The Frederick Goodwin/Infinite Mind case has become one of the defining controversies for a crucially important health policy issue. Some of us have become hot-headed in our comments, largely because this is something we feel so passionately about. So, in this post, I’ll be keeping my cool, and will pluck some of the significant issues from the morass of accusations into which this debate has degenerated.
1. This is a debate about disclosure of potential conflicts of interest, and not a debate about Dr. Goodwin’s scientific views or his academic integrity.
Let’s not get sidetracked into a discussion of whether antidepressants do or do not cause suicidality. On "Prozac Nation Revisited," it was clear that Dr. Goodwin and his guests believed that this danger has been exaggerated. I happen to agree. But that’s not the issue here.
Nor is this about Dr. Goodwin’s scientific work over the years, which has been excellent. His writings have always struck me as scientifically fair and balanced, including his industry-sponsored CME articles, which is a tall order, given how difficult it is to keep MECCs from sweetening CME with pro-sponsor messages.
No, this debate is specifically about how, when, and where academics should disclose potential conflicts of interest with the pharmaceutical industry. And I believe that "The Infinite Mind" should have disclosed to the listeners, at the beginning of each program, all potential conflicts of interests relevant to the topic of that program.
2. I do not believe that the mere disclosure of conflicts of interest is an admission of “guilt” or “bias,” but audience-members need to be informed so they can judge for themselves.
If an academic takes money from the drug industry and then educates physicians or the public about drugs, this is, inherently, a potential conflict of interest. Here is the conflict: on one hand, the speaker has an interest in providing accurate, useful, and unbiased information to the audience. But on the other hand, the speaker has an interest in maintaining the flow of money from the company, and companies are paying out the money to improve sales.
Speakers with such conflicts may do one of three things. First, they may knowingly bias the talk in favor of the sponsor’s drug. Second, they may unconsciously bias the presentation. Or third, they may not bias the talk in any way at all.
The audience has no way of knowing what goes on in the mind of the speaker, so they have no way of knowing whether they can trust what he or she has to say. In my opinion, the best way to resolve this problem is for doctors to stop accepting money from drug companies for promotional activities. However, at a minimum, listeners needs to know what the potential conflicts are, so they can be on the alert for potential bias.
3. Many have pointed out that “we all have biases,” so why focus on those related to drug company payments?
Yes, many forces and experiences influence our opinions. As a psychiatrist, for example, I might choose drug X over drug Y because:
--A relative did well on drug X.
--A relative did poorly on drug Y.
--I don’t like company Y’s marketing practices.
--I publish a newsletter, and my readers enjoy hearing me criticize drug Y.
--I’ve made $1 million doing promotional talks for drug X, and I’d like to make another million (I haven’t!).
--I’ve done 10 years of research on drug X’s mechanism of action, and if I get one more paper into New England Journal of Medicine I’ll be promoted to full professor.
And so on. There are innumerable sources of potential bias, and we should disclose those that are most clearly identifiable. In my opinion, financial conflicts are the easiest to identify, and also the easiest to resolve. I can choose not to take the money, but I cannot choose to change the fact that a relative did poorly on drug Y, or that I have staked my career on drug X, etc….
This is why we focus on financial conflicts of interest.
4. Finally, this is not about whether Senator Grassley, Senator Kohl, or the New York Times are trying to destroy psychiatry as a profession.
Most of the targets of Grassley’s investigation have been psychiatrists. Some have been cardiologists, and some have been orthopedists.
Psychiatrists have been particularly targeted because, at least in two of the states where drug companies are compelled to disclose payments to physicians, psychiatrists have topped the list. As a profession, I believe psychiatrists are the most vulnerable to the blandishments of the pharmaceutical industry, for various reasons.
First, we psychiatrists make less money than most other medical specialties, and want to supplement our income with drug company money. Second, psychiatrists, by abandoning psychotherapy to those “lower” on the pecking order, such as social workers and psychologists, have painted ourselves into a corner in which all we do is prescribe drugs. Thus, we are exquisitely dependent on information on pharmaceuticals, information which is usually funded by drug companies. Finally, we have a chip on our shoulders in relation to the rest of medicine. Are we “real” doctors? Are we as “good” or as “scientific” as our colleagues in other specialties? Psychiatrists obsess about such questions. Working closely with the pharmaceutical industry makes us feel valued, scientific, and powerful.
Let’s keep the focus where it belongs.