September 29, 2009

Is More Regulation Needed?

I know disagreeing with Daniel Carlat is like disagreeing with Obama-- how can you?-- but someone has to.

The article is called, "Has the regulation of physician-industry relationships gone too far?"

Dr. Daniel Carlat starts with a rhetorical trick, conceding ground at the outset thus establishing himself as a practical centrist and not an ideologue, and then stealing the ground back.  Remind you of anyone?

I disagreed with many of the presenters but was in absolute agreement on one point: interaction between industry and physicians is a good thing.  It is crucial to scientific progress.
It's an election year trick.  Carlat followers already know exactly where he is coming from; so conceding this much isn't going to turn them off.  "It's politics.  He has to say that."  Those who don't know him can be soothed by what sounds like a reasonable voice.

But suppose I want to find out whether Drug A is better than Drug B.  Would I go to Company A for this find of advice?  Of course not-- this is the last place I would go.
I realize this seems unassailable, but it's not only theoretically wrong, it's actually false.

First, Company A can't actually say it has a better drug than Company B.  It's illegal.  They can't even tell you about a published study, even one they didn't do.  (Don't worry, I'm sure doctors will come across it on their own.)

Second, if it was allowed, why wouldn't you want Company A's answer?  It may be biased, but you already know the bias, and they're not allowed to lie.  Does Company A have nothing useful to say?  Then you can ask Company B what they think.  Isn't that how people pick their President?

But here's why it's actually false:

Likewise, I would not go to a physician paid to promote Drug A for this advice.  I would go to a source without that conflict.
He means a unicorn.  It does not exist.

In fact, he does go to Company A for the info, he just blinds himself to it.  The studies, academics, Departments, journals, reviewers-- all are eye deep in Pharma money.  "It's not Company A money."  Oh.  So when a Republican senator who does not get oil money votes for an oil project, you figure he conducted a dispassionate analysis of immediate energy needs vs. environmental/climate impact?


... I know about human nature.  When you have a financial incentive... you will respond to that incentive.
I know something about human nature, too: more powerful than money is the desire to maintain identity.  Narcissism.   When a politician "gives the money back" in order to keep his job, he's not doing it because the job will get him more money, he's doing it because the job is more important than the money-- it's his identity.

Your identity is so powerful that it actually biases other people more than money. Look back at my Republican/oil example.  It fit perfectly, it made sense to you.  But if I had made a Democrat/labor union analogy, it would have rubbed you the wrong way, even though they are equivalent.  You're biased, and for cheap.

That's why a man free of financial bias may be trustworthy, but he is not trustable.  Where's he coming from?  Is he pushing Depakote because he "believes" it?  Because his son, N=1, responded to it?    Because he works at a university where antiepileptics are the cause du jour?  Because his Depakote rep is hot?

I don't particularly want financial bias in my academics, but to single that out as the main source of trouble in our field is like singling out the elbow as the pivotal component of   matricide.


This is the same error people make about the need for government intervention, e.g. that the "free markets" have failed and more regulation is obviously needed.  Even if one were to agree on principle that people can't be trusted, the mistake is in forgetting that government is people.  These people are subject to the same biases, cognitive errors and general prejudices as the guys at Goldman Sachs, albeit currently it in the opposite direction.  We can argue that we prefer the government's biases, but one cannot argue that the government is less biased, self serving, or corruptible.

This may originally have been a country of laws, not men, but that's not the country most modern people want; they want to be able to alter the laws to suit the times.  Fine, it's your country.  But understand that if the laws are subordinate to men, then the enforcers of those laws will always have more power than you.  Has anyone tried to get an anti-Depakote study published in J Clin Psych in the past decade?

It's excellent that Daniel Carlat thinks doctors like himself cannot be trusted to read and interpret their own studies, and that some other group of-- doctors?  lawyers?  what?-- with special bias-immunity rings need to be assembled to protect us.  But those people are still people.  This is why the NIH, with their incestuous grant reviewers, crazy politics and flavors of the decade philosophies is so dangerous-- they're just as biased as Pfizer except you think they are objective.

In other words, before I agree to being regulated, I want the names of the people regulating me, so that I can at least laugh at the irony.

I am asked all the time, "where can I go for unbiased information on medicine?"  My God-- if the physicists don't have such a place, do you really think that medicine does?  And why does no one ever ask where they can go for unbiased political information?

People would do well to remember that at one point in our nation's history, "government" was George Bush.  When you argue that government needs to be more involved, you are arguing that George Bush needs to be more involved.  I do not trivialize this discussion by offering Barack Obama as an equivalent example of the government you want so desperately to supervise your lives.

also: The future of bias