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.