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460 Cobert’s Manual of Drug Safety and Pharmacovigilance
Dynamics in Play Regarding
Drug Safety and Consumer
Groups, Disease Groups,
and the Internet (Blogs,
Websites, Social Media, etc.)
These groups are usually non-profit organizations
created by patients with common diseases or medi-
cation use.
There are organizations or sites set up with other
goals in mind. They alert their readers about dan-
gerous drugs and may refer the person to an attor-
ney if appropriate.
Also see Worst Pills, Best Pills (www.worstpills.
org/), run by the Public Citizen’s Health Research
Group. This nonprofit group notes that it gives an
“expert, independent second opinion for prescrip-
tion drug information”.
A common view among some patient groups (and
even some medical groups) is that the industry is
monolithic and “bad”. The groups often believe
(sometimes quite rightly) that the industry regards
them as adversaries. They often believe industry can-
not police itself and do not trust industry drug safety
conclusions. Of course, the same has been said about
banks, stockbrokers, tobacco manufacturers, etc.
There are now many blogs, websites, Facebook/
Meta sites, podcasts, webinars, tweets, and all sorts
of other social media sources of “information”,
often uncurated, on drugs, drug safety, and related
issues. Some are polemical and have “aggressive”
points of view; others are more “balanced”; some
are academic; some are for-profit groups; some are
from pharmaceutical companies (though this is not
always evident) and more. Social media (Twitter/X,
Facebook/Meta, etc.) are now being used for drug
safety information both by companies and health
agencies and attempts are underway to try to use
increased buzz on social media as an early signal
for drug safety problems. Artificial intelligence and
machine learning are evolving to automate certain
aspects of screening these sources for meaningful
safety information. As always, a healthy skepticism
is necessary when visiting these sites, especially
when their provenance and funding are unclear.
Drug safety issues draw eyes to websites, blogs, and
television.
Such stories do not need to be based on scientific
data but may rather rest on accusations or human
interest issues. Safe drugs do not make good stories.
Dangerous ones or potentially dangerous ones do.
“Fake news” occurs.
There is no obligation to present both sides of a story.
There is little obligation to correct stories that turn
out to be incorrect, fake news or overblown (“A lie
can travel halfway around the world while the truth
is putting on its boots” — Mark Twain).
Experienced reporters and television personalities
are far more skilled at communicating on televi-
sion and in the media than drug safety personnel
(even those who have had “media training”) and
can make a non-media-savvy interviewee look quite
silly or foolish.
Data presented in the media may be “precise” but
not “accurate”. Data may also be presented that are
of little clinical meaning or that represent a hypoth-
esis, or a “study” based on a handful of patients
(“coffee linked to pancreatic cancer”).
Dynamics in Play Regarding
Drug Safety and Lawyers/
Litigation
Few people in the medical profession want to have
anything to do with lawyers or litigation. Drug
safety personnel in the industry and government
are no different and generally do not like to give
depositions or testify in court; most try to avoid
lawyers and litigation.
Dealings with lawyers and litigation tend to take
enormous amounts of time and offer little in
return to the safety personnel involved. Testimony,
whether in court or at depositions, is usually highly
stressful and time-consuming.
Law and litigation involve, usually, adversarial pro-
cedures and are very different from the collegial,
consensual, and scientific approach most safety
officers have from medical training, experience, and
affinity. There is no obligation to be even-handed or
to present both sides of the story.
Ethical Issues and Conflicts of Interest 461
There are monetary goals involved in lawsuits in
addition to the claimed goals of fairness and justice.
Codes of Conduct
Various groups have put out codes of conduct (usually
voluntary) for marketing and detailing drug information
to physicians and other healthcare professionals. See, for
example, the codes put out by the American pharma-
ceutical industry association PhRMA at https://phrma.
org/ or by the EFPIA in the EU (https://www.efpia.eu/).
Furthermore, strict codes putting limits on detailing
have been put forth by hospitals, medical centers, and
certain US state governments. There is a lively debate
ongoing about the best way to convey information on
pharmaceuticals to physicians and other healthcare pro-
viders as well as patients. Similarly, direct-to-consumer
advertising in the United States has elicited strong and
sometimes angry discussions. The use of social media
and the Internet is now playing a large role in this now
rapidly changing area and is often out of the control
of government or industry. Most physicians now use
handheld devices, e.g., smart phones, to access medical
information. Whether this is improving the health of the
public is unclear though.
Comments and Summary
The entire field of drug safety is chock full of poten-
tial conflicts of interest and personal or institutional
agendas, some of which are obvious and some less so.
No one owns the truth. Trust but verify. All statements
should be questioned, and skepticism is a virtue. Safety
profiles of products are incredibly dynamic and change
almost daily. What is true today may not be so tomor-
row. Beware of statements such as those listed below.
They may not all be false, but they should be viewed
with skepticism until proven otherwise:
“Of course I’ve consulted for XX, Inc., or received a
speaker’s honorarium or accepted travel funds, but
they do not influence my judgment in any way.”
“Of course I see drug reps, but they are not my
sole source of information and I make independent
judgments.”
“I’ve never received a dime from industry. (But
I own a lot of their stock. Or my wife or children
do.)”
“This drug is (perfectly) safe.”
“This drug has no side effects.”
“Our only interest is the public health.”
“I only do what is right for the patient, not the clin-
ical trial or company.”
“This drug has not been proven to produce atrial
fibrillation” (or some other serious AE). “The cases
we do have are under investigation and all the
patients had risk factors.” “The serious AE was due
to the patient’s lifestyle and risk factors.” (This may
be true today but it may change tomorrow).
“We have no reports that this drug caused atrial
fibrillation.” (But someone else might and we hav-
en’t looked.)
But all is not lost, nor does cynicism reign every-
where. The current system, which is made up of mul-
tiple competing forces sometimes pulling in different
directions and sometimes even in the same direction,
has tended to arrive at the truth after all is said and
done. It arguably takes too long and some people are
hurt and some even die in the course of getting to the
“truth”.
From the ethical viewpoint, PV people working
in the pharma industry must be clear about what is
and is not acceptable to them in their daily business.
Each person must have clear ideas on which limits are
ethically acceptable (patient protection and healthcare
professional information) and which ones are not. Unfor-
tunately, most ethical issues are grey, not black and white.
Thus, the line between acceptable and not acceptable is
not hard and fast. What was acceptable 40 years ago (e.g.,
placebo controlled trials, trials in prisoners) and what is
acceptable now may change. Each person must decide in
each tricky case what is acceptable and what is not; and
he or she must decide what could justify further actions
such as: (1) disagreeing with management (for a pro-
posed labeling update for instance) or (2) even going up
the company chain to the chief medical or safety officer,
(3) an alert to make public your disagreement within the
company, public media information, etc., or (4) as a last
resort, resignation. Fortunately, such situations tend to
be rare and exceptional within pharma companies, but
they do happen.
462 Cobert’s Manual of Drug Safety and Pharmacovigilance
We have nothing better yet, but many people in
the health agencies, the industry, and elsewhere are
searching assiduously for better validated methodol-
ogies in the world of drug safety. That will probably
arrive sooner rather than later as we learn glean insights
from the massive volume of accessible data in digital
form. The conflicts of interest, however, will likely con-
tinue. The history of science suggests we will get better
and better, though slowly, asymptotically, and with pain
along the way.
CHAPTER
463
45
Universities and
Academic Medical
Centers
T
his chapter was written to give
you a sense of how these enti-
ties may interact with the safety
and pharmacovigilance function. It
also provides some historical context
so that one may understand how we
came to where we are today in terms of
the often unique interactions between
institutions and the pharmaceutical
industry.
Universities and academic medical
centers have multiple areas in which
they interact with the drug safety
world:
Discovery and licensing;
Translational medicine;
Specialized clinical research units (CRUs) that run
studies;
Other clinical divisions that run studies;
Development of “companion” diagnostics for novel
therapeutics;
Training medical students, pharmacists, nurses,
epidemiologists, and other healthcare professionals;
Ethics Committees/Investigational Review Boards;
Data safety monitoring committees and adjudica-
tion committees;
Consultation to the industry and regulatory assess-
ment panels;
Reporting suspected ADRs that occur in the hospi-
tal or public health clinics.
The Bayh–Dole Act in the
United States
The Bayh–Dole Act, or Patent and Trademark Law
Amendments Act, was passed in 1980 (35USC200-21
464 Cobert’s Manual of Drug Safety and Pharmacovigilance
and 37CFR401). Among other provisions, it gave uni-
versities the right to hold patents for discoveries from
research that they performed that also had federal fund-
ing. Government agencies had been hesitant about let-
ting universities and small businesses obtain or license
government-held or government-sponsored patents.
This law encouraged universities and small businesses
to move discoveries into the marketplace. Examples
include the following:
Professor Jan Vilcek and colleagues at the New
York University School of Medicine developed the
drug infliximab (Remicade
®
), from which many
millions of dollars in royalties were made. Profes-
sor Vilcek donated $105 million to the medical
school (New York Times, August 12, 2005). NYU
made $1 billion in research-related income, pri-
marily from Remicade
®
. Such arrangements even-
tually made it possible for NYU medical students
to study tuition-free.
Emory University entered into a royalty agree-
ment for $525 million from the sales of emtricit-
abine (Emtriva
®
), a nucleoside reverse transcriptase
inhibitor.
Northwestern University received $1.3 billion in
pregabalin (Lyrica
®
) licensing revenue.
Columbia University received $790 from the “Axel”
DNA splicing patents.
Cohen–Boyer patents on recombinant DNA tech-
nology, which were licensed nonexclusively to over
400 firms, brought in $255 million to Stanford
University.
Not all patents from universities are biomedical,
however. The University of Florida made $288 million
from Gatorade
®
licenses (an electrolyte-replenishing
drink used by many athletes). Many other universities
have made significant income from information tech-
nology patents.
In the American setting, the development of uni-
versity-held patents has, of course, produced lawsuits
over royalties:
In 1999, Glaxo Wellcome agreed to pay the Uni-
versity of Minnesota royalties on the company’s
worldwide sales of abacavir sulfate (Ziagen
®
), an
antiviral AIDS drug, to settle a lawsuit brought by
the university over royalties for patents held by a
College of Pharmacy professor and subsequently
licensed to Glaxo.
Princeton University and the drug manufacturing
company Eli Lilly filed a lawsuit, “… against Barr
Laboratories, alleging that Barr was infringing on
a University patent covering the active chemical in
the cancer drug Alimta.
®
The suit aims to prevent
Barr from manufacturing a generic version of the
drug that brought in more than $1 billion in reve-
nue for Lilly last year” The Daily Princetonian, May
11, 2009.
Stanford versus Roche (2011) involved the issue of
who was the primary owner of a patent. This case
went to the US Supreme Court which held that a
patented invention vests first in the inventor and
assignments of the patent to a third party (e.g.,
Roche) are secondary (563 U.S. 776 (2011)).
If universities and medical centers conduct clin-
ical studies, they also have the usual obligations of
the investigator to report certain safety information to
health authorities, ethics committees, and IRBs, as well
as to contractual partners.
In the EU, even if some academic people are devel-
oping drugs, devices or other treatments, it remains
complex to create an ad-hoc specific private company
which will be in charge of developing, submitting and
marketing the treatment.
Clinical Research Units/
Academic Study Units
Many universities have established clinical research
units (CRUs) in the US, Canada, and elsewhere, includ-
ing the University of Chicago, University of Buffalo,
University of Medicine and Dentistry of New Jersey–
New Brunswick (Rutgers), Duke University, University
of Miami, University of Pennsylvania, Georgetown,
NYU, University of Virginia, State University of New
York, University of Arizona, University of Kentucky,
McGill University, University of Alberta and many
Universities and Academic Medical Centers 465
more. In addition, there are units in the United King-
dom, Belgium, Canada, Germany, France, and many
other countries.
Duke University in Durham, North Carolina, for
example, runs a clinical research organization, which
is one of the largest academic clinical research organi-
zations (CROs) in the world. They have over 200 fac-
ulty members and do phase I–IV trials in 19 therapeutic
areas.
These units may perform both inpatient and outpa-
tient studies in phase I–IV. When functioning as spon-
sors, the CRU takes on all sponsor responsibilities as
outlined in the local laws and regulations (and insti-
tutional policies) for the study wherever it runs as if it
were a pharmaceutical company or a large consortium
running trials (e.g., cancer trials, National Institutes of
Health). When it functions as a study site for a pharma-
ceutical company, its safety functions revolve primarily
around sending AEs (particularly serious ones) to the
sponsor and notifying the IRB of serious cases. Thus,
such units may take on some or all of the safety func-
tions in the trial.
Frequently, individual investigators within univer-
sities or medical centers contract with pharma compa-
nies, CROs, consortia, the National Institutes of Health,
and others to run studies or participate in multi-center
clinical trials. These trials are run separately from the
CRU (if such a unit exists in the institution). In such
a case, the investigator is responsible for complying
with all safety obligations under the regulations and
local university policies. Many universities now set
up offices within the administration that handle such
“extramural” research activities. They offer assistance to
the investigators and ensure that the university collects
the appropriate fees for use of their facilities. Doing
clinical trials may serve as a significant source of rev-
enue for academic centers. Some pharma companies
encourage their medical staff to remain in contact with
medical centers, and physicians in companies often
hold appointments in academia. Some controversy has
arisen where academic physicians and researchers form
for-profit companies that aim to discover, market, or do
further research on drugs. Universities in the US and
elsewhere are now attempting to create clear “firewalls”
between companies and academia even to the point of
forbidding company detailers (reps) from coming on
site. Some academic centers do not allow their staff to
use pens with drug or company logos.
Some countries have much tighter ties between
academia and government. The French health author-
ity has a network of over 30 academic medical/
Pharmacovigilance centers that collect ADRs, advice
and train physicians and other health professionals on
drug safety matters. They also are involved in the safety
signal detection & risk management processes and pro-
vide consultative work for the agency upon request.
Translational Medicine
This concept has two definitions:
1. “For many, the term refers to the “bench-to-bed-
side” enterprise of harnessing knowledge from
basic sciences to produce new drugs, devices,
and treatment options for patients.
2. For others…translational research refers to trans-
lating research into practice; i.e., ensuring that
new treatments and research knowledge actually
reach the patients or populations for whom they
are intended and are implemented correctly.”
1
Translational medicine aims to combine disciplines,
resources, expertise and techniques from the benchside,
bedside and community to promote enhancements in
prevention, diagnosis and therapies. It is interdisciplin-
ary and plays a large role in universities doing clinical
trials. For example, at NYU the Translational Medicine
Division’s goals are as follows:
To understand the action and metabolism of drugs
currently in use;
To help translate laboratory discoveries into agents
for use in clinical care;
1
From Stephen Wolfe, The meaning of translational research
and why it matters, JAMA 2008; 299(2), https://web.archive.org/
web/20100612200225/http://medqi.bsd.uchicago.edu/documents/
TranslationaltheoryT1T2WoolfJAMA1_08.pdf.
466 Cobert’s Manual of Drug Safety and Pharmacovigilance
To understand the genetic and metabolic bases
for responses to and toxicity of pharmacologically
active agents;
To understand and influence those factors that gov-
ern the patient’s capacity and willingness to comply
with pharmacologic regimens;
To study the effects of drugs upon human diseases
as a means to investigate the underlying pathogenic
mechanisms.
Drug Safety Training
in Academia
North America
Academia in the United States and Canada plays a grow-
ing role in drug research though less so in drug safety
and pharmacovigilance. This is unlike the situation
in France, the UK, and elsewhere. There are at most a
handful of departments of pharmacology, medicine, or
epidemiology in North America that play major roles
in the drug safety world. Although academics sit on
advisory committees for health authorities (FDA, Euro-
pean Union member states, Japan), many more make
speeches (often for a fee paid for by the pharmaceutical
companies’ “speakers bureaus”) around the US regard-
ing drug therapy. This is now changing as conflicts of
interest are being actively sought out and, in theory,
stamped out (if that is possible) or at least minimized.
See “Bad Behavior” section.
In addition, many academics perform clinical tri-
als paid for by pharmaceutical companies often as part
of academic CROs or Translational Medicine Units,
thus removing them as neutral observers or consul-
tants on safety. Pharmacology departments in medi-
cal schools have historically played only a minor role
in pharmacovigilance. Much of the drug safety inter-
est and research is coming from IT and biostatistical
departments in universities looking at pharmacoepide-
miology, data mining, electronic health records, drug
utilization, and such.
Pharmacovigilance is rarely taught to medical or
nursing students in North America. On the positive
side, pharmacy schools seem to be incorporating more
drug safety concepts into their curricula, and some
universities are now developing academic certification
and degree (MS, PhD) programs in pharmaceutical
medicine.
Some universities and medical centers offer train-
ing in pharmacovigilance and pharmacoepidemiology
both on site and via distance learning. These include
Temple University, Rutgers University, in the US and the
University of Hertfordshire, London School of Hygiene
and Tropical Medicine, University of London, and the
University of Portsmouth. Some offer degrees (usually
at the Masters level) and others offer “certificates”.
The training that does occur usually involves classi-
cal pharmacology and treatment with minimal (if any)
discussion of the pharmaceutical industry, the FDA or
Health Canada, and the subjects addressed in this book.
Similarly, nursing and other allied medical programs
also have little emphasis on drug safety. Some pharmacy
schools and public health training programs cover drug
safety and epidemiology in their curricula and may
establish rotations through industry or health agencies
during the training of the students. The rudiments of
epidemiology (though not pharmacoepidemiology in
most cases) are taught to medical students.
Europe
Unlike the US, European academic institutions play a
major role in drug safety, often working with the gov-
ernment and health authority. In several western Euro-
pean countries, drug safety teaching seems to be well
integrated in those university hospitals where a phar-
macovigilance reporting center, a drug information cen-
ter, a poison control center, or a pharmacoepidemiology
or epidemiology department exist.
See the European Programme in Pharmacovigi-
lance and Pharmacoepidemiology (https://www.eu2p.
org/about-eu2p/education-programme). This is a con-
sortium of several universities, two regulatory agencies
and 15 industry partners. The universities are Univer-
sity of Bordeaux, France; Fundacio Institut Catala de
Farmacologia Barcelona, Spain; U of Hertfordshire, UK;
Erasmus Univ Medisch Centrum Rotterdam, The Neth-
erlands; Univ Utrecht, The Netherlands; University
degli Studi della Campana Luigi Vanvitelli, Italy and
Universities and Academic Medical Centers 467
associated partners including pharmaceutical compa-
nies and a CRO. They offer short courses, certificates,
Masters and PhD degrees. Most of the training is on line.
Independent Drug Safety Certificates are also available
(Lyon, France)
There are other programs offered in Europe and
Asia as well as occasional courses in South America and
Africa.
Academia in the United States is discovering phar-
macovigilance and transitional medicine and the other
functions of the industry and incorporate them into
training healthcare professionals and others.
Obviously, it is in everyone’s interest for drug safety
and pharmacovigilance to become topics in which all
healthcare professionals are trained and contribute.
Academic Consultation
When academic researchers (physicians primarily)
and healthcare workers consult to the pharmaceutical
industry, much controversy results. This can include
giving (for a fee) opinions on clinical trial programs,
protocols, clinical development, and drug safety issues.
In particular, a sponsor may ask one or more academic
clinicians or pharmacologists to review one or more
case reports of AEs reported with the use of a drug. The
review would help determine whether the AE is related
to the drug.
A google search on
“universities partnering
with pharmaceutical
companies” will reveal
many instances of these
arrangements. Bad Behavior
Various reports in the news and online have indicated
that some physicians involved in clinical trials have
been consulting with Wall Street financial analysts (for
a fee) and it appears that the analysts wanted some
indication of how the particular drug was faring in the
clinical trials, usually in matters of safety as the effi-
cacy data were blinded. Trouble can ensue. In one case a
physician was charged with leaking insider information
on a clinical trial to a hedge fund (“Bail Set for Doctor in
Insider-Trading Case”, Wall Street Journal, November
26, 2010).
Other examples include companies using undue
influence (e.g., money) to influence physicians to pre-
scribe their drugs. The Oxycontin story involving Pur-
due Pharma is another example of harmful interactions
between pharma and physicians, pharmacists and oth-
ers. Books, articles, television shows and other media
have documented this situation. Servier is still involved
in litigation in France over their product Mediator for
appetite suppression in which some 500 people died
from heart valve problems. The product remained on
sale in France even though the drug was withdrawn
years earlier from the US, Italian and Spanish markets.
Consultation also includes giving “scientific market-
ing talks” (discussions of diseases or particular drugs)
to other physicians and healthcare workers on mar-
keted drugs that the sponsor makes. The controversy
here revolves around the independence and impartiality
of consultants who are also receiving sums of money
for scientific marketing activities. Some believe that
full disclosure of all financial ties, even remote, permits
objectivity. Others believe that objectivity in such a cir-
cumstance is never truly possible and that comments
on clinical trial efficacy or drug safety are not unbiased.
Because this practice is fairly widespread, it has pro-
duced, in some cases, difficulties in finding consultants
with no industry ties to serve on FDA advisory commit-
tees and data safety management boards.
See the important article by Marcia Angell, MD
entitled “Drug Companies & Doctors: A Story of Cor-
ruption” in the NY Review of Books January 15, 2009.
The Pharmaceutical Research Manufacturers of Amer-
ica (PhRMA), the organization of the pharmaceutical
companies, has put out several codes and guidances on
industry actions and behavior in research, marketing,
and sales. It has been signed by some 50 companies and
sets certain voluntary standards on drug marketing.
Universities and medical centers are placing more
and more limits on what drug company representatives
468 Cobert’s Manual of Drug Safety and Pharmacovigilance
(“reps”) can say and do in their institutions. In the
United States, many institutions are limiting samples,
free lunches, detailing, and other pharma company
activities in their centers. In France, limits have been
placed on what reps can say and how many free samples
are dispensed to physicians, and it is claimed that these
requirements are now stricter than those in the United
States and Canada.
2
The Joint Commission standard COP.11.6 requires
organizations to monitor the effects of medications on
patients. However, the requirement is not explicit on
reporting adverse drug reactions (or medication errors)
to the FDA, although this is encouraged by the FDA via
the MedWatch Program. Thus, hospitals must develop
some level of drug safety expertise and local standards of
behavior. This is usually via the pharmacy department
or the formulary committee (the group that decides
which drugs will be kept on formulary and which will
not). Requirements outside the United States vary from
country to country.
The Sunshine Act
Since 1999 there have been financial disclosure rules
in the US for Investigators, Industry, and FDA staff.
The regulation (21CFR§54) requires applicants who
submit a marketing application for a drug, biological
product or medical device to file certain information
concerning the compensation to, and financial inter-
ests and arrangements of, any clinical investigator con-
ducting clinical studies covered by the regulation. The
regulation requires applicants to certify the absence of
certain financial interests and arrangements of clinical
investigators that could affect the reliability of data sub-
mitted to FDA. If the applicant does not include cer-
tification and/or disclosure, or does not certify that it
was unable to obtain the information despite exercising
due diligence, the agency may refuse to file the applica-
tion. The government publishes this (see below). Many
companies also disclose all payments to investigators
2
Silversides, Tight regulation of French drug reps mean French
doctors get more balanced information than doctors in the US, BMJ
2010; 341: c6964.
(including fair value of any donated equipment, etc.)
on the company website.
In 2010, the US enacted the “Physician Payments
Sunshine Act” (also called “Open Payments”). This
law requires that drug, biologics, device and medical
supplies manufacturers collect and publish all finan-
cial relationships with “covered recipients”: physicians,
dentists, podiatrists, optometrists, chiropractors and
teaching hospitals. The law covers companies which
provide products to Medicare, Medicaid and the State
Children’s Health Insurance Program. This essentially
covers most of the health companies in the US. It went
into effect in 2013.
It covers such things as the cost of meals provided
to the covered recipients, payments made for services
including advisory boards speakers’ programs, con-
sulting as well as other “transfers of value” not in cash
such as travel expenses, journal articles, equipment, or
subscriptions, etc. It includes indirect payments made
by a third party. It also covers research payments. The
reporting threshold is about $10.
The goal is to make the financial relationship
between the physicians (and other healthcare providers)
transparent to expose and lessen conflicts of interest.
See the Centers for Medicare & Medicaid Services
website covering open payments: https://www.cms.gov/
OpenPayments/
The data is available at https://openpaymentsdata.
cms.gov
There is a search tool for the database which is
moderately user-friendly. One can find summary pay-
ments but also specific physician and hospital payments
and how much the company actually paid that physi-
cian. The data can also be downloaded. The summary
page shows that in 2022 the total money involved was
$12.59 billion to 588,514 physicians and 1,200 teach-
ing hospitals.
Unsurprisingly, various organizations have ana-
lyzed these data and listed the highest monetary com-
panies and physicians. See for example: https://projects.
propublica.org/docdollars/ which has data 3 through
2019.
Universities and Academic Medical Centers 469
This site also allows one to search by doctor or com-
pany name is a user-friendly way. The top company was
Genentech at $478 million and the top doctor received
$29 million in 2018. The top teaching hospital (Univer-
sity of Pennsylvania) received $26 million.
Comment: Has this worked? Is the sunshine help-
ing? The jury is out. Fair compensation for time and
talent at market value is reasonable, but high payments
continue.