Friday, February 02, 2007

Then What Happens...

Recently, a reader had an excellent comment to which I responded. The content of these comments seemed like they may be of general interest, so they is reposted below, with very slight trimming of both the reader's comment and my response. All emphases are added in this version...

nab said...

The next logical step from Healy's accurate description:

For all of those patients who have been betrayed - directly or indirectly - or any of us who are on the "outside" should/do not really care whether this was complicity or whether many were (as I think) hoodwinked.

Accountability must be demanded from the entire system (academic - research - clinical): we don't care how you do it, you just need to not have these results. If you are a clinician and you get fooled, then I don't feel you to be gaining personally, but I would like to see the scrutiny that people like you are demanding, or else, how do we know this sort of thing won't keep happening.

That trust is fragile, and that is why (a) I truly appreciate the outrage we can from you - CL Psych and the likes of Healy, Avorn, etc., and (b) am completely frustrated and disturbed by the general lack of such a response from the mainstrean medical community.

For a profession that demands - and is mostly granted - autonomy in its decision-making, I don't really care - to a large extent - how or why bad knowledge was propagated. Obviously those directly responsible should individually be held to account, but at the institutional or professional level, these are examples of a systemic failure.

I feel that many doctors reach Healy's conclusion, shrug their shoulders, and say, "damn, those bastards fooled us, but I didn't do anything personally wrong so whatayagonnado?" Why do we not hear more outrage? Where is the outrage about Vioxx for example?

Regardless, I know Healy means well, but it is quite an indictment of the entire system - not just the pharmaco. or specific academics and clinicians involved. I feel that organized medicine (and doctors generally), love to point the finger at the insurance companies, the pharmaceutical companies, hospitals, anyone besides themselves.

Unfortunately, this causes them to ignore the obvious fact that the practicing doctors on the frontline and the honest and honorable academics researchers have the most power and could be the most effective at remedying these problems. And they ignore this at their own peril because if they don't demand accountability then ultimately soneone has to.

My reply
More scrutiny from practitioners would indeed be a good step. I suspect that a large majority of clinicians have no idea of the degree to which the system has been corrupted.

How can anyone practice Evidence Based Medicine when the Evidence Base is full of half-reported data that is often sold like a used car in such forums as industry-sponsored consensus guidelines, continuing medical education, journal supplements, doctor dinners, and conferences which resemble Disneyland more than a scientific learning environment?

My thoughts: Med schools need to step up their ethics training. Likewise, when the vast majority of of physicians are not trained in research design or statistics during med school, they are not well trained to sniff out the BS in studies.

I believe, perhaps naively, that a class in research/stats and a class that details the numerous examples of what can go wrong when industry and science mix would really awaken med students. That would allow them to have a chance at bucking the system. Reforming the infomercial continuing medical education system would also be a nice touch.

There are surely other ways to go about this, but those are my initial thoughts.
Feel free to add your two cents. Someone has to come up with some answers.

7 comments:

nab said...

I am not sure if it is considered proper etiquette to be the first to comment on a discussion that one started, but at the risk of being redundant or obsessive, I would like to throw out a quote from a BBC story on Panorama/GSK/Paxil from Fiona Godlee:

The editor in chief of the British Medical Journal, Fiona Godlee, said that what she calls the "blind-eye culture of medicine" should be exposed by professionals.

She has written in response to the Panorama film: "We shouldn't have to rely on investigative journalists to ask the difficult questions.

"Reputations for sale are reputations at risk. We need to make that risk so high it's not worth taking."

I would focus on that last idea: "making that risk so high."

"Medicine" (to whatever degree that really is a cohesive concept) has the power to do this. Keller, for example, should be basically black-listed regardless of motive. Even if he were a simple knave, who cares? Either he sold his name, or he was an active participant in this mess, who cares? Why would anyone trust him again?

My thinking is that non-statistically minded clinicians SHOULD be able to trust the literature/peer-review again, but we need to do a lot of house cleaning before we can reach that point again.

Anonymous said...

I think the first step, if not the last step, is to understand that the licensure system causes far more harm than good, and abolish it. Set up a internet rating system for all I care.

This isn't to say that doctors and the like shouldn't have standards, but rather that standards that all too often are honored in the breech are harmful, because they provide a false sense of security.

Today doctors can truthfully claim that they are only doing their duty, and its an illusory dream that myopic$ of Keller's ilk are ever going to completely be regulated away; the art of medicine is far too complicated.

Making it clear to the patient that he / she had better do her own homework, and that he / she will ultimately bear the consequences if things go wrong, is the first step in the right direction. This, by the way, is already beginning.

Then, make all clinical studies be reported in real time, with raw data.

Granted, there will be more rogues, but people like David Healy who disagree with the party line will enjoy much more freedom.

Another part of the problem is insurance companies who are mainly worried about earnings; medical savings accounts make so much more sense.

Alone said...

Now we're on to something.

Sure Pharma puts pressure on doctors, and forces through studies that are helpful to them (and suppresses those that hurt them).

But the real problem in medicine is the academic centers. Their bias is dangerous because it's so subtle and pervasive.

If Astra Zeneca does a Seroquel study, I think we can guess the bias. But when Assistant Professor Jones does a Seroquel study-- funded by the NIH-- is that study magically free of bias? What about Jones's beliefs on medications (he thinks pharmacotherapy is a gold mine, or is he anti-drugs and pro therapy?; maybe he's pro-seizure drugs (Depakote, Lamictal) and anti-antipsychotics (or the other way around?) Maybe his mentor gets AZ money (which is used to pay his salary through the university?) Maybe NIH has a stake in getting expensive drugs like Seroquel to look bad (e.g. CATIE?)

And journals are worse: think that the editors of a journal don't have biases-- even direct pharma ones?

And the three peer reviewers?

Ever wondered what articles don't get accepted for publication, and why (and I say this as someone who has a pretty high rate of publication success).

And why do those journals-- which publish public data-- cost $1000/yr and can't be accessed by the public?

The first and most important step to fixing medicine is abandoning the journal system. All articles, including the raw data that generated them, photos, scientific notebooks, etc, should go online. Let the world vet the data.


http://thelastpsychiatrist.com

Anonymous said...

I think any time a physician is doing work for a pharm company and prescribing that pharm company's drugs they should have to report that to patients. Let the patient decide if there is bias or not.

paula said...

Personally I'm a bit confused who said this:

"Regardless, I know Healy means well, but it is quite an indictment of the entire system - not just the pharmaco. or specific academics and clinicians involved. I feel that organized medicine (and doctors generally), love to point the finger at the insurance companies, the pharmaceutical companies, hospitals, anyone besides themselves. "

AND maybe I'm reading that paragraph wrong? but David Healy is a GOOD man, and has lost a great deal, including professional credibility, standing up against the corruption involved. Without his courage a great deal of the fairly recent changes could not have happened in the UK and USA.

paula said...

David Healy doesn't just "MEAN well", he has ACTED and risked his career for years to protect people against lack of scientific integrity.

A good place to look to see what he has actually DONE (rather than 'meaning well' but NOT actually doing) is here:

http://www.socialaudit.org.uk/58000-00.htm#Correspondence

In the same site thre's also a review of the Panorama programme

http://www.socialaudit.org.uk/6070130-REVIEW.htm#"What%20they’ve%20done

"...They are among the heroes, along with the brave, indefatigable Professor David Healy. He is the shining exception to the general rule..."


If anyone deserves to be treated with more respect than to be referred to as 'I knkow he means well, but' it is David Healy. How many other professionals care enough to risk their career to actually DO something?

CL Psych said...

Thanks for the comments, all.

I absolutely agree that making the risk of getting involved as a corporate shill higher is a great idea.

Healy has done some great work in the area. I can't think of a psychiatrist or psychologist who can match Healy in terms of making an impact and drawing attention to these issues. I give him oodles of credit for what he has done.

The house of academic medicine does indeed require cleaning.