers to flush the medication and start taking care of their bodies. What I have to tell them is how the medication will “help” them, and how they should take it faithfully. I’ve played the part as long as I can. I’m getting out. I can’t in good conscience keep shoveling this stuff out. Keep up the good work!”—Tired Pharmacist
[5] Chain store pharmacists very often don’t have adequate staffing to allow for substantive discussions with customers about the risks versus benefits of pharmaceuticals.
Production metrics are what drive chain drug stores. Understaffing increases profitability by forcing all employees to work at maximum output for their entire shift. With severe understaffing at chain drug stores, there are simply not enough warm bodies present that would allow pharmacists the opportunity to engage in thoughtful discussions with customers about the risks vs the benefits of pharmaceuticals. When pharmacists express some doubt about a drug, our customers rightly expect us to explain our reasons in adequate detail.
Giving positive answers to customers’ questions about the safety and effectiveness of drugs simply makes the production line move faster. The big chains don’t want pharmacists who spend too much time speaking with customers and discussing the importance of prevention through dietary and lifestyle changes.
[6] Pharmacists believe that our customers want us to validate their preference for pill solutions for everything.
Customers want quick-fix pill solutions for every health problem and they have unrealistic expectations for pharmaceuticals as a result of lavish spending by Big Pharma on drug advertisements. Customers are often disappointed when a pharmacist attempts to direct them toward non-drug solutions such as dietary/nutritional and lifestyle changes.
Too many pharmacy customers seem to want pharmacists who reinforce their (the customer’s) view that there is a pill for every ill. These customers come into the store looking for a pill and seem to be disappointed when they get verbal advice rather than a recommendation for a specific miracle pill. These customers want definitive solutions (a specific pill, liquid or cream) rather than a more nuanced answer like the need to eat more nutritious food, lose weight, exercise, avoid tobacco and alcohol, etc.
Customers seem to think there’s a single best product for every medical complaint.
Pharmacy customers seem to believe that every medical problem has a definitive solution just like every math problem has a definitive solution. Typically when I provide a nuanced answer, the customers are irritated or disappointed. They often seem to assume that my nuanced answer (involving dietary and lifestyle changes) is a sign that I don’t know what single product is best for their medical problem. As they walk away, their attitude seems to be “Well thanks anyway. I’ll try to find a pharmacist who knows the correct answer.”
I concluded shortly after graduating from pharmacy school that I needed to recommend a product when requested, rather than recommend a dietary or lifestyle change. These customers come into the drug store looking for a product and they are invariably disappointed to receive dietary or lifestyle advice instead of the recommendation for a specific product.
“I just don’t have any energy. Can you recommend a vitamin?”
One of the most frequent questions that customers ask pharmacists is, “I just don’t have any energy. Can you recommend a vitamin?” I learned very early in my career that most customers don’t want me to tell them that dietary/nutritional changes, getting more sleep, etc. may be more effective than taking a vitamin supplement. So I typically recommended Centrum because it is a well-known product and, if the customer didn’t experience any improvement in his/her lack of energy, he/she would blame the Centrum, not me.
[7] Pharmacists have a tremendous fear of being sued if our comments about the risks versus benefits of drugs cause a customer to unilaterally discontinue a drug and something bad happens as a result.
It is extremely risky for pharmacists to be critical of pharmaceuticals because, for example, one or more of our customers might decide to discontinue the pill we criticize, and then if something bad happens as a result of discontinuing that pill, we could be sued and our future livelihood could be in jeopardy.
It is so much easier to have a positive attitude toward all the pills we dispense. That keeps our employer happy, it keeps doctors happy, it reinforces our customers’ expectations that there is a pill for every ill, it makes the production line run faster and smoother, and it means that we are not risking being sued because someone discontinues a drug as a result of our criticism of that drug.
[8] Pharmacists largely agree with Pharma’s focus on the health of individuals rather than on the health of society.
Pharmacists were force-fed in pharmacy school the view that targeting the individual person (or, more specifically, targeting an individual’s molecules and cells) with pharmaceuticals is a more rational approach to health than focusing on better nutrition, cleaner air and drinking water, exercise, avoiding tobacco and alcohol, etc.
Pharmacists have accepted as normal our hyper-individualistic culture. Pharmacists don’t seem to understand or care about social, cultural, political, economic, dietary/nutritional and environmental factors in the causation of human disease.
That’s why I feel that a pharmacist’s education should move toward a focus on social sciences and away from chemistry. In pharmacy discussion groups, pharmacists often comment disparagingly that pharmacy school requires a heavy emphasis on chemistry even though pharmacists rarely use that knowledge of chemistry in the drug store. The public is shocked by that fact given that many people associate pharmacy closely with chemistry.
Most pharmacists seem to be very comfortable with Big Pharma’s focus on individual pathology rather than the pathological aspects of modern societies. Pharmacists seem to accept as reasonable Pharma’s focus on manipulating molecules and cells with synthetic chemicals (pharmaceuticals) that are foreign to human evolution. Pharmacists don’t seem to question the reality that Pharma routinely tinkers with highly complex and often poorly understood biological processes that Mother Nature had well in hand for hundreds of thousands of years.
[9] Pharma’s massive advertising brings customers into drug stores.
I doubt that most pharmacists know that only the USA and New Zealand allow direct to consumer advertising of prescription drugs. I suspect that many pharmacists have come to accept drug commercials on TV as somehow normal. In a rational world, pharmacists would shout from the rooftops that advertising prescription drugs like beer, diapers, and detergent is absurd and something that no sane society should allow.
In my opinion, prescription drug commercials on TV are a sign that our health care system is out of control, that the modern drug store is an example of marketing gone mad, and that the FDA has been fully captured by Pharma. The term “regulatory capture” refers to a situation in which an industry regulated by a governmental agency ends up controlling that regulator.
[10] Pharmacists have a financial incentive to downplay adverse effects of drugs.
Pharmacists have a huge financial incentive not to believe or accept criticism of pharmaceuticals. Most pharmacists have a family and are confronted with paying off their college loan as well as house payments, car payments, and saving for kids’ college education. Pharmacists perhaps understandably don’t want to hear criticism of pharmaceuticals because such criticism represents a threat to their livelihood. Without a doubt, the dispensing of pills is far more financially lucrative than teaching people to be healthy so they need fewer pills.
[11] In pharmacy school, pharmacists were force-fed a very narrow view of health based on manipulating delicate biological processes with synthetic substances
In my opinion, most pharmacy students graduate from pharmacy school starry-eyed over the molecular and cellular approach to health. They maintain throughout their career a fervent belief in a technological approach to human health, rather than an approach based on the importance of dietary and lifestyle factors. The absence of emphasis on the importance of dietary and lifestyle factors in my pharmacy school curricula was, to me, egregious and shocking.
In the USA with its abundant social, cultural, political, economic, and political problems, pharmacists cling tightly to molecular and cellular explanations for disease and health. Why don’t pharmacists look around and see the widespread pathology in our society and see how it adversely affects human health?
I am quite serious in stating that pharmacy school has an eerie resemblance to a seminary. In pharmacy school, it is taboo and almost blasphemous to say that prevention of disease may be superior to pills.
Pharmacy school has a powerful effect in causing students to have a positive attitude toward the drugs they dispense. If I were to stand up in pharmacy school and say that I’m more interested in prevention than pills, I would be viewed as an outcast or enemy. Pharmacists earn their living by selling pills, not by advising people how to prevent disease with dietary and lifestyle changes.
Pharmacy professors’ definition of acceptable science is comparing Drug A vs Drug B or placebo rather than comparing, for example:
Drug A vs dietary change
Drug A vs exercise
Drug A vs lifestyle change
Drug A vs weight loss
Drug A vs getting more sleep
Drug A vs getting a divorce
Drug A vs a change in jobs
Drug A vs a whole foods diet
Drug A vs a firmer mattress
Pharmacy professors seem to have a very narrow view of what constitutes acceptable science: science in the service of pharmacy as a business. Pharmacy schools promote a view of drugs that basically aligns with Pharma’s view.
I view most retail pharmacists (as opposed to hospital pharmacists) as having an attitude similar to a small town grocer. The pharmacist’s job is to sell pills, not to educate the public about how to prevent disease.
12] Pharmacists truly believe that modern medicine and pharmaceuticals (not public health) are the primary reasons for the big increases in life expectancy in the last hundred years.
Modern medicine has played a role, but that role has been modest compared to public health factors like better sanitation, better nutrition, better housing, cleaner water, etc. For example, see Ilana Strauss, “Does Medicine Actually Make People Live Longer?” HuffPost.com, Jan 10, 2019.
In Conclusion
For these twelve reasons I believe it is highly unlikely that pharmacists will blow the whistle on Pharma any time soon. Pharma has succeeded in co-opting pharmacists the same way it has co-opted doctors, the FDA, academic medical centers, medical journals and even the U.S. Congress.
Dennis Miller, R.Ph. is the author of The Shocking Truth About Pharmacy: A Pharmacist Reveals All the Disturbing Secrets. The entire book is available for download from Amazon for 99 cents.
