Tuesday, November 27, 2007

"Return the 30K, You Cheap Thief"

Or so opines one of the commenters on the WSJ Health Blog, where you will find many angry folks calling me a "hypocrite," a "pathetic liar," etc....

I'd be curious to hear opinions about: A. Whether I should return the dirty money; and B. Where it should go if I can bear to part with it?

Other comments that I've received about Dr. Drug Rep:

--"Don't blame Wyeth, blame yourself. Nobody was holding a gun to your head--you chose to take the money." Can't argue with this. The article was, in fact, a long confessional about a series of unethical choices I made every step of the way. I don't blame Wyeth, nor do I blame the pharmaceutical industry in general. I blame the doctors who allow themselves to be complicit and corrupted by the allure of money. And yes, I was there with the worst of them!

--At his excellent blog, Hooked, Howard Brody raises the interesting possibility that Wyeth paid me the 30K as a bribe to get me to prescribe more Effexor in my practice. I'm sure that was one of the motivations, and I received letters from some drug reps indicating that this is standard operating procedure in the industry.

--I've received many letters from people who either are taking Effexor now or had difficulties coming off the drug in the past. While my article may have seemed an indictment of Effexor, it was not meant that way. Effexor is a very effective antidepressant, and I continue to prescribe it in my practice, usually as a second-tier agent. But the hypertension and drug withdrawal risks are real. For a very interesting article profiling one man's struggle with Effexor withdrawal, see Bruce Stutz's article, "Self Nonmedication," also published in the New York Times Magazine.

--Many physicians wrote their own mini-confessionals about giving drug talks. One doctor, also a reformed Effexor speaker, described a teleconference in which Norm Sussman minimized withdrawal problems with Effexor. In response, the doctor had an "ethical lapse" and couldn't help mentioning to the audience that Lexapro might be an easier drug for primary care doctors to prescribe, much to Sussman's annoyance. The writer eventually quit speaking for Wyeth.

--I've also received some shocking marketing stories from drug reps and former drug reps, some of which I'll be sharing in the future as I get permission to do so from the parties involved.

24 comments:

bill said...

"I blame the doctors who allow themselves to be complicit and corrupted by the allure of money. And yes, I was there with the worst of them!"

What matters is that you decided to do the right thing in the end and that are not there with the worst of them now.

Anonymous said...

It's a corrupt system and you were sucked in by the lure of hard cash. All these stupid "anti-depressants" do only ONE THING: Depress the individual into numbness. The statistics of the "success" of these drugs is pathetic, twisted and bull.

Reforming is not dropping your lucrative drug talks - though that is a commendable step in the right direction. Reforming would be to stop prescribing drugs and actually deal with conditions. Perhaps a course in Nutrition wouldn't be amiss.

I'm in the UK and it disgusts me how easy it is for US "doctors" to prescribe, prescribe, prescribe as the only solution. Psychiatry: a joke of a profession.

MarilynMann said...

Let he who is without sin throw the first stone.

Anonymous said...

Good on you for writing this piece and then publicly opening yourself up to feedback!

I think you should donate the money to a charity.

Would you agree that being well-informed on these issues would have helped you make a better decision in the first place? What can be done to make sure that practicing psychiatrists are well-informed on these issues?

Would you agree that any mental health academic should be informed on these issues- that those that study the mental health system would hardly be surprised by a single word in your essay?

Again, thanks for writing this, it's an important contribution. And your newsletter is a wonderful resource which I enjoy, so I hope I am not coming off too critical.

Anonymous said...

I think it took a lot of courage to reveal the process you went through. I used to work in a hospital and though I was only a secretary, drug reps came to visit me frequently to try to get to the doctors I worked for. They are no different from any other salespeople--except that they have a lot of money to throw around, AND, what they are selling can have profound and long-term effects on many people's lives. I know. My mother was on 'psychiatric drugs' for most of her adult life. I have an intimate experience of what they did to her, and how psychiatrists in various settings really abused these drugs, and destroyed her in the process. I can't say what she would have been like without them, but it would be hard to imagine a worse situation. Drugs are practically forced on us at every turn. Schools are kicking children out who don't get on medication. Shocking. And very sad.

How do we even know if drugs 'help' people, when we don't give other alternatives much of a chance?

I consider drugs/medication pretty much a legalized form of torture. I'm not exaggerating. I saw my mother in physical and emotional agony from the side effects. I spent a lot of time in psychiatrists office discussing her 'condition' and time in psychiatric hospitals observing the treatment. We are still very much in the dark ages. I mean that literally.

We wonder why medical costs are through the roof. The high cost of these ridiculously harmful drugs that are making drug companies billions of dollars and leaving the rest of the population debilitated could have something to do with it.

Julie said...

Dr. Carlat, Thanks so much for your candor in your nytimes article. I think plenty of the people calling you names would also start to rationalize what they were doing if offered $30,000 -- it's a human error.

I really appreciate your honesty; people need to see exactly what's going on w/ drug companies.

Jayne said...

Why not you use the money to start a campaign for getting people off psych drugs. Try getting other psychiatrist to donate their money. We learn more each day about the faulty research and marketing pratices of just how these drugs get to the market the harm of these drugs. Maybe with what we know, it would be in the best interst of millions of people to stop taking these medications. Oh yeah, I forgot, psychiatry's only "theraputic options" are these drugs. There really is no ethics in the profession is there? Maybe all your article was really stating was "hey, pharma is doing a pretty bad job representing us, lets take some control back!"

laura said...

Thank you for going public.
Re: what to do with the dirty money, suggest contributing it to not for profit organizations (e.g. AHRP) that work to address the corrupting influence of the pharmaceutical industry on psychiatry.
Another area where you might be able to help is in developing resources (clinical oversight, access to residential detox) for people who need assistance in withdrawing from psychiatric drugs.
Please continue to speak out.

Anonymous said...

Your piece in the NY Times was clear and humble, and you aren't proud of yourself for taking the drug companies' money. In my opinion you don't need to give it back, or give it to charity, either -- whether you like the way you earned it or not, you did earn it. (Yes, being paid $750 a week or more means you were being very highly compensated, but how many drug company CEOs make twenty times that much, for doing even less work?)

Anonymous said...

Give the money to some cause that helps people hurt by uninformed psychiatrists.

bill said...

I think that last comment is a good one.

$30,000 dollars isn't enough to do the following, but put with money from other people who have 'dropped out' and want to use that money responsibly, maybe it would be possible to:

start a project somewhat on the lines of Loren Mosher's Soteria
HERE but perhaps more along the lines of a rehabilitation centre for people in deep trouble from effexor and other drugs. That could eventually make a real difference.

There is help available for people who have suffered from 'illegal' drugs, but NONE for people in difficulty in or from prescription drugs.

Stephany said...

It takes guts to speak out against a corrupt system while still remaining a practioner. The awareness raised into the public via your "confession" is worth taking the heat over. I wouldn't complain here any more about being attacked, as whistle blowers know, it's a lonely road to travel. Some end up losing careers, or changing careers, to stand up for what is right.

What to to with the money ppl are freaking out about?> FUND A SOTERIA HOUSE.

Basically, take the high road and while you are there, keep exposing the industry to the public.

Anonymous said...

Psst everyone. I have a secret to share: hospitals (billboards that announce they're "Number 1"), health insurers ("Best" in *insert*), medical device manufacturers ("superior!") and the larger physician groups ALL twist, turn, spin, massage and sometime manufacture their own and others' numbers to convince health care consumers that they offer more than their competition - not only because they genuinely believe they ARE the best but because they also want to grab as many of your health care dollars as possible. And they're off the hook because.... they're not for profit? or don't pay their executives exorbitantly? have community-minded mission statements? Shocking, I say, SHOCKING.

I think of the comparison between pharma and the rest of the industry much like Richard Nixon and his predecessors: they were ALL doing it, but Nixon raised it to a higher art form and got caught.

I heard you on NPR Dr. Carlat. Nice job. After listening, I think your intentions at the beginning, middle and end of your remarkable journey are the same then as now: quite honorable. It can be a struggle to do the right thing in a very messy human enterprise called health care.

Anonymous said...

Daniel Carlat is an assistant clinical professor of psychiatry at Tufts University School of Medicine and the publisher of The Carlat Psychiatry Report.

The New York Times November 25, 2007
Dr. Drug Rep By DANIEL CARLAT

'Confessions of a Psychiatric Doctor'
'Confessions of an Economic HitMan'
'Confessions of a Professional Engineer' - not quite exactly the same.

1.)Attractive, seductive environment
the wine, the great food, the proximity to a famous researcher
dazzling smiles of receptionists contrast with the harsh lights
of the hospital and children crying.
Seminars now have 'role play' actresses and models, like the car shows.
2.)doctors will trust other doctors, not salesmen.
engineers speak the jargon with other engineers
3.)lack of continuing education
half life of knowledge of a professional engineer is as little as six years.
biased information is better than nothing.
4.)economic incentive to 'set the standard' and make huge profits due to monopoly power.
why have dues increased for ALL non-profit organizations?
A.S.M.E. Hydrolevel Case before the Supreme Court. Volunteers colluded to set standards.
Standards have the force of law for boiler safety.
Think of engineers when you walk through a hospital.
5.)completely legal. no secret that names of conferences are published on the boards of hotels.
6.)comparison with the 'known authorities', who are paid a LOT of money.
Engineers tend to follow authority.
7.)dynamic speakers are well trained and rehearsed
few other places that you can meet those 'speakers' except conferences.
Conferences are highly expensive and the quality varies highly.
The exceptional ones tend to be 'company sponsored.'
8.)understand different points of view
no OVERT attempt to suppress criticisms, but sending them to 'committees', for further study, etc.
9.)research is expensive and many professionals do not understand heavy math/statistics
personal experience/clinical/garage mechanic versus study/designed tests.

10.)use of euphemisms
Pharmaceutical “detailing” is the term used to describe those sales visits.
11.)lack of interest by non-profit associations like AMA - medical or NSPE - professional engineers
i2 disclosing compensation of professionals by companies.
13.)make associates feel flattered
V.I.P.s and even presidents of companies WILL return your phone call.
I felt quite flattered to have been recruited.
14.)Occupational Hazards
Space Shuttle Challenger explosion. Only a few will challenge.
think of myself (an educator, a psychiatrist, a consultant), I was now classified as a 'sidekick.'
Help society, advance engineering/technology progress, 'light the world'; classified as professional developer,
and sales aid.
Was I too boring?
For the first time, Will fellow engineers laugth at my jokes?
14a.)joke
The Guillotine
An engineer, a mathematician, and a doctor are each sentenced to die by the guillotine.
The doctor says:
I have saved many lives and perhaps mine will be saved.
The blade falls and sticks half way down. The crowd cheers and says, let the doctor live.
The mathmetician says:
the probabilities are high, but perhaps fate may intervene.
The blade falls and sticks half way down. The judge says, you have beaten the odds and so you will live.
The engineer says:
Now, I see what the problem is; there is a small catch mechanism on the side.
15.)diffuse responsibility; the 'buck does not stop here'
was my salesmanship going to bring harm to anybody?
Engineers are part of team; rely upon the expertise of others.
16.)enlistment in a higher cause
best way to teach is to learn/consult.
astonished at level of detail and subtle influences.
17.)Non-Profit organizations are useful in the age of lawsuits on anti-trust
The American Medical Association is also a key player in prescription data-mining.
Most of top officers are 'sponsored' by large companies, with specific time allowed for the
'benefit of engineering/society.'
18.)Time, structure and 'Death by PowerPoint Slides' are key.
I didn’t mention any of this in my talks.
Criticism is difficult in less than a minute and a half.
19.)Universities teach little about 'ethics'
I knew I had not lied.
In engineering, cause and effect is separated by a long time. The dam cracked
after forty years, rather than seventy years.
20.)professional lives are not lucrative
some engineers made more money in the Chinese Restaurant business than in engineering.
30K additional to 140K = 20%
15K additional to 80K = 19%
21.)careful monitoring of dissidents
Have you been sick?”
22.)final results
Did I contribute to faulty medical decision making?
Did I contribute to faulty engineering decision making? how about that expensive MRI machine?

draft, generalize only. many
professions are similar

Anonymous said...

I read your recommended post: Bruce Stutz's article, "Self Nonmedication".

Are you really a doc? You are endorsing an n=1 as something to take notice of to support your ramblings?

If 30k made a difference in taking care of people - you are a weak person. If it didn't change the way you practiced or others practiced then no harm no foul. You felt dirty, you moved on. Who cares?

Anonymous said...

Well now, another Doctor lured by the big bad drug company; that's a new one....ad nauseam...
If Dr. Carlat is perplexed over the vexing issue of what to do with the 30k he received for his "services," I can provide him with a list of names or agencies that would be grateful for a small percentage of that money.
Remember, truth may be appear humbling but action speaks louder than words.

Anonymous said...

If you can bear to part with it? Jesus, I hope you're joking. Look, even the extra $30K isn't going to make your med-school friends think you're a real doc. Do the community service. Donate the money to county services, spend the money advertising the withdrawal effects, or do the pro bono work. I get a really uncomfortable feeling that you're getting off on all the attention, and I must say it's not helping to improve my perception of psychiatrists.

Just have some class, willya? Go put the money back in some ethical way -- maybe, deep down, you have some sense of what this might mean, and figure it out yourself -- and continue the exposes without the focus on you, you, you. Meh. Really, your continued behavior here makes it unsurprising to me that you took the money in the first place.

Nick said...

Dr. Carlat I found your story riveting, and I’ve been thinking about it for days now. I’m disappointed to see this blog though because it seems to me people have missed what I found to be the point. For me it painted a vivid picture of how someone who’s educated and experienced can slowly be pulled into something that may not be entirely ethical; a tribute to American marketing.

Imagine how different our country would be if you were the only one to believe a marketing pitch. In reality, from the politicians we elect to the brand of potato chips we buy, we are constantly influenced by our capitalistic society. Nope, I myself am not a socialist but I do recognize that there are both benefits as well as downfalls to the system we have in place and I believe you’ve experienced one of the cons.

One blogger writes “Actions speak louder than words”. I agree, your action to quit the job instead of continuing to receive money for doing what you believed was unethical in my eyes was not only the right choice but rectified your error. The $30,000 was for the work you did and whether you like it or not, you’ve already done the work and earned the money, giving the money away will not change anything.

Congratulations on being an ethical individual and leaving when you did. Keep the money and let it act as a reminder to always question whether something IS too good to be true. Good luck with your practice and thanks for letting all of us learn from your mistake.

Anonymous said...

Dr. Carlat,

I wanted to comment specifically on this particular part of your remark:

--While my article may have seemed an indictment of Effexor, it was not meant that way. Effexor is a very effective antidepressant, and I continue to prescribe it in my practice, usually as a second-tier agent--

And there in lies the problem. I am curious as to what you would classify as effective in light of these statistics on the effectiveness of antidepressants as a whole:

Quoting from the Furious Seasons site where this quote come from an NIH document, "Even when they do receive treatment, only slightly more than half of all of them respond well to therapy, defined as experiencing a 50 percent or greater reduction from baseline symptom severity. If complete symptom remission or restoration of function is the outcome, then the proportion is even lower"

http://tinyurl.com/2sdv5m

Also, effexor doesn't look too good in this study:

http://tinyurl.com/2olydn

"Bupropion-SR, Sertraline, or Venlafaxine-XR after Failure of SSRIs for Depression"

QIDS-SR-16 response rates were 26.1 percent for sustained-release bupropion, 26.7 percent for sertraline, and 28.2 percent for extended-release venlafaxine.

This was after people had not succeed on trials of SSRI medication. It was for 727 patients.

Dr. Carlat, as someone who is tapering of of psych meds due to side effects concerns and who felt the meds really weren't effective, to me, the honesty issues transcend the $30,000 whether that was your intention or not. It is about psychiatrists being honest with their patients about these statistics, which are from mainstream sites respected by the medical profession.

It is about giving your patients all the necessary information to decide whether they want to risk serious side effects.

It is about taking what patients say seriously about side effects and not minimizing their complaints as due to their illness.

It is about exploring alternatives with patients who don't want to go the med route.

I applaud you asking what to do about the $30,000 but as long as people like you continue to avoid facing the cold hard facts that these meds are not as effective as you make them out to be and minimize the side effects, it doesn't matter to me if you were going to give $500,000 back. Well, I would applaud you but again, you confession in tne NY Times Magazine, while quite admirable in many ways, only begins to scratch the surface of what is wrong with psychiatry in my opinion.

AA

Anonymous said...

Attacking you and calling you names is not at all a constructive means of dealing with an extraordinarily complex system and situation. Your article in the NYT is however a constructive means of developing a system of transparency. I have no problem with you or anyone else being a paid spokesperson or consultant or (for that matter) researcher for a large biotech or pharmaceutical concern. What I would prefer however, is that there is transparency and "truth in advertising".

The evolution of the efficacy of Effexor (or any relatively new) medication that is cited may have been just the natural evolution of a drug when it is monitored in a "real life" setting rather than in the bounds of a clinical drug trial (Phase II-IV). Much of this is related to nonrepresentation of everyday patients by clinical trial participants.

However, if the change in efficacy and (even more damning) the potential side effects of a biologic agent, is related to some sort of corporate malfeasance, well then this speaks to a fundamental flaw in our system.

While I will be the last in line to defend PhARMA, they do have a purpose and a place in our current Market based health care system. I congratulate you on your excellent article and again feel this is a constructive step toward improving what we currently have.

James said...

I am surprised by so many negative comments about one of the bravest confessionals ever written! Those of you who rail against the author, have missed the salient point by a very wide margin.

Think of a pharmaceutical, like Effexor, as having its own "lifecycle." The drug's "life" starts with a new drug application to the FDA, and ends with the branded agent losing its patent to a generic distributor. During the course of any drug's lifecycle, side effects come to light, new indications are approved (or not), and physicians refine their use of the drug by measuring their patient's response. Part and parcel of that cycle is the professional dialogue between doctors.

It is very rare that a physician would have the guts and moral fortitude to use HIMSELF as a case study in front of the entire World. Dr. Carlat—at his own personal expense—has done the medical world a giant service. He turned $30,000 into a million dollars worth of ethical scrutiny which can only result in better patient care.

I agree wholeheartedly with Nick, who wrote, "Congratulations on being an ethical individual and leaving when you did. Keep the money and let it act as a reminder to always question whether something IS too good to be true. Good luck with your practice and thanks for letting all of us learn from your mistake."

Impactiviti said...

Your article was very timely, because the very week it appeared, I was making a transition (with doctor's approval, of course) from Effexor XR to a cheap generic (Prozac) to see if it would be just as effective. My life has been utterly transformed by the use of Effexor XR over the past 3 years, and I was hesitant to tamper with success! And, sure enough, for several days I did experience mild dizziness. But I was at the lowest dose of Effexor, and the withdrawal effects were relatively transient - and, happily, the generic seems to be just as effective!

For those ignorant broad-brushers who dismiss anti-depressants out of hand as "bad medicine," get a grip. Just because something can be abused or improperly prescribed at times is hardly an indictment of the near-miraculous impact these medicines have had on some of us who suffered in silence for decades!

Anonymous said...

I must ask, didn't it seem very obvious from the training and the slide kits, the "message" you were to deliver that this was none other than the same slanted data heard from the reps with the glossy detail pieces and the "cherry picked" data from clinical trials that puts the drug in a favorable position?

The reps do it, but the Drs have their credentials behind them, and Drs listen to their peers. That said, isn't it still very obvious these are canned pitches?

Perhaps I am just more skeptical than many, or the DRs who are groomed for the role as opinion leader really don't feel that what they are required to present is all that slanted.

As a former drug rep, I was probably not considered the ideal "rep" because I was always questioning things in meetings about what our claims were, wondering about the clinical trials we did not use for promotion because they didn't serve the drug well and yet it was important data for a true view of what was known...It is embarrassing if you ask me.

It was embarrassing I should say, because I know I don't hold a medical degree and yet I am speaking to physicians on the efficacy, safety and tolerability of drugs EXPECTING them to call bullshit.

Once after a meeting about Baycol issues, where we memorized and role played what to say to physicians about safety concerns in light of several patient deaths in my city due to rhabdo, I was scheduled to work with my manager the next day in the field. On my first call, I only gave a warning about Baycol without the fluffy "no worries" script given to us the day before.

My manager asked me once we left the Drs office what the heck kind of sales call did I just make? I said he could say what he wished about me possibly alarming the Dr., but c'mon...we weren't called in for an emergency meeting because everything was A-ok. I proceeded to tell him I preferred not even speaking about Baycol, because no doubt there is going to be a recall. He agreed it was a bit "suspicious". Just 2 weeks later Baycol was pulled from the market.

I am no longer in the drug promoting business. Denial runs so deep it makes perfectly sane people lose all sensibility!
Regards,
An Ex-Pharmer

Anonymous said...

I must ask, didn't it seem very obvious from the training and the slide kits, the "message" you were to deliver that this was none other than the same slanted data heard from the reps with the glossy detail pieces and the "cherry picked" data from clinical trials that puts the drug in a favorable position?
The reps do it, but the Drs have their credentials behind them, and Drs listen to their peers. That said, isn't it still very obvious these are canned pitches?
Perhaps I am just more skeptical than many, or the DRs who are groomed for the role as opinion leader really don't feel that what they are required to present is all that slanted.
As a former drug rep, I was probably not considered the ideal "rep" because I was always questioning things in meetings about what our claims were, wondering about the clinical trials we did not use for promotion because they didn't serve the drug well and yet it was important data for a true view of what was known...It is embarrassing if you ask me.

It was embarrassing I should say, because I know I don't hold a medical degree and yet I am speaking to physicians on the efficacy, safety and tolerability of drugs EXPECTING them to call bullshit.

Once after a meeting about Baycol issues, where we memorized and role played what to say to physicians about safety concerns in light of several patient deaths in my city due to rhabdo, I was scheduled to work with my manager the next day in the field. On my first call, I only gave a warning about Baycol without the fluffy "no worries" script given to us the day before.

After my Mgr asked me what had I just done in there alarming Doc? I said "We weren't called in for an emergency meeting because everything was A-ok." I proceeded to tell him I preferred not even speaking about Baycol, because no doubt there is going to be a recall. Just 2 weeks later Baycol was pulled from the market.
Denial runs so deep it makes perfectly sane people lose all sensibility!
Regards,
An Ex-Pharmer