ACRE Meeting: Welcome to Anger Village

Yesterday, I attended the charter meeting of ACRE (Association of Clinical Researchers and Educators) in Boston. The title of the conference was “Optimizing Value to Patient Care of Industry-Physician Collaboration,” and the schedule called for 23 speakers over a 6 hour period, all in a hot amphitheater crowded with pharmaceutical reps, doctors, reporters, and miscellaneous others.

Obviously, I arrived with a skeptic’s attitude. After all, I had already parodied the organization with this mock blog renaming ACRE “Academics Craving Reimbursement for Everything.” I was not alone in my difficulty taking the organization seriously. On the pharma gossip website, there was an even more vicious parody, in which the organization is renamed Forum for University Corporate Kickbacks in Education as Determined by University Professors, yielding a more colorful acronym which you can work out on your own.

Why is ACRE so very ripe for satire? Because it consists of rich doctors complaining that they want more money from drug companies, and such an organization lacks any inherent credibility, and seems, frankly, absurd. On the other hand, I like and respect the “two Toms” (Tom Stossel and Tom Sullivan) who formed the organization and I realize that there are some purer motives than greed operating here. That’s why I attended the meeting.

The whole experience felt very much like an anthropological expedition. I took Boston’s Green Line to Harvard’s Brigham and Women’s Hospital (where Dr. Stossel is an esteemed faculty member), a building so massive that the main hallway is called the “Pike.” I was directed by the information clerk to walk down the Pike and take “exit 6” to reach the Bornstein Amphitheater. I arrived 10 minutes late and encountered a small auditorium with steep rows of seats so crowded with pharmaceutical executives and physicians that people were sitting on the steps. I squeezed into a seat in the middle of a row that had been overlooked by the masses, and began my experience of the cultural village that is ACRE.

For the most part, what unreeled over the next 6 hours was an endless succession of smart, accomplished, and furious men (actually, there were three women—two of whom were patients).

Harvard’s dean, Jeffrey Flier, introduced the conference, but his comments must have been exceedingly short, because by 10:10 AM, Dr. Stossel was speaking. As I said, I’ve always liked Tom Stossel, even though we disagree about the value of industry’s use of physicians as marketers and educators. He’s always entertaining and creative. He’s the guy who hatched the evocative term “pharmascolds” to describe people like Senator Grassley and me and plenty others, and in this talk he called the current regulatory environment a “conflict of interest police state.” Though some paint Stossel as an extremist, he is not, and in fact made clear at the outset that the goal of ACRE is not to repeal the recent gift ban and disclosure law passed by the Massachusetts legislature. Rather, he wants ACRE to act as a forum for preventing further restrictions on industry-academic interactions which he feels would be detrimental to medical research and treatment. His heart is in the right place.

Unfortunately, after Stossel’s introductory remarks, the program devolved into a collective middle finger pointed at everybody viewed as the “enemy,” which included government, elite academics (yes, even though the conference was held at Harvard), bloggers, The New York Times, all medical journals, most lawyers, and then I began to lose count.

A major agenda of the speakers was to expunge the term “conflict of interest” from the English language. Dr. Lance Stell, professor of philosophy, said that since there is no “canonical” criteria to distinguish “undue COI” from regular COI, it would be better to just get rid of the term altogether. Other speakers, taking hints from the George W. Bush playbook (eg., it’s “climate change,” not “global warming”), introduced a series of substitutions for conflict of interest, such as “congruence of interests,” “overlapping interests,” “confluence of interests,” or, my favorite, simply “interests.”

It may seem comical, but something more serious than word-play was happening here. The defining problem with inappropriate industry influence in medicine, is, indeed conflicts of interest. When doctors are paid by drug companies to give talks, they are accepting two conflicting and competing incentives: first, deliver the carefully crafted marketing message provided by the drug company, or second, tell the entire truth, which may well include bad things about the drug. Except in rare cases, this ends up not being a convergence, an overlap, or a confluence—it is a conflict.

But industry “interests” were celebrated at this meeting. Culture shock really set in when
Dr. Michael Weber, a New York cardiologist with an Australian accent, described his industry ties by saying “I’m proud to say that my list of disclosures is longer than anyone else’s.” Everybody laughed. This was funny. This was clever. Subverting the “politically correct” value system of pharmascolds was a crowd-pleaser in ACRE Village.

Actually, Weber was wrong. University of Texas oncologist Avi Markowitz had him beat in the disclosure department. Markowitz also one-upped his colleagues in the sarcastic fury category. Sarcasm, anger, bitterness, and pride of massive industry involvement are popular emotions among ACRE-nauts. After dismissing the arguments of his critics as “inferential dribble,” Markowitz summarized the opposing side’s argument thusly: “Obviously, if you work with industry you’re evil.” One of his slides encapsulated the baseline attitude of most ACRE-nauts: “#1 Lie in Life: Hi! I’m from the government and I’m here to help you.”

But the eeriest presentation came from one J. Michael Gonzalez-Campoy, an endocrinologist who was flown out on the ACRE-jet from Minnesota. His job was to convince everybody that Minnesota’s 1993 physician payment disclosure law (the first in the nation) was an awful mistake. His tactic, theoretically, was a good one. “The law has been terrible for patients,” he declared, speaking in the ominous tones of a doctor notifying you of grim laboratory results.

“Oh boy,” I thought, pen poised, “finally, some data on the effects of transparency laws on patient outcomes.” But alas, Dr. Gonzalez-Campoy’s evidence base amounted to a single patient, a 73 year old man with severe diabetes. “Do you know what drug he was on?” He asked incredulously. “The cheapest drug money will buy—Glyburide….When I asked my patient why he was on that drug, I was appalled by his answer. He told me that his PCP said it is the most cost-effective drug.” It got worse: the patient had apparently been reading newspaper articles saying bad things about the newer diabetes drugs, like Avandia. The kicker was when he told Dr. Gonzalez-Campoy that “I’ve read that doctors are getting brain-washed by drug companies to prescribe these drugs.” Don’t you see what the Minnesota disclosure law has wrought? Patients getting prescribed generic medications. Patients reading the newspaper. Patients questioning the morals of their physicians.

“Please learn from our mistakes,” Dr. Gonzalez-Campoy, now impassioned, concluded. “Massachusetts should have asked us before they passed their law. They didn’t.”

Thank the Lord!

Tom Sullivan, who put together the event, sounded entertainingly like one of his blog postings—outraged, sarcastic, but with enough actual policy information to keep my attention. Boy, is Sullivan ever pissed at Senator Herb Kohl , who has just announced a senate hearing on industry funding of CME to be held next Wednesday. “Senator Kohl woke up one day last week,” he riffed, “and decided that his staff hadn’t done anything for a while, so he told them to get a hearing together.” I can see why Sullivan is threatened—industry-funded CME is his company Rockpointe’s bread and butter.

There are various awards to be given. Dr. Carey Kimmelstiel, an interventional cardiologist and a professor at my own medical school, Tufts, gets the award for whiny entitlement. His talk was about the value of industry-supported promotional talks. Among the benefits: You learn a lot when you give them, you can network with your colleagues, and your colleagues learn a lot from you. That’s true, but has nothing to do with industry support. It’s possible to give the same talks to colleagues and reap the same benefits without getting a drug company check. It’s actually part of the job of being a medical school professor. But this was merely the irrelevant portion of his talk. The whiny entitled part came when he showed us an email from Doug Drachman, a Mass General cardiologist who has been organizing quarterly meetings of Boston interventional cardiologists to talk about interesting cases. His email broke the bad news that because of the Massachusetts law banning industry from taking doctors out to fancy dinners, these meetings are being postponed. Dr. Kimmelstiel was outraged. Look at the unintended consequences of the gift ban law—now cardiologists can no longer meet with another. That’s rich. Interventional cardiologists are some of the highest salaried professionals in the world, and yet they refuse to pay for their own dinners four times a year? That’s why I call the organization Academics Craving Reimbursement for Everything.

Oddly, the best and most convincing presentation was also the shortest. Dr. Jeffrey Garber, chief of endocrinology at Harvard Vanguard, profiled the American Association of Clinical Endocrinologists, of which he is the president. He outlined all the good things the organization is doing to educate primary care doctors and the public about diabetes and thyroid disease, all of it funded by industry. His point was that without industry money his organization couldn’t do all these great things. Probably true, though there are other ways for doctors to learn this information, like grand rounds, journals, and meetings that they might have to pay for themselves.

Henry Black, the President of the American Society of Hypertension, basically made the same case as Garber, arguing that his entire organization would cease to exist without drug company money. Unfortunately, Dr. Black got the day’s award for the most mangled slide. In a tirade against a recent JAMA paper recommending that medical societies cease industry ties, he started insulting the individual authors, saying, essentially, that most of them are washed up has-beens. Unfortunately, he had Dr. James Scully listed as the “president of the Josiah Macy Foundation,” rather than his actual job, which is the executive director of the APA. I didn’t point it out, because he was just working up steam and was beginning to froth at the mouth.

It was the quintessential ACRE moment: fury, self-righteousness, and getting everything a little bit wrong.