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Monday, November 26, 2007

Dr. Carlat's NYT's drug rep-md "expose"-must reading

Dr. Daniel Carlat has written an eye opening piece in the NYT Magazine describing his activities as a physician-drug detail man promoting Effexor. For regular medical blog readers there may not be many completely new revelations but his story is important for those who have not realized the ways that drug companies can influence drug sales and how physicians may be complicit and while I was well aware of the drug- dinner-drug promotional activities I had not heard that physicians paid by drug companies would actually go to individual doc's office and hawk their wares with over a free lunch and pocket a nice fee.

Carlat is a practicing psychiatrist who writes an excellent blog dealing largely with psychiatric medications and critically analyzes clinical trials with psychotropic drugs. (There are a number of blogs dealing with that general topic and if a small fraction of what they say is true, you would probably never prescribe or take psychotropic medications.) His NYT article deals with several issues that I tend to harp on time and again in my blog including:

1 The idea that meta-analysis MA) should not be placed on the same pedestal in the hall of evidence based medicine (EBM)that houses the randomized clinical trial. They should be considered "observational " studies in which the subjects are trials and can rise or fall based on what studies the author includes and what summary statistic(s) the author chooses to use. And, of course, if the RCTs that comprise the MA are flawed the MA will be mega-flawed. I have written about that issue before here. As illustrated in Carlat's article, a MA presented by someone with appropriate academic credentials can be quite persuasive and such a presentation at a company sponsored training program was one of the major elements in the argument that convinced ( at least for a while) Dr. Carlat that Effexor was superior to the SSRIs .

2.Drug companies (or anyone for that matter) can stack the deck and cook the books of RCTs so that the efficacy of a given drug is put in the best light and the adverse effects minimized.As time went on Dr. Carlat became more aware of the deficiencies in some of the RCT which were used to support the position that Effexor was superior to the SSRI family and became more concerned with the hypertension and withdrawal symptoms that are associated with Effexor use.

3.His article refers to events that provide examples of how the tenets of EBM and the desire of physicians to have better treatments can be and are perverted .

Dr. Carlat was recruited by Wyeth and invited to their training seminar replete with various perks and cash payments to learn how to promote Effexor by visiting practicing physicians offices and educating them about the medication's purported superiority in the treatment of depression.

His article describes his gradual disillusionment with the arguments supporting Effexor and his activities and his decision to quit. He deserves much credit for admitting what happened and I admire his courage.

There is so much in the article that makes one feel bad about the medical business and the role that physicians play (as drug salesmen and sometimes as those who should know better when a salesman comes to call, and the AMA whose role in making money by allowing drug companies to have access to physicians' prescribing patterns-that still boggles my mind). This is not what I thought being a physician was all about. I cannot believe-as the article claims-that 25% of physicians act as drug shills one way or another , but if the number is even one tenth of that, I feel ashamed. On the other hand if you read this post, maybe 25 % is not too far off.

In the interests of holiday cheer, let me interject a positive story ( at least positive in regard to the actions of some retinal specialists).Go here for the tale of two drugs and the treatment of wet retinal degeneration and how the eye docs seem to be doing the right thing while the drug company...

1 comment:

Daniel Carlat said...

I agree, the 25% figure is astonishing. It is based on a recent NEJM article:

A National Survey of Physician–Industry Relationships

Eric G. Campbell, Ph.D., Russell L. Gruen, M.D., Ph.D., James Mountford, M.D., Lawrence G. Miller, M.D., Paul D. Cleary, Ph.D., and David Blumenthal, M.D., M.P.P.

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PubMed Citation


Background Relationships between physicians and pharmaceutical, medical device, and other medically related industries have received considerable attention in recent years. We surveyed physicians to collect information about their financial associations with industry and the factors that predict those associations.

Methods We conducted a national survey of 3167 physicians in six specialties (anesthesiology, cardiology, family practice, general surgery, internal medicine, and pediatrics) in late 2003 and early 2004. The raw response rate for this probability sample was 52%, and the weighted response rate was 58%.

Results Most physicians (94%) reported some type of relationship with the pharmaceutical industry, and most of these relationships involved receiving food in the workplace (83%) or receiving drug samples (78%). More than one third of the respondents (35%) received reimbursement for costs associated with professional meetings or continuing medical education, and more than one quarter (28%) received payments for consulting, giving lectures, or enrolling patients in trials. Cardiologists were more than twice as likely as family practitioners to receive payments. Family practitioners met more frequently with industry representatives than did physicians in other specialties, and physicians in solo, two-person, or group practices met more frequently with industry representatives than did physicians practicing in hospitals and clinics.

Conclusions The results of this national survey indicate that relationships between physicians and industry are common and underscore the variation among such relationships according to specialty, practice type, and professional activities.