Monday, October 25, 2010

Two more from Dollars for Docs: Psychiatrists Rule the Hired Guns, and "Thought Leaders" are Cash Cows

Psychiatrists are at the top of the Hired Gun list

According to Medscape, psychiatrists accept more money from drug companies for promotional speaking than any other specialty listed on ProPublica's Dollars for Docs database.

Of the 384 physicians in the $100,000 group, 116 are psychiatrists. Leading all psychiatrists was Roueen Rafeyan, MD, in Chicago, Illinois, who received $203,936 from Eli Lilly, AstraZeneca, Johnson & Johnson, and Pfizer, mostly for professional education programs."

While discouraging, this does not surprise me, since American psychiatry has fallen into a practice style that relies on medication at the expense of getting to know patients. The slogan of the modern psychiatrist has become "I prescribe, therefore I am," and drug companies are quick to approach them with offers of cash payments in return for prescriptions. While this deal is never made explicit (it would be considered an illegal kickback), in fact the expectations underlying these financial relationships are painfully clear.

NPR Shows how "Thought Leaders" are really "Prescription Writers"

NPR ran a nice piece (which can be read here) scrutinizing whether drug companies hire speakers because they are experts, or rather because they prescribe a lot of their drugs and are good at getting other docs to follow suit.

First, they interview child psychiatrist Lance Clawson. According to this entry on the Dollars for Docs website, Dr. Clawson has spoken for Eli Lilly, which
paid him $56,800 in 2009 and $7,661 in the first three months of 2010. Clawson tells NPR that he feels no guilt about these talks: "I'm going out there and trying to educate other doctors about how to treat ADHD appropriately and safely," he explains. Since Clawson said he is talking about ADHD I assume he is promoting Strattera, which is Lilly's only FDA approved ADHD medication. Strattera is, indeed, effective for ADHD, but is significantly less effective than stimulants. During Dr. Clawson's talks, I therefore wonder how much time he devotes to educating his audience about this study, which showed that Strattera is significantly less effective than Concerta, or this study, showing that Strattera is much less effective than Adderall XR. Since hired guns are forced to use only the company's slides, I suspect that Dr. Clawson educates doctors the Lilly Way, rather than the Evidence-Based Medicine Way

NPR then interviews a current drug rep who knows exactly why doctors such as Clawson are chosen as "thought leaders"--because they have lots of patients to whom they will prescribe lots of the company's drug.

According to the rep: "I think nowadays a thought leader is defined as a physician with a large patient population who can write a lot of pharmaceutical drugs. Period." Furthermore, according to NPR's sources, reps very closely monitor the prescriptions of speakers after they are paid to give talks, and, according to one rep, paying a speaker $1500 to give a talk may well yield $100,000 or more in extra prescriptions.

I'd be curious to get the prescription reports for Dr. Clawson's practice after he gives his talks! I'm sure his rep has the data squirreled away in the company laptop.


moviedoc said...

"American psychiatry has fallen into a practice style that relies on medication at the expense of getting to know patients."

Why do you pick on psychiatrists? Do you think orthopedic surgeons or endocrinologists "get to know" their patients? Don't patients with family problems, personality disorders and other mental illnesses seek treatment from cardiologists and dermatologists? Why shouldn't they be doing 50 minute sessions?

Daniel Carlat said...


If psychotherapy were a crucial and foundational part of the treatment repertoire of cardiologists and dermatologists, then, yes, they should be doing psychotherapy with their patients. But it is not.

In psychiatry, on the other hand, psychotherapy is foundational. It is as effective as medication for many of the diseases that we treat, and it is arguably more effective than meds for panic disorder, PTSD, personality disorders, and relapse prevention in depression. It is also a highly effective adjunct to medication treatment of such "biological" illnesses as schizophrenia and bipolar disorder.

I don't buy the argument that tries to compare the relationship between psychiatrists and therapists with the relationship between, say, cardiac surgeons and cardiologists. In these medical cases, each specialist possesses a series of unique and highly technical skills for the treatment of disease. It would be impossible for one person to master all the skills of a cardiac surgeon and the skills of a cardiologist, and to excel at either.

But it is entirely possible, and in my view necessary, for one person to master both psychopharmacology and psychotherapy. The technical aspects of both of these techniques are substantial and yet are primitive and underdeveloped in relation to the rest of medicine. There are both learnable in the context of 5 or 6 year post-graduate training program.

And yes, of course any doctor in any specialty must learn to relate to patients but that is a far cry from the skills of evidence-based psychotherapy.

Anonymous said...

"Why do you pick on psychiatrists? Do you think orthopedic surgeons or endocrinologists 'get to know' their patients?"

Moviedoc--the orthopedic surgeon who rebuilt my knee 25+ years ago spent far more time explaining his diagnosis/my treatment options to me than did the psychiatrist who incorrectly diagnosed me with bipolar disorder after I had an extremely adverse reaction to an SSRI.

The orthopedic surgeon spent time explaining the anatomy of the knee, showing me the imaging studies, explaining the proposed procedure, asking how active I wanted to be at 50, talking about the possibility of developing arthritis, future advancements in knee replacement, pretty much anything that might affect my decisions about treatment.

After I told the psychiatrist about my reaction to the SSRI, she gave me a cursory interview, announced that I had bipolar disorder, told me my choices were lamotrigine or lithium for life, with other drugs most probably added later, and steadfastly refused to answer any questions about how she arrived at the diagnosis.

I'm still skiing, hiking, biking and running at 54. Thanks orthopedic surgeon!

Oh, and three years after diagnosis, I'm not on any psych drugs. No thanks, psychiatrist!

Dr John said...

"Thought Leaders" huh?

I would say "Useful Idiots" would be far more appropriate.

These guys better save their pharma nickels. In 10 years psychiatrists will be at the bottom of that list because there just is not going to be much new crap to shill.

The fact that "talking" to people is as effective as anything for the "diseases" we treat pretty much sums up the the validity of the disease model of pathology in psychiatry.

I wonder if "anonymous" got ripped off and his orthopod could have just talked him out of his bad knee? Maybe he just needed group therapy with other cripples? I suppose a "12 step" approach would have been out of the question...

Joseph P. Arpaia, MD said...


I disagree that other doctors are different from psychiatrists.

The question is not psychotherapy vs medications. Its education vs medication/procedure.

For example, there is nothing that prevents an orthopedic surgeon from knowing enough physical therapy to offer that to most patients with back pain. But the reimbursement from that would be much lower, so they do operations. This in spite of the fact that most people who receive spinal operations for low back pain would have been better off without the surgery.

The whole system is medicine is warped because the reimbursement schedule rewards people in a way that has little relationship to outcome.

Another exmple: Medicare pays for proton beam therapy for prostate ca when there are equivalently good treatments costing 1/4 the amount.

Psychiatrists are no different than surgeons, cardiologists etc. They, with occasional exceptions, are spending time doing the CPT codes that bring in the highest return.

The problem is the CPT reimbursement rate and unless that is radically altered nothing is going to change.

Sara said...

I do agree with Dr. Arpaia that our health care needs to have a lot more focus on outcomes in all the specialties, not just psychiatry, although I truly think psychiatry is one of the worst offenders (in part because it isn't easy to measure outcomes given our current paradigms and the mainstream assumption that almost all symptoms after treatment starts are "worsening of the disease" rather than adverse effects. It really doesn't take a rocket scientist to figure out that unless we start getting really serious about outcomes and what works to make someone well and what doesn't, we are going to bankrupt our country and our future.

moviedoc said...

Psychotherapy (except perhaps the psychodynamic types) does not equate to "getting to know" or "talking to" the patient. Shame on Anon's psychiatrist for failing to adequately explain the risks and benefits of meds, especially if she failed to describe alternative modalities, like CBT. Psychiatrists should know as much about psychotherapy as orthopedists know about physical therapy. (Thank you Dr. A. I'll bet physical therapists get to know their patients, but that's not treatment.) But you don't have to have and MD or DO to be a skilled psychotherapist.

Wright & Thase have the right idea in the Oct Psychiatric Times "Combining High-Yield CBT Methods and Pharmacotherapy in Brief Sessions." But all physicians should learn some of those interventions instead of thinking they can provide optimal care by pawning off the "difficult patient" on psychiatrists as specialists in "getting to know."

I don't believe the 45-50 min. session is routinely necessary, regardless of your profession. Dr C, do you know whether anyone has studied how much of that time psychiatrists actually devote to psychotherapy as opposed to talk about meds and side effects, or sitting there while the pt. talks on the cell phone, or addressing talking on the cell phone during "therapy" sessions as an "issue?"

Maybe we should solve the orthopedic surgeon shortage by letting physical therapists do hip replacements.

(Thanks for letting us get off topic here Dr. C.)

Unknown said...

(BACK on topic - though "therapy vs meds" is never far away)

If the numbers stated are correct (I doubt it, but maybe close), then there must be something about psychiatry that makes this kind of "thought leader" game more useful in psychiatric pharmaceuticals than other fields. What do you all suppose it is? Poor pharmacology understanding? Heavier reliance on "authority figures?" Being generally frustrated with so many patients whose treatment seems inadequate that we'll try anything? Is it that so many medicines seems to be about equally efficacious for the same disorders? Are psychiatrists more susceptible to looking for a "magic bullet" treatment than other fields? Are FP's somehow less frustrated with the complaints of chronic fatigue and back pain and insomnia than psychiatrists are for the chronic complaints in their field? Or is it MAYBE that the psychiatric speakers are not primarily talking to psychiatrists - but instead to the FP's and Internists who are prescribing the majority of the initial treatments for psychiatric disorders. Maybe the huge boost in sales driven by "thought leader" speaking engagements is brought about by changing how generalists are prescribing?!

I don't know the answers, but I'd sure be interested to find out. I'm curious what other readers think is the reason psychiatry seems to be at the top of this list.

moviedoc said...

My (pat) answer for Scott: science has failed psychiatry.

Joel Hassman, MD said...

Dr Arpaia:

Keep writing things like "I disagree that other doctors are different from psychiatrists." As Obamacare becomes entrenched, watch how psychiatry gets pushed to the door as this kind of mindset just reinforces psychopharmacology can be handled by PCPs/Family Docs.

We are not equal to other MDs, and I am offended that this attitude gets reinforced by my colleagues! I will agree that there is a population of psychiatrists who shill for dough as equally as other specialists.

But, they do not represent or speak for me. Maybe it is time for the majority of us who feel this way to show this in effective ways?

Like, stop going to these lame CMEs as a start!?

Anonymous said...

"If the numbers stated are correct (I doubt it, but maybe close), then there must be something about psychiatry that makes this kind of "thought leader" game more useful in psychiatric pharmaceuticals than other fields. What do you all suppose it is?"

It seems to me that there are a number of factors driving this phenomenon. The most obvious, to me, is the fact that the mind is not the knee. Psychiatry simply lacks the knowlege base to provide concrete answers and treatments at this time. This opens up the field to dishonest and predatory tactics by pharmaceutical companies and their confederate physician/thought leaders. Primary care care docs are writing more and more prescriptions for psych drugs, based on the assurances of the thought leaders. The psychiatrists in the trenches are cleaning up the damage, under pressure to assign a DSM code, get insurance reimbursement and get 'em out the door. It all amounts to quite a bonanza for the drug companies and their henchmen.

I really think most psychiatrists have honorable intentions, but at some point the profession has to know what it doesn't know, and to honestly disclose this to and discuss this with patients. We can handle the truth.

I do appreciate that most of the doctors commenting here seem to be honestly searching for a way to improve patient care.

Anonymous with the rebuilt knee.

Anonymous said...

No... psychiatry has failed science... and ethics.

moviedoc said...

Anon, psychiatry is a medical sub-specialty whose role is to diagnose and treat mental disorders (sick people). How could psychiatry fail science?! Maybe the odd "mad" scientist.

But I completely agree with you that psychiatry, at least organized psychiatry in the form of the APA, has failed the public and psychiatrists miserably in its duty to enunciate and enforce a consistent code of ethics.

David M. Allen M.D. said...

There are a whole host of factors that have led psychiatrists to label many behavioral disorders as "brain diseases" and medicate everything in sight. (And despite the protests of the anti-psychiatry lot, there are real brain diseases as well).

As I describe in detail in my new book, all of these factors coverged in a perfect storm. As has been commented on previously in this blog, part of the problem is coming from patient demand as well as the greed of psychiatrists, PhARMA, and insurance companies.

There's no shortage of blame to go around, but blindly bashing everyone is not likely to lead to any effective problem solving.

Joel Hassman, MD said...

Anonymous with the rebuilt knee:

Well said! I am sorry to be repetitious, but once again, if people don't show to CMEs by less than transparent presenters, and do not participate in these "freebie" CMEs by various journals that are covert sales pitches, then does the adage "no demand will lead to no supply" end up applicable?

I sure hope so!

And you are so on the mark, as I have had somatic colleagues say in so many words, "I read it in a journal by a credible source, so it must be valid."

Uh, didn't we prove Chicken Little wrong?

Anonymous said...

Moviedoc -
My endocrinologist regularly spends 50-70 minutes with me. In fact, I cannot remember the last time I had an appointment with her that lasted less than 45 minutes. And yet, she bills for 30 minutes. Imagine that. She asks me about my diabetes and she also asks me about the rest of my life... because the rest of my life matters to my diabetes treatment. This strikes me as humorous in the context of your comment because life IS what matters to psychiatric treatment, but psychiatrists for the most part refuse to acknowledge this and instead, choose to practice using an assembly line model. Dr. Carlat picks on psychiatrists with very very good reason.

Anonymous said...

You were quoted in the Chicago Tribune today. You are getting more exposure!Keep up the good work.

moviedoc said...

Anon: Your endocrinologist sounds wonderful, but one wonders how she pays her overhead (probably $100's per hour) not to mention how she makes a living. The highest pharma paid doc I know personally on the ProPublica list is an endocrinologist. Maybe if we keep picking on psychiatrists we'll have fewer psychiatrists and more endocrinologists. Is that what you want? Will that lead to longer visits with psychiatrists? I don't think so. Be careful what you wish for...

What did your endocrinologist do with all that time? Chat with you about sports? I believe all physicians, perhaps especially those who treat diabetes, should have training in psychotherapy interventions. People with psychological challenges don't just go to psychiatrists.

Dr John said...

I was thinking the same thing as moviedoc. There just is no way that lady is in private practice or has to feed her family because you do not do that with 50 min f/u visits.

moviedoc what specific "psychotherapy" interventions do you believe folks who take care of DM should be trained in? Why mostly DM? I doubt that Anon's endo Dr had such training yet Anon believes that Dr is the best thing since sliced bread. I suggest it's just because he/she gives a shit.Really that's about all people care about and they know who gives a shit and who does not.

Too bad you can't train people to do that.

moviedoc said...

Dr. John: Dr. C is the expert on training and psychotherapy. I suspect Anon's endocrinologist was winging it as best she could with probably no training. If psychotherapy experts put there heads together they could come up with brief and effective interventions to teach to all med students, that don't require weekly 50' sessions, but could help them better manage general medical problems.

Anon's doc sounds like an angel, but not the best business person.

Diabetes: I just know it's a tough illness to endure or to manage, in many ways like psychiatric disorders, and with extensive emotional and behavioral impact.