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.


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.