No free lunch

The following is my article originally published in Ethical Times (No. 16, Fall 2008), the bulletin of the Program in Medicine and Human Values at California Pacific Medical Center. Since this piece appeared, PhRMA has voluntarily suspended the distribution of branded items and certain food gifts to doctors (see my post).  The ethical argument still holds and is, I believe, still widely overlooked.  Reprinted by permission. Pharmaceutical promotion is big business. In the US alone, the industry spends billions each year (about $16 billion in 2000) to market its products. Most of this budget pays for extensive, multifaceted marketing to doctors, much of it delivered in person by salespeople called "pharmaceutical representatives." A smaller but still sizable portion of funds produce direct-to-consumer "ask your doctor" ads on television and elsewhere. Pundits debate whether such lavish promotion drives up the cost of health care or helps to contain it, whether it enhances or detracts from patient care. Most of this focus has been on the industry side of the equation. Yet medical ethics demands that we physicians assess the other side of the equation: our own participation in these promotional efforts.

Advertising and product promotion are everywhere in our society, exerting their influence in largely non-rational ways. We imagine that we rationally weigh the features and benefits of competing products and make logical choices. Yet advertisers "sell the sizzle, not the steak." Catchy jingles, the look of a product and its packaging, celebrity endorsements, associations with attractive people or lifestyles — these appeal to our emotions, often bypassing intellect and logic.  In everyday life we sense no ethical impropriety in allowing ourselves to be influenced this way. Who knows, or cares, why we prefer one brand of soap over another? If we choose a household product for its captivating name or fancy packaging we may be misguided or superficial, but we are certainly not evil. We face no ethical dilemma in accepting a free food sample at the supermarket, even if it evokes pleasant associations in us about being fed or induces a subtle wish to reciprocate the generosity. Marketing works at both surface and subterranean levels. As a society we accept that.

Likewise, it is not ethically problematic for patients to respond to television ads by "asking their doctors" about prescription medicines, even though these ads employ the same non-rational enticements used by other industries, such as memorable product names, evocative catch phrases, and scenes of active, happy people. (Some argue it is unethical for the companies to advertise this way, but that is not our focus.) A patient may inquire about a particular medicine for countless reasons, ranging from careful research, e.g., on the Internet, to an offhand comment by a friend. There is no requirement or expectation that a patient's interest be rationally based. From the patient's perspective, there is nothing wrong in hearing about a medicine, even from an ad, and asking one's doctor about it.

The physician, however, is in a very different position. There is an expectation that a doctor's interest in a particular treatment be rationally based. Moreover, medical ethics requires it.

The doctor-patient relationship is fiduciary. It is founded on the patient's trust that the doctor always practices medicine in the patient's best interest. Like other fiduciary relationships (e.g., bank-customer, corporation-shareholder, and attorneys and accountants with their clients), the doctor-patient relationship is vulnerable to conflicts of interest that can undermine trust. In all of these fields, professional ethics dictate that the trustee take reasonable steps to avoid conflicts of interest and divided loyalties.

Physicians in particular must strive to practice medicine in an unbiased, scientific fashion. This is more difficult than it sounds, since influences that are widely accepted and considered benign in everyday life can represent trust-threatening conflicts of interest here. The non-rational influences of product promotion — the gratifying visits by friendly, attractive salespeople bearing personal gifts and free food — directly threaten the fiduciary doctor-patient relationship. By participating in these encounters, physicians actively invite non-rational bias into treatment decisions, in direct violation of the trust patients place in us. It follows that medical ethics should condemn active involvement in this process by physicians, and that reasonable steps should be taken by ethical physicians to avoid participation in promotional activities.

Many physicians defend current practice by claiming that they are immune to non-rational promotional efforts. The pharmaceutical industry does its best, they say, but smart doctors see through the attempted influence and "ignore" it. This rebuttal is not new.

A historical review (1) in a recent issue of JAMA quotes the same view from apologists 50 years ago. However, then as now, there is no evidence that doctors enjoy any special resistance to non-rational product promotion. On the contrary, several empirical studies document the effectiveness of such promotion in swaying the prescribing patterns of doctors. It is tortured logic to assume that a sophisticated industry wastes billions every year on harmlessly ineffective promotional efforts — especially when the very same strategies work well in other industries. Wishful thinking and hubris alone cannot stand up to this evidence.

Increased public scrutiny has prompted modest reforms over the past few years. A growing number of medical centers and teaching institutions now restrict promotional activities on campus. The pharmaceutical industry itself has voluntarily dropped or limited some types of product promotion. Congress is working on legislation requiring public reporting of industry largesse to doctors. These actions recognize the seriousness of the problem. But, beyond all efforts to prevent undue compensation or to make it transparent, the ethics of the physician are the strongest bulwark against improper influence on prescribing practices. Unfortunately, at this time only a small percentage of individual doctors decline sales calls and similar contact with industry. Surveys show that patients express more concern than physicians over this issue.

Being a physician bestows many rewards and gratifications. These are balanced by the restrictions on our actions that are part of ethical practice. We must act professionally and always in our patients' best interest. We must be competent and skillful, stay current in our field, and use evidence-based approaches when possible. And we must strive to avoid making clinical decisions based on non-rational factors. While this ethical restriction may deprive us of branded coffee mugs and pens, free lunches, and opulent sponsored "educational" dinners, it is a small price to pay for earning our patients' trust.

—

(1) Podolsky SH, Greene JA, "A Historical Perspective of Pharmaceutical Promotion and Physician Education,"

Journal of the American Medical Association

300(7), 20 August 2008, p 831-833.

Psychiatric disability

Since psychiatric disability is often invisible and unquantifiable, considering oneself psychiatrically disabled can take on many meanings.  Certainly there are those who assess their limitations, whether imposed by thought disorder, anxiety, or mood extremes, and accurately gauge themselves disabled.  It is a strength to accept reality for what it is, to live one's life accordingly, and to claim the assistance society offers.  However, self-labeled psychiatric disability is not always accurate.  Clinically depressed patients sometimes underestimate their abilities and call themselves disabled the same way they call themselves failures, or bad or stupid — as self-denigration.  Others who yearn for nurturing or attention use disability as way to obtain these from caregivers.  And there are those who feel entitled to special privileges and treatment, and make undue claims on others using disability as a tool.

When I see a clinically depressed patient who is temporarily unable to work, I fill out disability paperwork, usually the California SDI form.  Such forms always ask me to estimate when the patient will be able to resume working.  With proper treatment, most depressive episodes significantly improve in less than three months, so that is what I usually estimate.  I consider this a little on the generous side, as I want my patient to have the disability benefit he or she deserves.  However, unlike recovery from pneumonia or a broken leg, recovery from depression varies widely.  Some patients are back to baseline in less than a month, others take much longer than three.  I have long been fascinated by the dynamics of predicting recovery.  Depression, almost by definition, leads to pessimism.  For this reason, my three-month estimate often strikes the depressed patient as too soon — too soon to hope to be well, perhaps too soon for me to expect much improvement of them.  Yet part of helping someone overcome depression is to lend optimism and hope.  I'd rather err on the side of quick recovery than to pessimistically assume long-term disability.  Indeed, when I've sometimes overestimated the recovery time, and the patient feels well in three weeks instead of three months, I feel I've made the more serious error.

A small subset of patients I see are, for want of a better term, "professional patients."  It is their identity to be ill and disabled.  It is their defining characteristic, the first way they introduce themselves.  Saying it this way risks "blaming the victim," as these people did not choose to be sick.  They are not malingering (intentionally faking illness).  However, even unwanted illness can assume a purpose for itself.  Disability becomes a calling card to see a variety of doctors, to call the crisis line and talk, to try a shopping bag full of medications.  It becomes a ready answer to that very difficult question: Who am I?  Some patients remain psychiatrically disabled because it is a way to be in the world, the only way they find comfortable or familiar.  It can be challenging to explore the meaning of such disability in therapy.  Patients sometimes complain that I don't "believe" them, that I should take their disability on face value.  I prefer to help them find more options in life, as sometimes disability itself is a state of mind.

From the psychiatric perspective, there is a fine line between assertiveness and undue personal entitlement.  On the one hand, it is healthy and strong to assert one's needs, to make a place for oneself in the world.  On the other, diagnostic terms like "narcissism" apply to people who feel, without reason, they are so special they need not obey the same rules as everyone else.  As described in my last post, some claims to keep pets in "no pets" housing, or to bring them to work or shopping for "emotional support," seem to cross over this line.  Since narcissism is ego-syntonic (not seen as a problem by the patient himself), it is frequently difficult to address in psychotherapy, or to interest the patient in therapy at all.

I have given three examples of dynamics that may prolong self-rated psychiatric disability: depressive pessimism, dependency and identity needs, and narcissism.  I could equally and conversely write about denial and counter-dependency as factors that might prevent a truly disabled person from acknowledging it.  However, the legal entitlements granted on the basis of disability make the former a more interesting social conundrum.  On the one hand, our sense of charity calls for helping the distressed and disadvantaged.  On the other, we recoil at self-declared victimization as a means to special treatment.  When disability is subjective and difficult to quantify, as it is in many psychiatric conditions, society does not know whether to embrace or reject it.  A culture of innate entitlement only makes this approach-avoidance conflict more acute.

Psychiatric disability and service animals

This post has taken a while to percolate, and has turned into two posts.  As often happens, what got me thinking was an article in the New York Times, this time on the expanding definition and use of service animals by the disabled.  Service animals now go far beyond Seeing Eye dogs.  The article introduces us to monkeys, miniature horses, even a parrot.  A quadriplegic's assistance by a trained monkey strikes me as ingenious.  In certain respects a horse is better than a dog as a service animal for the blind.  But psychiatric service animals are a trickier issue, and quickly lead to complex questions about labels, stigma, entitlement, and how disability is defined.

My introduction to this issue came long before the NY Times article.  Years ago a patient asked me to write to her landlord, arguing that her building's no-pets policy should not prevent her from keeping a dog for emotional support.  I felt reluctant to write such a letter.  Doesn't everyone get emotional support from a pet dog?  On what basis could I argue that my patient was more entitled to a dog than her neighbors were?  On what basis did she believe she was more entitled?

I did not quiz my patient about her rationale.  It seemed she would truly benefit emotionally from keeping her dog, and on that basis I did end up writing a short letter.  I asked, not demanded, that the landlord consider making an exception in view of my patient's emotional condition (which of course I did not specify).  Whether due to the clout of my letterhead or other reasons, the exception was granted, and my patient kept her dog.  Yet I was never quite sure if that was a good outcome.

The law distinguishes service animals and "comfort" or "therapy" animals.  The latter are not necessarily trained, and enjoy no special legal status.  When I worked on a psychiatric inpatient unit in the early 1990s, a volunteer would usher in animals for "pet therapy."  These were extremely cute and docile dogs, cats, rabbits, and sometimes other fuzzy creatures that brought joy and maybe calm to the patients.  They didn't perform any function other than being themselves.  In contrast, a service animal is trained to do a job.  According to the Americans with Disabilities Act (ADA), such an animal is "individually trained to do work or perform tasks for the benefit of an individual with a disability...."  Service animals are permitted by law to accompany their disabled owners into almost any business or organization that serves the public.

However, as the NY Times article notes, the line between therapy animals and psychiatric service animals has always been blurry.  Does an animal's ability to actively soothe its owner qualify?  Adding to the confusion, the Department of Transportation (DOT) ruled in 2003 that comfort animals, not just service animals, were allowed to accompany airline passengers:  “Animals that assist persons with disabilities by providing emotional support qualify as service animals.” Such animals could be any species and needed no special training.   A 2006 NY Times article describes passengers bringing untrained goats and ducks aboard planes for "emotional support."  Even if this was somehow legitimate, the DOT ruling was mistakenly extended to settings other than airplanes.  Although the ADA rules had not changed, the article tells of a "veritable Noah's Ark" of animals brought to cafes, offices, and other businesses for emotional comfort, falsely justified by the rights of the disabled to bring service animals into these settings.  The article also relates abuses where healthy owners have brought animals into businesses by falsely claiming they are service animals.

As the menagerie of service and comfort animals has expanded, occasional community backlashes have charged that the animals represent health or safety hazards, or an excessive burden to others.  At a general level, this reflects a longstanding American debate between equality and relief from a tyrannical majority on the one hand, versus the view that minority entitlement or "special interests" demand too much of everyone else.  Medically disabled Americans have legal entitlements, including the right to use service animals, guaranteed by the ADA and other laws.  Such entitlements are a point of endless political contention.

Neurologists, I imagine, readily declare quadriplegics disabled, and harbor no misgivings about endorsing their "special interest" in a service animal.  I was less at ease declaring my patient disabled, and hesitated endorsing her "special interest" in keeping her dog for emotional comfort.  Is this simply because psychiatric disabilities are harder to quantify?  Is subjective disability a coherent concept?  In my next post, I will put psychiatric service animals in the larger context of psychiatric disability.

Drug companies and doctors

Happy 2009!  As promised, I'll start adding photos to brighten up the page, and maybe illustrate a point at times.  This one is a mid-winter tribute to spring.

As you might surmise from past posts, I have long-standing concerns about commercial influence on the practice of medicine generally, and psychiatry in particular.  I have two bits of personal news to report on that front.  First, I authored the lead article in the current issue of Ethical Times, the quarterly bulletin of the Program in Medicine and Human Values established at the medical center where I teach.  Although Ethical Times eventually appears online, I may seek permission to reprint my article here.  Basically, I argue that it is incumbent upon ethical physicians to resist commercial influence in making clinical decisions -- whatever pharmaceutical companies or device manufacturers do or don't do.

Also, starting this month, I will serve as chair of the medical center's CME committee.  As I posted in October, continuing medical education (CME) is both required to maintain medical licensure, and is rife with potential conflicts of interest when funded, as most of it is, by industry.  It will be interesting to be on the front lines dealing with these challenges.

In related news, the Pharmaceutical Research and Manufacturers of America (PhRMA) recently revised and expanded its voluntary restrictions on interactions with physicians.  The full text is available here.  The relevant New York Timesarticle emphasizes the new moratorium on branded office items such as pens, notepads, and coffee mugs.  While my view is that the onus more appropriately rests with the medical profession itself to resist commercial influence -- and accordingly some groups have tried for years to convince doctors not to fill their offices with promotional giveaways -- this is a step in the right direction.  By my reading, though, the new PhRMA standards are considerably more limiting than the prior version in other areas as well.  New restrictions on wining and dining doctors may ultimately wield a bigger impact than the disappearance of cheap pens with drug logos.

Much more commercial influence remains, as an editorial in today's New York Times points out.  Meanwhile, in the current issue of the New York Review of Books, Marcia Angell, former Editor in Chief of the New England Journal of Medicine, presents the field of psychiatry as Exhibit A in a shocking review of undue industry influence on research and practice.  We still have quite a ways to go.

State of the blog

I'll be taking a break through the end of the year, and thought this would be a good time to size up this blog creature I created. In nearly two months I've posted about 20 essays.  Over that time I've also read a number of other psychiatry and general medical blogs, having started this one with little prior exposure to blogs at all.  I see that "Reidbord's Reflections" is atypical and, to be honest, rather unbloglike.  Unlike mine, most are anonymous, allowing more freewheeling commentary.  The popular ones are more casual, personally disclosing, and include human-interest tidbits, photos, graphics, and sometimes embedded videos from elsewhere on the net.  They don't stick to the topic, but are more warm and human.

As a psychiatrist who conducts psychodynamic (neo-Freudian, sort of) psychotherapy, I tend not to disclose facts about my private life to patients.  Likewise, I am reticent to offer a lot of personal details here.  At some point I'm sure I'll post something about this; I'm well aware there is no absolute prohibition regarding self-disclosure, and sometimes it can really help.  Nonetheless, most blogging is more exhibitionistic than I care to be.  My intent is to write about psychiatry, not about myself.

Google Analytics tells me I have a modest readership of about 150 unique visitors so far, widely scattered across the US, with a few in Canada, Europe, and the rest of the world.  (Don't worry, the data do not identify you, just your general location.)  Technorati ranks "Reidbord's Reflections" about number five million in the blogosphere.  (Now there's a humbling statistic.)  I've been told that readers rarely comment because I am not controversial or inflammatory enough.  The post that did attract the most notice was perhaps the most contentious, about my almost becoming a speaker for Wyeth.

On the bright side, I enjoy writing.  I have more topic ideas, and I plan to continue doing this.  The page hit rate is slowly increasing over time.  I also have ideas for improving the blog, and would be very grateful for yours as well.  Here are mine: 1.  Include some photos to add interest and color to the page 2.  Invite colleagues to write guest pieces 3.  Include more day-to-day type reflections 4.  Change the font size or colors to make the page more readable

If you have any ideas or suggestions for this blog, the best way to reach me is by commenting on this or any other post.  Please write "do not publish" so I know not to put your comment on the site.  I will read it personally, and I thank you in advance for helping to improve this effort.

Thanks to all my readers for your attention.  Happy Holidays, and see you in 2009!