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Wednesday, September 30, 2009

We cannot trust drug company studies so we need a government panel,one that is not biased

I read the medical blog "The Last Psychiatrist" (TLP) regularly.Sometimes I think I understand it.I keep going back because at some level I just know he has a lot to say even if some(much) of it escapes me.

In this entry (see here) he takes on a recent commentary by Dr. Daniel Carlat.Dr Carlat gained some degree of name recognition when he renounced his lucrative life as a drug company paid speaker and has become an outspoken critic of many of the drug companies practices including those involving paid physician spokesmen.

TLP quotes Carlat making the point that people respond to incentives and with financial incentives at work how can you trust someone's analysis of the value of a given medication.How can you trust what a drug company's research or spokesman says?

Here is the passage from The Last Psychiatrist that really nails it: (my bolding)

This is the same error people make about the need for government intervention, e.g. that the "free markets" have failed and more regulation is obviously needed. Even if one were to agree on principle that people can't be trusted, the mistake is in forgetting that government is people. These people are subject to the same biases, cognitive errors and general prejudices as the guys at Goldman Sachs, albeit currently it in the opposite direction. We can argue that we prefer the government's biases, but one cannot argue that the government is less biased, self serving, or corruptible.

This may originally have been a country of laws, not men, but that's not the country most modern people want; they want to be able to alter the laws to suit the times. Fine, it's your country. But understand that if the laws are subordinate to men, then the enforcers of those laws will always have more power than you. Has anyone tried to get an anti-Depakote study published in J Clin Psych in the past decade?

It's excellent that Daniel Carlat thinks doctors like himself cannot be trusted to read and interpret their own studies, and that some other group of-- doctors? lawyers? what?-- with special bias-immunity rings need to be assembled to protect us. But those people are still people. This is why the NIH, with their incestuous grant reviewers, crazy politics and flavors of the decade philosophies is so dangerous-- they're just as biased as Pfizer except you think they are objective.

He captures the basic thoughts of the "Public Choice" school of thought. The people who comprise the government are just like the people not of the government in that they too are biased,self-serving and corruptible and respond to incentives and constraints just like everyone else.

His closing paragraph make it clear

People would do well to remember that at one point in our nation's history, "government" was George Bush. When you argue that government needs to be more involved, you are arguing that George Bush needs to be more involved. I do not trivialize this discussion by offering Barack Obama as an equivalent example of the government you want so desperately to supervise your lives.


Roy M. Poses MD said...

Yes, everyone has biases, but some are more biased than others. Everyone has some kind of conflicts of interest, but some people are more conflicted than others.

Suppose you could listen to 2 talks. One speaker is a physician whose only income comes from fees for service and from a medical school salary. The other gets $50,000 a year in consulting and speakers' fees from a pharmaceutical company plus his clinical fees and medical school salary. The subject of the talk is a disease for which the pharmaceutical company is marketing a drug. Which talk would you trust more?

Also, some people are subject to influences that align, and others are subject to influences that conflict. People in government may be biased, but sometimes the biases of those in government might counter-balance the biases of others.

Finally, in health care, the choice between having government do it and having unregulated for-profit corporations do it is a false dichotomy. Government can regulate, police, try to keep a level playing field without picking economic winners and losers. Sometimes not-for-profits (that are really not for profit, and run by people with strong financial ties to either government or for-profit corporations) can do it. Sometimes professionals (without such ties) can do it.

james gaulte said...

Dr. Poses,

Thanks you for your comments and your points are well taken.
The bias titer of individuals along with the level of transparency does vary.Fortunately, the medical profession is much more aware of the potential bias of the drug company sponsored medical speakers than we were in the past,thanks in no small part to efforts of concerned physicians such as those who contribute to Health Care Renewal.

"Sometimes ,the biases of those in government might counter balance the biases of others" Yes,they might but I worry about the creation of expert panels whose power will do more than merely offer a counter balancing view; their decisions will be determinative and greatly influence medical practice. To appreciate the power of expert panels we need only consider what the RUC has meant to the practice of medicine.

James Gaulte