Dollars for Docs

I apologize to my loyal readers for not posting in a long while.  Fortunately, I was awakened from my torpor by an eye-opening new database that lists some of the money paid to specific doctors by pharmaceutical companies.  The Pulitzer Prize winning investigative journalists at ProPublica tapped the public disclosures of seven companies that have begun posting names and compensation on the internet, some as the result of legal settlements.  ProPublica's "Dollars for Docs" provides both an overview of the issue, as well as a handy database search function.  It is easy to look up specific doctors, or (as I did)  to scan through a whole city or town to see who received money from these seven companies in the past two years. Some caveats are important.  First, the seven companies represent just over a third of all pharmaceutical sales in the U.S.  The health care reform law, signed in March, mandates that all drug companies report such data to the federal government beginning in 2013. That information will be posted on a government website.  So, this is a preview of the data to come.  Research funding is not included here, only speaking, consulting, and related activities.  It is also important to keep in mind that listed payments are not automatically unethical or illegitimate.  For example, honest consulting relationships between doctors and drug companies reasonably include travel expenses and a consulting fee.

Nonetheless, most of the listed activity is pretty suspect.  I first learned about "Dollars for Docs" from Dan Carlat's blog.  As Carlat points out: "The vast majority of payments are for doctors who give 'educational' talks to other doctors, presumably focusing on one of the drugs made by the funding company."  And as he notes, the sheer enormity of the database is probably its most striking aspect — published surveys show that well over 100,000 doctors receive cash from drug companies.  Most of the amounts in the database are small, up to a few thousand dollars, not much compared to the income of most doctors.  But some are considerably higher.  My eye-opening experience was to scan the list of San Francisco doctors, where I found a few colleagues I know who added tens of thousands to their income in 2009 and 2010 speaking for drug companies.  It makes me think differently about those doctors — which is the point, right?

Supporters of the status quo argue that there are many other potential conflicts of interest, and that not all recipients of industry money are necessarily biased.  Both of these points are true, but irrelevant.  Money is universally recognized as motivating; that's why people are paid to work.  A universally recognized motivation, voluntarily chosen and standing here in plausible conflict with unbiased patient care, should be unacceptable from the perspective of medical ethics.  Medical ethics does not stop with financial conflicts of interest.  Physicians are prohibited from sexual relations with patients for similar reasons: A sexual motivation is very likely (although not absolutely guaranteed) to conflict with clinical care.  Other systematic sources of bias will be addressed when they can be identified and controlled.  The fact that we can't minimize all sources of bias is not a compelling reason to ignore obvious financial ones.

When comprehensive numbers are available online in 2013, we will finally have meaningful disclosure about this potential conflict of interest.  What we as a profession, or as the public, do with these disclosures is another matter.  As I've noted before, the public seems more concerned than the medical profession itself about industry-fueled bias.  To that end, patients may begin to use such public databases as a means to choose doctors.  The website of the newly formed Association for Medical Ethics features a searchable database similar to "Dollars for Docs" but with a more explicit message: that accepting industry support is unethical in clinical practice.  If this idea catches on — and I suspect it will, at least in some areas — speaking and consulting fees will not be the only financial motivation at play here.

Carlat on mindless psychiatrists

My fellow psychiatrist and blogger Dr. Daniel Carlat has an article in this weekend's New York Times Magazine.  "Mind Over Meds" is a memoir of Dr. Carlat's growing realization that psychiatry can't be done well in 15-20 minute medication visits, that talking to patients as people is important too. I'm generally a fan of Dr. Carlat.  His blog is one of the few listed on my blogroll (the short list of links over there on the right of this page).  He writes well, and I share his skeptical attitude toward overzealous promotion of psychiatric drugs to our profession and the public.  "Mind Over Meds" is a good article: Carlat reviews the swing from the "brainless" psychiatry of early 20th-century psychoanalysts, to the "mindless" psychiatry of today, where symptoms are treated with medications and the patient may be lost in the process.

This is all on target, and I appreciate how Dr. Carlat is willing repeatedly to make it personal and write about revisions in his own thinking — as he did in this prior NY Times Magazine article, also well worth reading.  The gist is that psychiatry has painted itself into a corner by limiting itself largely to psychopharmacology, i.e., medications, and ceding psychotherapy — understanding the patient as a person — to other mental health professionals.

Unfortunately, "Mind Over Meds" goes off the rails in two ways.  The less important is a passage that I have to believe is just badly worded, as it seems to denigrate psychologists and other non-psychiatric therapists:

Like the majority of psychiatrists in the United States, I prescribe the medications, and I refer to a professional lower in the mental-health hierarchy, like a social worker or a psychologist, to do the therapy. The unspoken implication is that therapy is menial work — tedious and poorly paid.

A couple of early commenters have already chided Dr. Carlat for this "mental health hierarchy" language.  Discussing whether mental health professionals constitute a hierarchy is beyond my scope here, but I believe Dr. Carlat is well aware that the expertise of many psychologists (for example) to do psychotherapy surpasses his own.  In fact, he has recently taken a contrarian position in favor of granting psychologists prescribing privileges.  I doubt he meant this talk of hierarchy as a putdown, but he should have been more clear.

The bigger gaffe is that the article ultimately calls for psychiatrists to do "some sort of psychotherapy... when our patients need more from us than just medication."  Dr. Carlat seems to be satisfied with a little support here, a few extra minutes of listening there.  However, that isn't psychotherapy except in the most meaningless, hand-waving sense.  That is just listening to one's patients, something every doctor should do, from dermatologists to orthopedic surgeons.  I hate to say it, but it's no wonder health plans won't pay for that.  It used to be part of the job, not something extra.

Psychiatrists have a lot more going on than mere doctor-patient rapport — or at least we used to.  Even psychiatrists who choose not to conduct psychodynamic therapy still learned, or should have learned, about psychodynamics, an intellectual and historical cornerstone of our field.  A psychiatrist's work needs to be psychodynamically informed even if he or she only prescribes medication.  As the most obvious example, a dynamic understanding may shed light on a patient's medication non-compliance and help to address it.  Even better, a dynamic understanding of the patient may obviate the need for medications at all.  (To those who argue that psychodynamics has been supplanted by cognitive-behavioral therapies, I note that Dr. Aaron Beck, the founder of cognitive therapy, was a psychoanalyst first.  Even cognitive therapy works better if it is conducted by a psychodynamically informed therapist.)

Dr. Carlat should have gone farther.  Psychiatry needs to retake the position that we strive to understand and heal the mind from the molecule on up  (a position taken by Freud, among many others).  It is true that this encompasses a dauntingly wide spectrum, from psychopharmacology to psychological treatment, and beyond that to social and cultural influences.  As physicians we are the only mental health discipline with the training to appreciate the whole span; other professions, like clinical psychology, may have more in-depth knowledge and treatment skills regarding a particular part of this spectrum.  Of course, any given psychiatrist may choose not to practice at all of these levels — probably cannot, given the sweeping range.  But it is the essence of psychiatry to know about the full spectrum, and either offer whatever treatment is needed at any level, or refer the patient to a professional who can provide it.

It is necessary but not sufficient to see a patient behind the symptoms, to listen.  It is also incumbent on psychiatrists to conduct real psychotherapy, dynamic or otherwise, when sitting with a patient for 50 minutes and charging for it.  Ceding "real" therapy to others has diminished our field and has turned most psychiatrists into technicians.  "Mind Over Meds" is the right title for a much deeper topic.

Thanks, Dr. Carlat

Daniel Carlat MD of the popular Carlat Psychiatry Blog, linked to my post about nearly becoming an unwitting speaker for Wyeth.  He recounted his own experience speaking for Wyeth in a great New York Times Magazine article last year.  Thank you, Dr. Carlat, for welcoming me into the psychiatric corner of the blogosphere.