Tuesday, July 21, 2009

ACRE: Physicians Who Wish To Maintain Status Quo Fight Back

This Thursday, at Harvard Medical School, there will be a one-day conference that amounts to a new front in an ongoing war within the medical community. Probably no more than one or two hundred people will attend. I doubt it will get much play in large media outlets, but its agenda, and whether or not it wins the hearts and minds of the next generation of physicians, could have a major impact on determining the quality of care for patients for the next several decades, possibly just as important as the health-insurance reform bill working its way through Congress.

So what's the conference and why such a big deal?

First, some background and a little explanation of the "war." Over the past decade or so, an increasingly vocal but small minority of physicians have begun to publicly question the relationship that physicians have with for-profit companies involved in medicine, primarily pharmaceutical companies. They have noted that many physicians have become wealthy, for instance, by serving as "professional experts" earning honoraria speaking to audiences of physicians who are fed free dinners (compliments of the company sponsoring the event) and who receive credit for "continuing medical education." They have questioned the structure of postgraduate medical education, which can be heavily influenced by the pharmaceutical industry in the form of Medical Education and Communication Companies, or "MECCs," allowing pharm companies to sidestep sticky conflict-of-interest issues by paying physicians directly for teaching, instead using the MECC as a third-party payer. Indeed, they have highlighted the problems of medical school education as well, since many of these doctors who serve as paid speakers for drug companies also teach medical students without ever revealing that they do so.

Many docs have become involved in this critique of the current relationship between physicians and industry--and I count myself among these people--but probably none is more important than Marcia Angell, whose book The Truth About Drug Companies: How They Deceive Us and What to Do About It lays out in just over 300 pages, and in fairly lurid detail, the tactics used by the pharmaceutical industry to deceive physicians and patients alike in order to boost sales and profits. It is an excellent and highly readable book, and remains the best overview of the critical problems in this often overlooked area of medicine.

There is a lot of pushback by the industry and those physicians already co-opted by them. One small, precious example can be found here, where one Jonathan Leo, professor of Neuroanatomy at Lincoln Memorial University in Tennessee, tried to point out to the Journal of the American Medical Association, one of the premier medical journals in the US, that one of the lead authors of a paper had not properly disclosed a serious conflict-of-interest to the journal. The study involved giving antidepressants to stroke victims prior to developing depression in an attempt to prevent it (depression being a common condition following stroke); the lead author had been a paid consultant by the very company whose drug was being studied. When Dr. Leo questioned the conflict, he never received a reply from the JAMA editors, so nearly six months later he had his letter published in the British Medical Journal, which was met with howling outrage by the JAMA editors who not only verbally threatened Dr. Leo, but also told reporters at the Wall Street Journal that Leo was a "nobody and a nothing," and that "he is trying to make a name for himself." (Question: isn't that what you're supposed to do in academics? And he sure did! And for the right reasons!) Best part: while the study showed that treatment with the study drug (Lexapro, generic name escitalopram) was significantly better than placebo, it failed to show that it was significantly better than psychotherapy. The mainstream media who picked up the piece, however, quoted the study authors as saying that they believed all stroke patients should be given antidepressants--no quotes could be found about the fact that the drug was no better than therapy.

Anyway, Thursday's get-together at Harvard is the inaugural meeting of a group called the Association of Clinical Researchers and Educators. They state that "ACRE seeks to define and promote balanced policies at academic medical centers and within government that will enhance rather than interfere with our highly valued collaboration." Seems entirely innocuous, no? After all, who isn't for "balanced policies," whatever that is?

More specifics can be found elsewhere in the website, where they state that "ACRE is to be a forum for what we believe is a hitherto silent majority of individuals engaged in clinical service, medical education and medical innovation ready to oppose (but not debate) a small but well organized and well-funded coterie responsible for an anti-industry movement. This movement has inverted reality by extrapolating from an astonishingly small number of adverse events related to industry compared to the incontrovertible evidence of social good that has eventuated from thousands of industry actions over my lifetime in medicine. The movement particularly demonizes industry marketing, despite the lack of any evidence that, on balance, such marketing impacts anything but positively on patient care."

What the writer--who appears to be Dr. Thomas Stossel of Harvard, but not fully clear--means by "oppose but not debate" is unclear to me although it sounds vaguely undemocratic, but the idea that there is a "well organized and well-funded coterie responsible for an anti-industry movement" is so remarkably laughable that it must rank as one of the great overestimations in recent American history. (I particularly like the use of the word "coterie," as if somehow I've been sitting around in a parlor sipping tea with Doc Angell snarling about the bad guys of big pharma.) If critics like Dr. Angell, or the bloggers Dr. Dan Carlat, Dr. Doug Bremner or Allison Bass are so well-funded yet so anti-industry, who has the money to fund them? The local chapter of the American Communist Party?

More disturbing is a complete lack of data on the website; as far as I can tell ACRE does not marshal one fact to support their hypothesis. There are no references on the website, although there is a "link" page which includes several articles complaining about the critics, nearly half of those articles written by Dr. Stossel. Given that this is a website whose leadership consists of academic medical researchers, one would figure there would be at least a modicum of references and facts marshaled in order to make a convincing argument. But from what I can see, there's a lot of hemming and hawwing but no argument based in evidence. Ironically, the statement above notes that "the movement demonizes industry marketing despite the lack of any evidence that...such marketing impacts anything but positively on patient care" [my emphasis], which makes one wonder whether or not the authors have taken the time to even glance at the first page of The Truth About Drug Companies. Or Jerome Kassirer's book On The Take: How Medicine's Complicity With Big Business Can Endanger Your Health. Or Jerry Avorn's book Powerful Medicines: The Benefits, Risks and Costs of Prescription Drugs. Might ACRE disagree with their conclusions? Perhaps. But to me it seems fairly ludicrous to suggest that this whole critique has been generated of whole cloth. Meanwhile, ACRE has not generated one shred of evidence to support their claim on the website.

My suspicion is that they can't rely on evidence because it's not on their side, and they require strawmen to knock down so that they can look reasonable. I myself cannot speak for the other critics, but my main objection is that some doctors are allowed to generate large sums of money in the service of pharmaceutical companies in a variety of ways, and do not consider this inappropriate. Well, I consider this inappropriate, and I believe the overwhelming majority of patients consider it equally so. And I consider it inappropriate because drug companies exist primarily to make money while doctors exist primarily to serve their patients. Anyone who refuses to see that a physician cannot serve both ends hasn't been reading about what's been happening in medicine for the past two decades.

One last link: don't say docs don't have a sense of humor! Here is a link to a satirical twin of the ACRE website: "Academics Craving Reimbursement for Everything." One juicy quote: "ACRE is to be a forum for a hitherto silent majority of doctors which believes that a small but well organized coterie of do-gooders are conspiring to prevent them from buying that third home on the lake." They even get that coterie word in. Love that.

As a quick post-script, I note that one of the featured speakers at the event will be Dr. Jeffrey Flier, who is the current Dean of Harvard Medical School. A few months ago I had written about the Harvard medical students who launched a protest about the conflict-of-interest issues in the pharmacology course, and noted that Dr. Flier had made noises that he wanted to change the policies at HMS. While those changes have partially taken place (following the lead of Johns Hopkins, although this new policy is through the hospitals affiliated with HMS, not the medical school itself), I can't say I am especially encouraged by Dr. Flier's acceptance to speak at this gathering, though we will have to see what he will say.

1 comment:

  1. Great.

    Now, every time i give a lecture at a professional conference about my new dig site (Acre, Israel), am I going to be picketed by a pair of warring coteries?