November 29, 2007

One Of These Things Is A Straw Man, And The Other Is On Fire


straw men.JPG


Daniel Carlat, of the Carlat Report, has an article in the New York Times Magazine.  It's six pages long, and decidedly anti-Pharma.  But Daniel Carlat isn't from New York-- so why would he have an article published there?

You say: well, where he's from has nothing to do with it, the New York Times is publishing it because of what he says.

Exactly.

His article, well written and persuasive, stands as is, undisputed because there is no forum in which to dispute it.  I guess it would be nice if the Times would allow me to write an op-ed-- you know, in op to the ed-- but I guess this blog will have to do.

Carlat is wrong, very wrong, not because he is factually incorrect about his target, but because his target is a straw man.  The problem isn't Pharma.  It's doctors.


The article, called Dr. Drug Rep, chronicles his introduction into the world of lecturing for drug companies-- a company hires you to give a talk about a topic or drug to a bunch of doctors-- and the effects of the lecturing on doctors and himself, and then his pulling out.  For context, Carlat is a fairly famous psychiatrist blogger who is both a sort of watchdog of Pharma, as well as a source of information about psychiatric drugs. 

The general message is that Pharma softly manipulates doctors to act as proxy drug reps, which in turn lends credibility/celebrity endorsement to the Pharma message, and thus influences other doctors to prescribe the medicine.  Ok, I hear you.  I have no beef with Carlat, his point is not unique.

But break it down:

So we don't want doctors lecturing about the drugs.  Okay.  Well, who do we want?  More reps?  Here's where it all falls apart, and I defy anyone to contradict me: doctors aren't studying these drugs on their own.  Doctors wouldn't know anything about the medicines if it were not for Pharma and its tentacles (reps, speakers, drug company research and publications, etc.)  Carlat himself has written extensively about the supposedly objective "Continuing Medical Education" process being a Pharma -sham.  (Not to mention horrendously useless.)  There is no objective education in medicine.  None.  Stop pretending there is. 

If you want evidence of this, consider that the despite the cardiac risks of Vioxx being publicly-- as in Yahoo! News publicly--  known even in 1999, doctors were surprised when it was pulled.  "What?  They never told us about that..."

And don't tell me there are journals.  They're worse than literary quarterlies, and no one reads them anyway.  Don't believe me?  Ask your doctor to name one single article in any of this month's journals.  Not if he read it; just the title.

You say: well, we don't mind the lectures, per se, we just want them separated from Pharma money.  Oh.  Whose money do you intend to use?

There's a bit of a misconception about what goes on in these lectures.  A doctor doesn't stand up and say, "I've used Effexor, and it's awesome.  Way better than Celexa.  Which kills puppies."  They actually have to use an FDA approved slide deck from which they cannot deviate, even if it's a fact.   For example,  you can't say the following sentence: "There was a study published in the New England Journal..."  unless the FDA allows you to say that.  And doctors are obligated to give "fair balance," which means you must talk about the risks as well as the benefits.  Risks which are prominently featured on the slides.

But that's besides the point.  I am not an idiot, of course, and I understand marketing and how to lean a lecture.  But let's be rigorous. These lectures are intended to get you to prescribe Zoloft over Prozac, not over penicillin.   If I'm "influenced" to prescribe Zoloft instead of Prozac, what's the harm?  Not in theory-- in actuality.  Tell me when Zoloft is inappropriate that Prozac is appropriate.  And if you do discover such a mythical patient, then my choosing Zoloft for that person isn't a case of Pharma manipulation, it's a case of me sucking as a doctor.

The simple problem is that it sounds really bad to have Pharma be so much a part of medical education.  And it is, but there's no other system in place.  If today you fire all drug reps, then you will effectively freeze medical care to November 2007.

Because there is no "objective" system for evaluating and disseminating information, the only way to form an educated opinion is to listen to the different pitches and stories and parse out the truth.  And Pharma is very good at this: Zyprexa's diabetes risks were first popularized by Pfizer, who were defending against Lilly's attack on Geodon about QTc prolongation.   (And don't think for a moment doctors would have figured out QTc risks on their own.)  I think it would be great if academics, or some objective body, could be in charge of this, and in charge of publishing their findings, but this doesn't exist.  It would be great if legal issues could be resolved "objectively," too.  Wish it all you want; that system does not exist, all you have to work with is this the Pharma adversarial system. That's it.  You know what a Pharma free system looks like?  Cuba.

Pharma is the backbone of medicine, because, unfortuantely, medicine is about treatment, not prevention.  If a doctor recommends exercise, or garlic, or even aspirin, it's a sidenote, and a quaint one. "Oh, my doctor thinks I should move to Florida for my asthma!"   Meanwhile, they'll give out the amoxicillin to every crying toddler, even though they know that that is detrimental.  you know why?  Because it looks like a treatment.   It's not all the doctors' fault; but that's the system.

I'm going to repeat this because I know people are going to misunderstand me: the system that you want is impossible to construct in the framework of modern medicine, if for no other reason than doctors don't read-- derive no benefit from reading.  The system does not exist, and you cannot create it.  Psychiatry is politics; medicine is the justice system.  Pharma are the opposing lawyers, and doctors are the jury.  The jury must decide the fate of the defendant-patient.  And the FDA--judge simply makes sure everyone is civil.  Not accurate, save for outright perjury; just civil.

Does this scare you?  Me, too.  But that's the system.  Learn to work in it. 

I should mention that this system is the only one that allows the public-- patients-- access to the information.  In a closed, hierarchical system free of Pharma marketing, patients would have no choice but to completely trust their doctors to know about the medications.  Think about that.

A strange part of all of this is that the target "consumer" for Pharma is doctors; those are the people we want to protect from drug company influence.  But doctors are the most educated consumers anywhere; if they can't separate truth from marketing, what hope does the Chevy Truck demographic have, who hear about no money down?  Do we ban all advertising?

Blaming Pharma is a diversion.  It gets the world distracted from the real issue, which is that medicine is set up-- incentivized-- for mediocrity.





Comments

You say:But let's be... (Below threshold)

November 29, 2007 7:53 PM | Posted by Chris Christian: | Reply

You say:
But let's be rigorous. These lectures are intended to get you to prescribe Zoloft over Prozac, not over penicillin. If I'm "influenced" to prescribe Zoloft instead of Prozac, what's the harm? Not in theory-- in actuality. Tell me when Zoloft is inappropriate that Prozac is appropriate. And if you do discover such a mythical patient, then my choosing Zoloft for that person isn't a case of Pharma manipulation, it's a case of me sucking as a doctor.

I disagree here. I went to a pharma lecture on my third year clerkship, where a psychiatrist was paid to speak on behalf of Seroquel (i think) for maintenance therapy in bipolar, comparing to non-atypical treatments for bipolar maintenance. In this case it isn't one SSRI vs. another, its one drug class (antipsychotic) versus another (antiepileptic / lithium). You complain all the time of vested interests pushing "the Depakote story", but how is this different? One or two studies get used to push a "Seroquel story". And the result isn't docs picking Seroquel over Geodon, it's docs picking Seroquel over Depakote or Lithium.

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Let's say you're right and ... (Below threshold)

November 29, 2007 8:02 PM | Posted by DrSteve: | Reply

Let's say you're right and the average doctor doesn't read at all. The question is why? After all, these are bright, intellectual, ambitious types (at least they were when they got into medical school). Maybe 'mediocrity' is right, but again - why?
In a discussion which may be related, the blog 'The splintered mind' asks why it is that ethics professors are no more ethical than regular folks. Indeed, he notices that ethics book are often missing from libraries - are ethicists actually stealing books? A caterpillar effect is mooted whereby if you think about walking you trip over your own feet.
Now this doesn't answer why doctors don't read. But I'm writing something which may apply. In 2000 it was estimated that hospital-based clinicians needed to read 19 articles a year, 365 day a year, to keep up with the literature; it must be more by now. So, it's an impossible task. Could it be that doctors either choke or panic? Given the enormity of the task at hand do they give up hope and do nothing instead of something?

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I agree with your overall p... (Below threshold)

November 29, 2007 10:48 PM | Posted by Anonymous: | Reply

I agree with your overall point of doctors being accountable, but you miss the point. The truth is that there is an objective way of measuring data [ie RCTs] and that good psychiatrists [not just you] look at the data and "gasp" read articles. Pharma is not the only truth out there- there is a way of looking at the data in an honest way, and coming up with "good enough" rational clinical decisions in psychiatry. Also, in regards to Prozac vs. Zoloft- what about the fact that they have differing FDA indications [for example, prozac has an fda indication for Bulemia, zoloft does not.] Not all SSRIs are the same, they have subtle differences in receptor profiles. Isn't it important that there are at least two RCTs needed to get the FDA approval? At least with Prozac we KNOW that there are at least two RCTs that are positive, we don't know that for Zoloft regaring bulemia. Shouldn't we take that into consideration? Let's all [as psychiatrists] look at the data and really see what the it has to say about our treatments. At least Carlat is out there examining our literature in a critical light. Also, he has on numerous occasions in his blog put the burden on the doctors-not pharma-to begin to make more educated, rational decisions in psychopharm management. This is worthy of our respect.

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"I should mention that this... (Below threshold)

November 29, 2007 11:46 PM | Posted by Huefty Fingleroy: | Reply

"I should mention that this system is the only one that allows the public-- patients-- access to the information. In a closed, hierarchical system free of Pharma marketing, patients would have no choice but to completely trust their doctors to know about the medications. Think about that."
Whoa, only if you have a very interesting definition of "access to information" is this not way off. I'm thinking you mean access to information about the drugs or possible information about how they are marketed, something that isn't really an issue in other systems. My argument hinges on this implies Americans somehow have greater access to information than most everybody else.
Also, is the ability for someone to radically misdiagnose themselves and argue with medical professionals about what drugs they need really so valuable?

Don't act like the current

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Hm... I read. I read the ... (Below threshold)

November 30, 2007 7:58 AM | Posted by HaroldC: | Reply

Hm... I read. I read the Medical Letter and Journal Watch (both without advertising)and I gather my CME from these sources and not from conferences or lunches. I read and use Dynamed (and EBM data depository). I haven't seen a drug rep in over 10 years, and based on a MUSC study I rank above the benchmark in almost all quality markers of good primary care (i.e. LDL goals based on cardiac risk factors, HbA1C less than 7 for DM, BP less than 135 /85 for HTN pts, my current colorectal cancer screening rate is greater than 70% of eligible patients, ect.) Interestingly I know about medications, didn't use Vioxx or any other Cox2 med and never had anyone on Baychol before it was removed from the market. I propose that you can remain current and educated without the input of big pharma... Its more difficult but I feel well worth it.

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I liked the beginning of yo... (Below threshold)

November 30, 2007 8:12 AM | Posted by Steve: | Reply

I liked the beginning of your post, but was disappointed with the rest. Everyone likes to harp on Pharma, yet Pharma is doing what we'd expect them to do: sell drugs. The real problem are doctors who complain and moan about the influence of Pharma, yet most freely take the handouts offered by them. I think most folks would be sickened if they knew how much money and perks most doctors receive from the drug companies. But to say that's just the way the system is belies the responsibility of organizations like the AMA to provide continuing education. Now, I surmise many will say that's not the AMA's job. Why not?

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The real "straw man" here i... (Below threshold)

November 30, 2007 9:03 AM | Posted by Anonymous: | Reply

The real "straw man" here is Dr. Carlat. Instead of dismissing him, you should be applauding him for looking at the data carefully, being honest, and doing his best to review the literature and give his assessment of it. Your rant on him strikes me as defensive. I wonder how much money you are getting from pharma. My guess is that you are getting paid a good deal of money from pharma, and feel attacked by his editorial. This leads you to believe that he is "blaming" pharma, when he makes it clear in his blog THAT IT IS THE DOCTORS WHO ARE ULTIMATELY RESPONSIBLE, not pharma. Obviously, pharma is not to blame, they are trying to make a buck. He knows this, you know this, and I suspect you know that he is aware of this fact as well. Why would you rant on an MD that is doing his best to look at the data objectively, and being honest about his role as a psychiatrist? Isn't that what you do on this blog, Depakote data, child bipolar , etc? As psychiatrists we should applaud doctors in our field who are trying to sort out the data in an honest way to help people, not make snarky comments about them to make ourselves look smart and feel better.

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To use a famous quote:... (Below threshold)

November 30, 2007 9:51 AM | Posted by Phil McCubbin: | Reply

To use a famous quote:

This essay is so bad, it's not even wrong.

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Oh and Dr. Steve above, is ... (Below threshold)

November 30, 2007 9:55 AM | Posted by Phil McCubbin: | Reply

Oh and Dr. Steve above, is he a psychiatrist? He sounds like one. Has he never read any of the literature on the biasing, not-so-subtle manipulation, and problematic nature of clinical trials?

Let me answer the question: no, FDA approval for a specific indication just means that the compound outperforms placebo- and it doesn't mean squat. It means they took time effort and money to get approval- it doesn't mean Zoloft is any better than Prozac.

Undergraduates at liberal arts schools learn this kind of critical thinking when they are 20 years old.


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Oh and Dr. Steve above, is ... (Below threshold)

November 30, 2007 9:58 AM | Posted by Phil McCubbin: | Reply

Oh and Dr. Steve above, is he a psychiatrist? He sounds like one. Has he never read any of the literature on the biasing, not-so-subtle manipulation, and problematic nature of clinical trials? They are about certification, not science.

Let me answer the question: no, FDA approval for a specific indication just means that the compound outperforms placebo- and it doesn't mean squat. It means they took time effort and money to get approval- it doesn't mean Zoloft is any better than Prozac.

Undergraduates at liberal arts schools learn this kind of critical thinking when they are 20 years old.

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Had doctors in different st... (Below threshold)

November 30, 2007 10:59 AM | Posted by FedUp: | Reply

Had doctors in different states even bothered to read the medical insert before prescribing, a long-known bipolar relative would not have become destructively manic on Lexapro minus a mood stabilizer. Same for a galfriend who was thrown into months-long psychosis on Celexa, finally stabilized, then made manic with enough Ritalin to keep awake a narcoleptic. These considered "very good doctors" by associates eventually blamed the patient and/or disappeared. I could go on but I'll conclude from repeated personal experience that in the US, health care is an absolute mess. Kill the greed and fill the need.

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When I was working as a pho... (Below threshold)

November 30, 2007 2:27 PM | Posted by Fargo: | Reply

When I was working as a phone support guy for an ISP, it came time when it was obvious the company was total crap, so I told some folks of my plan to quit. One of them said something to the effect of "stay and change the system from the inside". This got me thinking, and eventually I responded with "No system can be changed from the inside, at best there are mechanisms to add crap on.". Along with a big speech on how, no matter how far you went within a company/government, you would remain powerless, and eventually you would burn yourself down to making insignificant changes, which are actually just some leeway in the system, like letting people go home early on Fridays, and consoling yourself with retarded platitudes like "At least I helped that one".

Sorry to be long winded. I don't think I even had a point, it just dredged up some memories.

In closing- "Kill the greed and fill the need."..... using slogans should be grounds for summary execution.

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Phil - Are you addressing ... (Below threshold)

November 30, 2007 2:39 PM | Posted by DrSteve: | Reply

Phil - Are you addressing my comment (DrSteve) or the one by Anonymous below mine? I've re-read my comment and can't quite see how this follows:
"Oh and Dr. Steve above, is he a psychiatrist? He sounds like one. Has he never read any of the literature on the biasing, not-so-subtle manipulation, and problematic nature of clinical trials?"

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it's anonymous actually... (Below threshold)

November 30, 2007 5:23 PM | Posted by Anonymous: | Reply

it's anonymous actually

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If a doc is also employed b... (Below threshold)

November 30, 2007 6:22 PM | Posted by Anonymous: | Reply

If a doc is also employed by a pharm company they should be required to release this info to their patients. I would like to know if the doc is making money off of the drug he is prescribing me.

Fair enough. Of course. But: do you also want to know if they make money per patient or flat salary? Or if they get paid a bonus by insurance company if they keep you out of the hospital; or use more generics; or perform fewer tests? Or if they get incentivized to refer you to therapists?

Or, let's get more raw: do you want to know if your doctor drinks? If he likes porn? Hates his wife, whom he thinks is a borderline? Was raised by a bipolar father, whom he is disgusted with? Or maybe he himself is under treatment for bipolar?

Would you like to know how many patients he's killed? And how this has changed his treatment of you?

If I could only ask my doctor one question about his potential conflicts, how much money Wyeth paid him would not be that question.

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If you want to know if y... (Below threshold)

November 30, 2007 9:27 PM | Posted by Stephany: | Reply

If you want to know if your doctor makes money from a drug company, receives gifts, parties, or RV's, then ASK. It's an interesting conversation if you are candid w your doc.

Also, I have a question for anyone reading here or the LP: Do we need to be concerned not only with monies received by docs, conflicted interests, but this is my question--Charles Nemeroff owns the patent for the Li patch. Let's say it goes on the market for a handy bipolar treatment for even distribution of medication --is that conflict of interest? does he receive money from that patch then? and ethically how does that pan out? under corrupt system? or the get over yourself, this is the way it works, be glad you don't live in Cuba category.

Alone's response: no, that's my point. There are so many different kinds of "conflict of interests" that it seems senseless to single out this one. If I get Wyeth money to do lectures, is that worse than getting money for a patent-- on a drug you will prescribe? OR, my personal favorite: if I'm dating a drug rep, do I have to disclose that? Again. I'm not saying that drug money doesn't present a potential conflict, I'm saying that focusing on this one, single, kind of conflict is a straw man, or a scapegoat. Meanwhile, hundreds of other much worse conflicts continue, because we're too busy yelling at Pharma. If an academic looking for tenure has decided to stake his claim on antiepileptics for bipolar, but "learns" they aren't that effective, then what...?

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Responding to Phil McCubbin... (Below threshold)

December 1, 2007 11:02 AM | Posted by Anonymous: | Reply

Responding to Phil McCubbin's post:
"Oh and Dr. Steve above, is he a psychiatrist? He sounds like one. Has he never read any of the literature on the biasing, not-so-subtle manipulation, and problematic nature of clinical trials...It means they took time effort and money to get approval- it doesn't mean Zoloft is any better than Prozac." Of course I am aware of the literature on biasing, and yes, pharma RCT trials are far from perfect. That was not my point. The point is that AT LEAST we know that there are two large trials that were reviewed by the FDA that were positive for the particular indication. Look at Lexapro as an example- it actually recieved two non-approvable letters from the fda for panic disorder[link:http://www.biospace.com/news_story.aspx?NewsEntityId=19241420] because that evidence was not there in the RCTs, and Depakote, which never got an FDA approval for bipolar maintenence[see link within this blog]. You cannot just magically get any drug approved for anything. OF COURSE these trials are biased, and have flaws. In psychiatry[as in most of clinical medicine] we have to deal with limitations in our data, big pharma, the currupt fda, and make the most of it. Phil, what would you like us to do, not look at any data, and just rx whatever we think works? Maybe we should just close our eyes and do nothing for our patients, because the data isn't perfect. How about this: let's all critically review the literature, examine the subtle biases, negative trials, etc, and do our best to make sense of it. In the end, it is about helping our patients in the best way we can.

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Because I am a patient, I w... (Below threshold)

December 1, 2007 1:36 PM | Posted by Stephany: | Reply

Because I am a patient, I would like to address anon's comment re: "In the end, it is about helping our patients in the best way we can."

I would like to know how many psychiatrists use anecdotal information from their clients/patients in rx'ing meds to other patients. My own pdoc and I have discussions over what "we have heard" or "what worked for another patient of mine" when considering medications. Psychiatrists, especially have a difficult job rx'ing, leaving all data and journals aside, we still do not often know why a drug works, it just does. If there were sure things out there, this wouldn't be such a challenge. I believe going beyond peer reviewed, ghost written journal articles,pharma funded CME, pharma rep teaching via drug companies, I think that the one thing I have never read on one psychiatrist's blog yet, is I ask my patient for assistance in helping them feel the best they can."

I feel that hearing DTD [Direct to Doctor}real life stories from patients is something valuable for a psychiatrist.

I find it insulting at best to be disregarded as a "patient who reads too much", "a patient who thinks they know how to be a doctor", "a patient who walks in the door with information and intelligent questions, and then considered over-bearing and doctor shopping".

I am an informed consumer, I challenge the paradigm based on medications only, I ask questions, and I want real answers. I would like a chemistry lesson on a chalkboard from my doctor explaining mechanism of action, and why my Lamcital for instance helps with bipolar and I don't have documented seizures.

I'm not a difficult patient, and I have the right to understand what everyone else here is trying to understand.

Not one psychiatrist here can tell me you've got all of the answers.

We [patients]are a valuable resource, cast aside until we get the same status as one of you.

Frankly, I have befuddled docs with my questions, and twice have been asked to bring in this information discussed. I found it on the internet. The same Journals, Abstracts, etc. So in fact, yes you are all correct, doctors do not READ.

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Responding to Stephany's qu... (Below threshold)

December 1, 2007 4:10 PM | Posted by Anonymous: | Reply

Responding to Stephany's question: I try to take into account my patient's experiences with the medication. To me, the experience of being on these meds cannot be captured from just reading the literature; it is also from listening carefully to how patients respond to the medication, and using their experiences as guidance to help others. I think most good docs do this. Good docs also welcome patients to become active in their treatment- after all, we share [or should share] the same goal. But please, let's not make flippant generalizations about how "docs don't read." The docs you have worked with my not have read everything, they are not perfect. I do know there are good psychiatrists out there who care about patients, collaborate with them nondefensively, and try their best to keep up with the literature.

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I should have phrased that ... (Below threshold)

December 1, 2007 5:47 PM | Posted by Stephany: | Reply

I should have phrased that "docs don't read" into my personal experience, rather than the generalization as you stated. I should state that several, yet not all docs I've had discussions with over the last decade or so, are for my daughter as well as myself, thus my non specific answer.

The doc I have now is exactly the one you describe, and why I encourage ppl. to have the discussions with doctors and be proactive. We discuss exact details of any adverse side effects, and out of box thinking regarding psychiatry in general, so comparing to other doctors my family has been to I made my statement. I also thought about my comment, and wanted to add that I treat doctors with respect, appreciate their authority and always have good discussions that are not as I appear in my writing here. I also like my current doc because if I bring up a topic he hasn't heard of, he asks for the literature. We've had some humorous talks about DTC, and why he likes the free lunches vs. other collegue friends of his that he calls "purists" and won't allow the Lunch and Learns. The reason I am having a good outcome right now is because my doctor is open-minded and listens, and is a partner in my wellness. I also have had a doctor say, "I'm the doctor." [and the other things I listed]. Thanks for the response, anon.I appreciate the dialogue.

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Stephany said:I find... (Below threshold)

December 1, 2007 9:07 PM | Posted by Anonymous: | Reply

Stephany said:
I find it insulting at best to be disregarded as a "patient who reads too much", "a patient who thinks they know how to be a doctor", "a patient who walks in the door with information and intelligent questions, and then considered over-bearing and doctor shopping".


You're not the only one that finds it insulting. I have always ben perplexed as to why on the one hand we are told to be educated consumers, that learniing as much about our "disorders" as we can is important etc.... and then when we do so and confront the doctor with with questions or conclusions about this or taht med, they get defensive or even pull a 180 and act totaly unprofessional and even cruel at times.

Seriously, I have been told I am obsessive about my medications AND THAT THERE WAS NOTHING THAT COULD BE DONE FOR ME (cruel) - I WAS STUCK THE WAY I WAS (cruel)- All because I wouldn't just take the Geodon that the doc suggested.

I had a good reason not to take the stuff: I have read quite a few horror stories of mania caused by it, AND it also acts as an SSRI and NARI (SNARI) as well as an antipsychotic...so, I wouldn't take the stuff because EVERY TIME I take an SSRI/SNARI etc., I go manic or mixed. So why am I going to mess with a AP that also has ssri/nari action when there are so many other drugs that wont venture into that dangerous teritory?

But dang, I explained to the doctor why I thought this wasn't the med for me and all of a sudden his attitude changed. He wouldn't even suggest another medication for me to try, such as um, maybe lithium? or anything other than the damn geodon. Just told me that he thinks that I am a hopeless case, stuck being the way I am because I wouldn't take the med he suggested.
I couldn't believe that I paid this guy $160 to tell me that I'll never get better because HE wasn't willing to dig a little deeper and suggest another medication option -WTF is that? talk about being lazy and a know it all. WOW, no use for me to try and get well if I am not willing to just do whatever the doctor wants me to -UHG! what happened to people being able to have a choice in their treatment?

I have had this experience too many times. Where I am told by a psyche doc to try yet another antidepressant despite having had very bad reactions over and over and over again to these types of meds. And then being labeled as "difficult" or being basicaly called names because I ask why they are suggesting I try a medication that is basicaly the same as three other meds I have tried that all made my condition much much worse. In my experience most doctors just don't listen. And then when you get peeved that they aren't listening and you start to talk about how certain meds work and what mechanisms of action you ALWAYS react badly too, and what types of meds you've reacted well to, and that maybe they ought to go from there in thier suggestions... God do they get pissed. Yeah they try not to let it show, but it does. When they dx you with anxiety or tell you that you're obsessing because you had to remind them AGAIN about something you've told them 15 times befor - I mean who wouldn't be anxious or feel the need to be a bit obsessive about their treatment when they realize their doctor isn't paying attention and is making suggestions, that if you were to follow them, you'd end up going completely bonkers again?

I mean I may be an idiot, but if I have had a bad reaction to multiple SSRIs, doesn't that mean that that mechanism of action is bad for me and should be avoided? I just don't get why the doctors get all wierd, or mean, defensive -whatever- (you guys just get strange when it comes to patients who DO read, and know how thier meds suppossedly work etc.,) - but anyways, why do you freak out as a profession in general when someone can speak the same language as you?

Not saying I'm as educated as a doctor, but if you as a doctor suggest a med for Bipolar, I can finish your sentences about how the med works, what the side effects and interactions are etc....- And if I do "slip up" and end up doing that when talking to a psyche doc, the whole feeling in the room changes.

It's sad, I have realized I have to play stupid, and use the "well I heard from a friend that this med is better than the one you're suggesting" line in order to push my treatment in the direction I want it to go - because if I do end up instead saying " I read an article, searched PubMed etc., about that med and this med and I think that I would like to try this med rather than the one you're suggesting because of what I learned..." - oh man, all of a sudden it's a god damn fight about it and for some reason the doctor starts getting waaaay more pushy about getting me on THE med he wants me on - whereas if I just say "my friend said this other med is better" - No problem, the doc rx's it with no questions asked and no freakinbg wierd ass debate over why I am an a-hole for wanting to be educated and have an educated guess as to what med is going to work better for me.

It's messed up that I can't be honest about what I know about how meds work or what I know in general without dealing with the whole doc-patient relationship becoming hostile. It's like some freaking power play ego issue and it makes me nervous because it MY freaking mental wellbeing they are messing with, and I don't understand why the doc would rather have me be a complacent idiot about it -willing to try any random medication without forcing them to take into account my PAST reactions to meds and make a choice based on my personal experience and history- It's like they want me to be that idiot I used to be, that got thrown into countless mania's and mixed episodes because I just did what they said, trusted them and never did a damn thing to learn about how these meds work, and so kept trying the same type of medications over and over with bad reactions.

WHY do psyche doctors do that crap? ARG! I just am very bitter with the proffession at the moment. If only I could meet a doctor who would talk to me like I'm not insane for wanting to know as much as I can about how all these treatments work.

I ask questions, I talk about articles I read, I read the PI shets befor starting the medication to make sure I'm not being put on something that is very similar to something else I have had a bad reaction to... and I get labeled as obsessive, manic, anxious etc. When in reality I am just honestly actually interested in this stuff and enjoy learning about it. Shit I don't care if I bring somthing up with the doctor and I am wrong - it's fine, go ahead and correct me, it's not about me being right. I just want to be able to have conversations with my doctor that don't have an undertone of the doc being pissed that I have been doing more reading in the past two months than he has in the past two years. Plus I have just a bit of a vested interest in psychopharmacology and psychiatry, cause ya know, I kinda need to know this crap cause if I didn't I'd be back on another antidepressant by now and once again completely mental - It's not like psyche doctors in general actually do a very good job at getting us on the right meds. I mean what is it 7 to 10 years in treatment for Bipolar disorder till one can expect, on average, to find an effective med cocktail? With those odds, I'd have to be insane to NOT want to know as much as I can and do what I can to help my doctor find the best treatment for ME AS AN INDIVIDUAL.

I'm not trying to be a jerk here - I do understand you guys are buisy, and you're too buisy trying to get soo many people well, to be able to invest all the time (outside of the visit) needed to investigate and learn about ALL the pertinent info to any ONE INDIVIDUAL patients case - So it's okay, I know it's hard to really get down to the nitty gritty details of every individual patients past history and response to all those meds they have tried, and to try and figure out what that says about thier unique "chemisty", and how that might predict responses to other meds. I understand that basicaly, because being mental is a lot more complex than having diabieties, that it is hard to really have any clue what will work best for whom -that psychiatry is more of an art than a science -and sh*t I know you guys don't even know what the problems with our brains are in the first place or even how antidepressants etc., actually work. -So I can forgive psyche docs for not being able to get great results for us mental cases. BUT, what I can not forgive, is when the psyche doc doesn't flucking listen to what the patient has to say/ can't have a civil conversation about the technical stuff without name calling...

REALLY- since it's such a crap shoot, game of medication russian roulette in the first place - WHY can't psyche docs have a little better of a bedside manner and allow the patient to have some say in which bullets we put in the gun?

It would make me feel soooo much better about what I am dealing with if I could just once see a doctor who doesn't resort to calling me obsessive, or overly anxious, or manic, or hopeless etc., simply because I have a fairly educated opinion about why I would rather try lithium than depakote.

It's not like I am trying to convince the doctor I don't need meds, or that he should give me penacilin for the "infection in my brain" , or crack rock for my depression. But I might as well be doing so.... man I could bitch and moan forever about this but I'll leave it here: Most Psyche Docs have ZERO bedside manner skills and the reason is simple: Psyche Docs are insecure because they don't actually know anything about what causes the illnesses they treat or how the medications they use actually work.

I just wish that this insecurity didn't come out as being jerks to your patients when they dare to challenge your best GUESS with thier own.

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" Again. I'm not saying ... (Below threshold)

December 2, 2007 5:49 PM | Posted by Stephany: | Reply

" Again. I'm not saying that drug money doesn't present a potential conflict, I'm saying that focusing on this one, single, kind of conflict is a straw man, or a scapegoat. Meanwhile, hundreds of other much worse conflicts continue, because we're too busy yelling at Pharma."

Thank you for the focus restoration. Do you feel one conflict of interest is the most important? Since there is a Pandora's Box of conflicts, what should the patient/consumer and psychiatrist/doctor be most concerned? Should we shift the focus to cooked data and false data, for example Zyprexa?

Also, would you, LP[or any other psychiatrist here], be offended, if a patient you see walked in and asked "how many patients died in your care?" I'm not saying I would do that, but as you wrote above, could that be why [we, generally speaking]patients benefit from the doctor's experiences that we may not know about, therefore questioning the doctor, and resulting [as some have written here]in a defensive undertone--could that be because the psych has not disclosed his/her personal reason for feeling challenged? I'm just thinking out loud here, and find this to be a good discussion, and taking the focus to the doctor/psych as a human being first, is a perspective patients need to consider, same as the doctor who treats them.
This is so complex, it's mind blowing.

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It is interesting that it h... (Below threshold)

December 3, 2007 1:05 AM | Posted by mo: | Reply

It is interesting that it has become perfectly reasonable to ask your surgeon about their education, experience and success rates for your contemplated surgery but to ask your psych doc the same seems somehow insulting.

I want to know how many times you have successfully and unsuccessfully treated patients for the same condition I have.
If you are uncomfortable with that you are telling me all I really need to know about your competence.
Whether you are having a non stop affair with Pharma? I couldn't care less.
I don't care what you do to educate or entertain yourself in your own time.
What is important is your personal stats. Are you on the whole a pretty successful doc or are you a mess that should be run from?

Here in Ontario hospitals are now being forced to publish their death rates..each service has to pony up the stats through a few different categories...expected deaths, unexpected deaths, medical errors leading to death etc. These are the real stats all patients need to see.

Talk about not seeing the forest for all those damn trees. Sometimes my cynical self says of course every profession preoccupies itself with squabbling over nothing. If we didn't we would be forced to actually address the real problems and holy crap No one wants to have to do that.

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I wanted to add to that hea... (Below threshold)

December 3, 2007 2:34 PM | Posted by Common Reader: | Reply

I wanted to add to that heartfelt essay from anonymous, which would make an excellent subject for a future blog post, that if you have children and you question psych treatment you don't just risk the doctor treating you like crap - you risk the doctor calling CPS.

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"Or, let's get more raw: do... (Below threshold)

December 3, 2007 3:26 PM | Posted by Anonymous: | Reply

"Or, let's get more raw: do you want to know if your doctor drinks? If he likes porn? Hates his wife, whom he thinks is a borderline? Was raised by a bipolar father, whom he is disgusted with? Or maybe he himself is under treatment for bipolar?"

I get your point. I understand that I can't know everything that could have affected tx, however I think if a doc is getting paid for promoting a drug and subsequently prescribes a shitload of it, that would be important info to know.

And you're right other things in my former doc's personal life affected his professional life, as well. I later learned (and kind of wished I hadn't) that my dr drank too much, hated his wife, had screwed up kids, diagnosed any woman who pissed him off with borderline personality disorder, etc. Had I known that I would certainly have gone somewhere else much earlier. That, however, doesn't change the fact that I think it's important to know when a doc has a financial conflict of interest. I'm not opposed to docs making money. I'm not even opposed to them making money from pharm companies, but it is a serious conflict of interest and one that should be disclosed to patients.

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“Fair enough. Of course. Bu... (Below threshold)

December 4, 2007 6:33 AM | Posted by herb: | Reply

“Fair enough. Of course. But: do you also want to know if they make money per patient or flat salary? Or if they get paid a bonus by insurance company if they keep you out of the hospital; or use more generics; or perform fewer tests? Or if they get incentivized to refer you to therapists?

Or, let's get more raw: do you want to know if your doctor drinks? If he likes porn? Hates his wife, whom he thinks is a borderline? Was raised by a bipolar father, whom he is disgusted with? Or maybe he himself is under treatment for bipolar?

Would you like to know how many patients he's killed? And how this has changed his treatment of you?” --- Posted by: Anonymous | November 30, 2007 6:22 PM

Quite frankly, I wouldn’t object to the availability of any valid information in trying to make the best medical decision for me or my charge. I find it difficult enough reading all the differences of opinion as it relates too many of the study data as evidenced on this forum, elsewhere and amongst the professionals.

In my mind the importance of understanding the information that is obtained is paramount. I am also reminded of this fact by the following statement:


“Also, would you, LP[or any other psychiatrist here], be offended, if a patient you see walked in and asked "how many patients died in your care?" --- Stephany


Several years ago the Sun-Sentinel ran an expose on cosmetic surgery and the number of deaths that ensued. Amongst the weeks of the expose there was also an article discussing the reporting of deaths and the doctors involved and how that information should be properly interpreted? One particular doctor had stood out in terms of the number of deaths under his services. Upon further and more careful scrutiny on the part of the reporter it was learned this particular physician undertook many terminal cases that most all other physicians simply gave up upon and felt nothing further could be accomplished.

Under the circumstances and reviewing the individual cases the reporter learned the doctor’s accomplishments and results were truly outstanding so much so that his peers also recognized and acknowledged this particular doctor’s remarkable accomplishments in saving many lives through his skills and knowledge despite what appeared as an inordinate amount of deaths.

The point being, I am appreciative of this and other similar forums for the information and views of the professionals hosting some of these sites as well as the dialog. I have also come to learn despite being shown the exact same data even the professionals come away with differences of opinion and having to deal with the Science of Psychiatry and its practitioners I am also aware of its many shortcomings and need for improvement and yet it still has benefited my spouse and in turn me.

Warmly,
Herb
VNSdepression.com


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What's wrong with medicine ... (Below threshold)

December 5, 2007 3:43 PM | Posted by Jason Boyd: | Reply

What's wrong with medicine in Cuba?

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Hey Alone, I tried to Digg ... (Below threshold)

December 5, 2007 11:49 PM | Posted by sunnygirl: | Reply

Hey Alone, I tried to Digg this story but they couldn't "find" it. Any idea of how that works? This article is too important to stay in just your blog...can you send it to the Times? It is a great and well thought out rebuttal.

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"You're not the only one th... (Below threshold)

December 6, 2007 8:36 AM | Posted by someone: | Reply

"You're not the only one that finds it insulting. I have always ben perplexed as to why on the one hand we are told to be educated consumers, that learniing as much about our "disorders" as we can is important etc.... and then when we do so and confront the doctor with with questions or conclusions about this or taht med, they get defensive or even pull a 180 and act totaly unprofessional and even cruel at times."

Maybe it has to do with YOU. Oh, I don't know, perhaps its b/c you leave 16 paragraphs of comments on a blog. You sound like a pain in the ass.

Patients love to blame their doctors for all that's bad in the world. But no one is putting a gun to your head: if you don't like psych docs, don't go.

And for all of you who complain about the lackluster performance of your psych drugs: why do you take them?

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"And for all of you who ... (Below threshold)

December 6, 2007 3:11 PM | Posted by Stephany: | Reply

"And for all of you who complain about the lackluster performance of your psych drugs: why do you take them?"

Because some people feel like holding a gun to their head, and are desperately trying to avoid that thought, therefore less than adequate pharmaceutical treatments are albeit a bandaid solution; but it sure as hell beats being 6 feet under.

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I couldn't not comment on "... (Below threshold)

December 6, 2007 4:35 PM | Posted by mo: | Reply

I couldn't not comment on "someone's" wee rant.
How about you replace cancer with mental illness. Why, look at that! your whole attitude just changed didn't it?
If a cancer patient was frustrated and upset about finding successful treatment I bet you would be oozing sympathy but because you don't consider mental illness life threatening or chronically dehabilitating you feel free to be flippant.
Your discrimination is showing.How about you put it away so we don't have to see it okay?

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thank you staphany and mo. ... (Below threshold)

December 10, 2007 1:33 AM | Posted by Anonymous: | Reply

thank you staphany and mo. Seems to be that whoever this "someone" person is doesn't know how to stop reading and skip over a response when they think it too long or find it disagreable. I guess personal attacks must be more satisfying for this person.

I would like to tell this someone person though that they are totally off base about my being a pain in the ass. I am not an annoying person, I don't actually talk much or even submit my thoughts in writing to my doctors because I know from the very little that I do say IRL, that if I actually wrote out what I truly feel, understood and wanted out of treatment, or said it all, they would end up being just as OUT RIGHT mean to me as this someone person has been.
Believe me I have dealt with enough abusive BS from psyche docs even when I have not been "a pain in the ass" that I do know better than to actually allow myself to be a real pain in the ass to my treatment providers.

The only reason I wrote so much here was because I know other psyche docs visit this blog and thought I'd share the perspective and frustraition of a patient on how conflicting the messages are with the responses we get and how it makes one feel to deal with this sort of stuff. I'd start my own blog since I enjoy typing up my thoughts so much but I have realized that anyone writing a blog and especialy those writing a blog on MI and the healthcare system are subject to all sorts of abusive responses. Seems even just keeping to replies to others blogs doesn't offer any protection from the same sort of thing.

I am sorry though if any doctors who read this blog topic and its comments, or the author end up taking the stuff I say personaly... but you ought not to since I am obviously not one of your patients and am speaking of other doctors I have seen... unless maybe I struck a cord that reminds you of something about yourself and your impatient and intolerant style of practice... reminding you of past abusive attitudes taken out on patients?... and so theres the need to go on the offensive and shut up another one of these "pain in the ass" loonies who can't just take their meds, accept the side effects, not push for better treatment and just shut up already and be good little bitches OR just stop "wasting psyche docs time" and quit taking the meds since they can't just shut up about and be completely happy with them and go ahead and get it over with and kill themselves so they won't be a pain in your ass anymore.

I am only assuming that "someone" is a doctor... could also be that they're just another A-hole without credentials that gets off on trying to make anyone who's already having a hard time feel worse.

whatever though. I at least know that I don't need to get upset about other peoples problems... but I guess this "someone" person hasn't learned that skill yet. yeah I am upset that doctors, people I am PAYING to be helpful and find solutions, have so often turned out to be jerks... but that is their problem and so I have each time went looking for a new doctor who doesn't have such problems. I have found one now but it amazes me what a huge problem it is in the psyche field to just find a doctor who thinks that what you want out of treatment is the main end and goal and that your being an educated consumer is a plus and not something you deserve to be talked down to or insulted for.

sometimes I really wonder why there are so many people who launch personal attacks on others on the web. I write my POV and am not even directly trying to put down anyone on this website and surely not "someone", just giving my POV and maybe people don't agree... but why take it personaly when its not meant that way (unless of course you can relate to being the sort of person/doctor I was complaining about and it pisses you off).. or if you are just the type that likes to be mean and call names for no good reason other than the fact that you didn't like what someone wrote and yet you couldn't bring yourself to skip over the rest of the paragraphs once you realized you didn't like what you were reading.


I dunno, even if I am a pain in the ass at least I am not a meany who says messed up things to people I don't even know a damn thing about except for a measly six paragraphs of writing ( or maybe, to play your game, that six paragraphs was just sooo much extra reading that it made your brain hurt cause you sound like a dumbass to me).... ha ha ha ha ha ha ha!

see I can be funny (well I think I'm funny cause bing a jerk is hilarious), mean and cool all at the same time just like you!

he he he...

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Amen Anonymous, flat salary... (Below threshold)

December 17, 2007 1:04 AM | Posted by FedUp: | Reply

Amen Anonymous, flat salary. Otherwise, let us put up for auction our ails and let 'healers' bid to provide our salvation. At least we'd be wealthy smitten.

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"And for all of you who com... (Below threshold)

December 27, 2007 1:21 PM | Posted by Anonymous: | Reply

"And for all of you who complain about the lackluster performance of your psych drugs: why do you take them?"

I don't. Not anymore. And you wonder why patients are noncompliant? I stopped taking them (because of their lackluster performance and because they made me a hell of a lot worse than I was before I went on them). When people are told they have a chronic illness, you have taken away their hope of ever being well. I've been off all meds, successfully, for over 5 years now (against medical advice). Best decision I ever made.

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