Does your doctor attend biased professional talks?

On October 3rd the New York Times reported that several prominent research psychiatrists are under Congressional investigation for failing to report income derived from consulting and speaking for pharmaceutical companies.  One of the field's most renowned and prolific researchers, Charles B. Nemeroff MD of Emory University, stands accused of concealing over $1 million since 2000, thereby violating federal rules aimed at avoiding conflicts of interest in medical research.  Senator Charles E. Grassley (R-Iowa), leader of the Congressional inquiry, has also sponsored the "Physician Payment Sunshine Act," which would require industry to publicly list payments to doctors.  Several states already require this, and two drug companies recently announced they will voluntarily list payments to doctors starting next year, even without legislation. Senate allegations of million-dollar malfeasance are, unfortunately, just the tip of the iceberg.  While professional journal articles, newspaper op-ed contributors, and bloggers (e.g., here, here, and here) have documented the problem for years, the public still has little grasp that over half of all continuing medical education (CME) in the US is paid for, legally, by commercial interests.  This often takes the form of sponsored talks:  Prominent physicians like Dr. Nemeroff are paid to speak to medical audiences about a specific disorder and its various treatments — one of which is nearly always a product of the sponsoring company.

To address the clear potential for bias, CME speakers are required to disclose to the audience any financial ties to industry.  However, it is unclear to what extent disclosure matters if the talk is subtly biased anyway.  After all, television commercials clearly disclose the company behind an overtly biased sales pitch, yet this form of advertising remains effective.  Corporate sponsors also argue that competition among products leads to the necessary scrutiny to arrive at the truth — speakers for Company A will critique drug B, and vice versa.  Meanwhile, the sponsored speakers themselves declare their own neutrality ("Money can't buy me!"), sometimes pointing out that, like Dr. Nemeroff, they are sponsored by so many different companies that they favor no particular product.

Since regular attendance at CME activities is required to maintain a medical license, the mere possibility that this information is slanted ought to raise alarms in the medical community and in the public at large.  Yet only a few studies have been done to find out.  A recent review of ten empirical studies concluded that "there is no empirical evidence to support or refute the hypothesis that CME activities are biased."  This conclusion has been systematically critiqued by psychiatrist Daniel Carlat MD here and here.

While conflicts of interest during presentations are worrisome enough, the biomedical research being discussed at CME talks is itself heavily funded by industry, leading to concerns (and some troubling data) about bias at even this most basic level of medical knowledge.

The ethical issues here are almost too obvious to point out.  Physicians are duty-bound to recommend the best treatment for a given patient, not the treatment presented most persuasively by an industry-paid speaker.  Willing receptivity to a possibly biased talk is little better than prescribing possibly tainted medication.  Sponsored speakers themselves ought to reflect on the ethics of giving talks they may subtly slant despite their own best intentions.  It may be sheer hubris to imagine that one can avoid any hint of favoritism when one's speaking fee is paid by the manufacturer of a product under discussion.  Stepping further back, educational institutions such as medical centers that review and approve CME ought to consider whether the industry money coming in justifies the potential bias coming out.  And stepping back again, the medical community as a whole should assess the price paid in professionalism and public trust when it accepts industry largesse.

I'm sorry to report that psychiatry is one of the medical specialties most accepting of Big Pharma money.  As a matter of principle, I avoid nearly all industry-sponsored CME (occasionally it is virtually unavoidable), as well as all direct marketing contact with sales representatives.  In my next post, I will tell how I nearly became an industry speaker myself without realizing it.

Are bad times good for psychiatrists?

Life seems stressful these days. With the current economic crisis and impending national election, there is a sense of instability in the air. Many Americans have seen their retirement investments dwindle, many others cannot find car or home loans. Most of us wonder what the future will hold. Acquaintances occasionally ask me if this situation is "good for business." Do stressful current events lead more people to seek psychiatric help?

At least in the case of economic downturns, apparently not. A recent Wall Street Journal MarketWatch article says that mental health visits decrease in bad economic times, with unfortunate results for patients. But how about seeing a psychiatrist to cope with other stressful events?

In my experience, people either seek my help for internal issues unrelated to current events, or for a repeated pattern of over-reaction to such events -- basically, something about them, not the situation. The only common exception is the death of a loved one.

This focus on changing oneself differentiates psychiatry from counseling or "coaching." Career counselors and life coaches help clients deal with life challenges, without attempting to change the client's personality or coping skills in any fundamental way. Talking things over with friends or family is similar: You are who you are, the problem is the situation and how to deal with it.

Tranquilizers, too, can help a person deal with stress without changing the person in any fundamental way. Tranquilizers are prescribed mostly by primary-care doctors like internists, family practitioners, and Ob-Gyns. They are best used only occasionally and for short periods of time (days not weeks). Psychiatrists also prescribe tranquilizers, although rarely as the main treatment for a patient's problems.

Psychotherapy, conducted by a psychiatrist, psychologist, or other mental health professional, aims for more than this. While we can't do anything about the stock market, we can help clients cope better with stress when it does arise. This is akin to the old saying, "Give a man a fish and he eats for a day. Teach him to fish and he eats for a lifetime." In addition, psychiatrists are medical doctors who can diagnose and treat conditions, like major depression, that impair coping across the board. Whether the psychiatric treatment consists of medications, psychotherapy, or both, the focus is on the patient, not the stressful situation.

What is a psychopharmacologist?

Sometimes potential patients ask whether I am a psychopharmacologist.  Often they are not sure what the word means, but have been advised to seek one by a doctor, family member, or friend. A psychopharmacologist is a psychiatrist who specializes in medication management.  It is a self-applied label, as there is no special credential or license for this.  All psychiatrists are qualified to prescribe medication.  Some make this a primary practice focus, and develop expertise with complicated medication issues.  Others virtually never prescribe medication, focusing instead on psychotherapy or some other aspect of practice.  Most psychiatrists, at least here in the Bay Area, are somewhere in between.

I am not a psychopharmacologist.  My practice leans toward psychotherapy.  Nonetheless, like most psychiatrists, I have prescribed plenty of medication over the years.  I weigh a variety of treatment options, and try to avoid a "one size fits all" approach.  Rarely, a situation of great medical complexity or mystery arises in which I believe a patient would be better served by a true specialist in psychiatric medication — a psychopharmacologist.  To be honest, it doesn't happen very often.

Colleagues as patients, and vice versa

Yesterday I was called by a psychotherapist who had referred a few of her clients to me in the past (she provided the therapy while I prescribed medication for the same people).  This call was not about a typical referral, though.  The therapist sought a medication evaluation for herself. Most of the medical field accepts without question that colleagues can treat one another.  A dermatologist looks at an internist's rash, the internist treats the dermatologist's high blood pressure.  It doesn't matter that they share some of the same patients.  The perception is that the dual roles of patient and professional colleague do not conflict.

Psychiatry has been different, particularly during the era when traditional ("psychodynamic") psychotherapy was the field's main tool.  In such therapy, the relationship is not incidental to the treatment provided.  It is the treatment provided.  The relationship-in-the-room takes the place of blood tests and brain scans in collecting data, and the place of medications and surgery in helping a person change.  Mixing this essential relationship with other types of roles — colleague, family member, golf buddy, or worst of all, lover — simply ruins it.  It also opens the door to unethical exploitation, as the therapist may unduly influence the patient in this other role.  Professional codes of ethics for psychiatrists and other therapists condemn dual-role relationships for this reason.

But what about medication management?  Most psychiatrists do little, if any, psychotherapy anymore, leaving that to psychologists, social workers, marital and family therapists (MFTs), and others.  When psychiatric treatment is medication and not the relationship itself, then the usual situation in medicine seems to apply.  Couldn't my colleague, the psychotherapist who called, see me for a medication evaluation just as she could a dermatologist or internist with whom she shared patients?

Although she only sought medication services from me, I can't help but think like a therapist.  I imagined the awkwardness of later speaking with her about a shared case if she divulged strong feelings related to her job.  I imagined I might expect less of her as a colleague if I knew her inner pain, yet this could shortchange the patients we shared.  I was concerned I might treat her differently as a patient, since I already knew her as a colleague.

I politely declined, and suggested ways for her to find a psychiatrist she doesn't work with professionally.

The reverse situation of "patient first, colleague second" has also come up.  A few patients of mine are themselves therapists, and occasionally ask to collaborate on a case.  I invariably decline, citing the dual-role concerns above.  It feels less clear when ex-patients later become therapists, and then refer their own clients to me.  Any word-of-mouth referral is a compliment, and the truth is, I have accepted such referrals.  But I still wonder about the potential clash of roles.

Welcome to my blog

Until now, my website had a "special projects" page.  It briefly outlined my concern about overzealous drug promotion, and it also said I sought to demystify psychiatry in general, perhaps through writing a book or a series of articles.

It occurred to me this weekend that a blog might address both of these "special projects," as well as many others.  Once I have this set up, I'll offer more thoughts (and links) that may be of interest to existing or would-be patients, to my colleagues, and to readers in general.