This weekend’s Sunday New York Times Magazine carries my article, “Mind over Meds,” in which I argue that psychiatrists should reclaim the skills of psychotherapy. Compared to many of my writings, the article is not particularly controversial, and I think most readers would agree with the main points.
However, the following statement from the article has generated a number of indignant e-mails:
“Like the majority of psychiatrists in the United States, I prescribe the medications, and I refer to a professional lower in the mental-health hierarchy, like a social worker or a psychologist, to do the therapy. The unspoken implication is that therapy is menial work — tedious and poorly paid.”
Several psychologists have pointed out that their work is just as valuable as the work of psychiatrists, and that they are surprised that I would consider then “lower” in the hierarchy. Actually, my point here got muddled, and it was just the opposite. Many psychiatrists have an elitist attitude toward psychologists, falsely believing that therapy is somehow less valuable than psychopharmacology. This view is reinforced by the fact that insurance companies pay less for therapy than for psychopharm visits. The view also stems from the fact that some psychiatric illnesses, such as schizophrenia, respond much more robustly to medication than therapy.
However, for most psychiatric problems, the dichotomy between therapy and medications is overblown. Both meds and therapy are crucial. The ultimate mental health practitioners, in my view, should be equally skilled at both psychopharmacology and psychotherapy. Unfortunately, there are very few practitioners who can offer the full package. Because of this, most patients have to see two professionals, one for therapy and one for meds. That’s a crazy system, and Unhinged (the book upon which this article is based) expands on this problem and offers a menu of solutions for solving it.
The Council of Medical Specialty Societies just announced a new Code for Interactions with Companies. They have received good press so far. According to AP,“It's the most sweeping move ever taken by the Council of Medical Specialty Societies to curb conflict of interest…”
But The Carlat Psychiatry Blog has just obtained a disturbing highly classified Q&A document leaked by a mole within the Council. Or maybe we just made the thing up. Read the following excerpt, and you can decide.
Q: Are there any provisions here that are going to significantly decrease the income we receive from drug companies?
A: Not at all. You can still receive all the drug company money you want for educational programs, “charitable” contributions to doctors, and research grants. The only semi-meaningful restriction we’ve added here is on funding for practice guidelines committees, but we even developed a work-around for that, which we can explain later.
Q: That’s good news. But I’m still a little nervous. I mean, this new code is a 25 page document, with dozens of elaborately numbered rules. There must be something in there that will change business as usual. Please reassure me that I'm wrong.
A: Don’t worry, be happy! Yes, we know the Code looks long and serious, but we were simply following the advice of our PR consultants (on loan from one of our sponsoring drug companies), who taught us about the first rule of advertising: “The more you tell the more you sell.” We learned that if you want to sell a product that actually has very little added value, you can’t just say, “Here’s my product.” Instead, you have to add a whole bunch of other stuff along with your offer, stuff that doesn’t actually add information content, but that keeps your audience engaged and focused on your product. That’s why we created this 25 page document, even though all the actual new regulations could have fit into a single paragraph.
Q: Whew! I am feeling a little less panicky. But still, I’d appreciate it if you could walk me through the document and explain to me exactly how each “new” rule is actually meaningless.
A: Sure. We start with a 2 page preamble that just says the usual blather about ethical standards and proper relationships with industry. Basically, we copied and pasted most of this from the latest PhRMA code on relationships with doctors. After all, why reinvent the wheel?
Q: Oh yeah, I remember that code from 2 years ago. That was the "Tchotchke Code." No more logoed pens or mugs. That turned out to be no problem for us. They can still bring us lunch and take us to fine restaurants as long as they have paid one of our doctors to give an “educational” talk.
A: Exactly--it resulted in very little financial pain for us. Same idea for our Code. To continue our guided tour, after the Preamble there is a section called “About the Code” where we just say “We decided we needed to write a Code, so we wrote a Code.” But we were able to fill two pages saying it, giving the document a little more heft.
Q: But why, exactly, did we even need to write a Code?
A: PR stuff entirely. The drug companies had written an ethical code in June 2008 and it was becoming embarrassing that the doctors had not produced their own ethics code. Also, we were getting some flack about this article in the Journal of the AMA that recommended a bunch of changes (don't worry, we artfully ignored the most significant ones). But the kicker was that the Health Care Reform Act that recently passed Congress includes a required physician payment registry, so all payments to doctors and societies are going to be forced out in the open soon anyway [Note to reader: After we posted the original version of this Q&A, we learned that the Sunshine act will not, unfortunately, require disclosure of payments to medical societies. Oh well!]. We figured this will make it seem that we are ahead of the curve on this.
Q: Okay. Then there’s this huge section with “definitions” of things like “business transaction” and “company.” Am I missing something here? Are the people reading this that uneducated?
A: The official line? We needed to spell out the definitions to clarify often misunderstood terms. The real purpose? We needed to add those 4 pages to achieve our goal of a 25 page document.
Q: Okay, so far so good. But when I started to read the section labeled “independence” and I spotted the phrase “discontinue payments,” I started to get a little queasy. What’s going on here?
A: Patience, grasshopper. Not to worry. If you read it carefully, we are suggesting that a grand total of only five people in each medical society should “discontinue payments” from drug companies: the president, the president-elect, the immediate past president, the CEO of the society, and the editor-in-chief of the society’s journal. Everyone else can still rake it in.
Q: Hey, not so fast. I’m thinking of running for president of my society. Am I being left out in the cold?
A: Of course not. There are so many exceptions and provisos that you will do just fine. Here they are:
1. If you were taking cash before you were elected, you can keep getting paid for a “reasonable period” after the election. What’s a “reasonable” period? That’s up to you.
2. You can maintain your consulting relationships with all the companies during your tenure; you just can’t accept a “consulting fee.” But here’s our clever workaround. You can still get reimbursed for all “travel expenses,” meaning that you can accept cash for airplane tickets to exotic locations, for hotel bills, for fancy meals with company executives, etc… Just make sure to call it “travel expenses” on your tax forms.
3. You can still accept cash for industry research studies, as long as you are not foolish enough to deposit the cash into your personal bank account. It has to go into a different bucket, usually your academic department’s account.
4. Finally, once your tenure as president and past-president are over, you can resume your full fledged financial relationships with companies immediately.
Q: What about the transparency provision. That’s not going affect the bottom line, is it?
A: No, it should not affect your income. Remember, this just means disclosing the income, not giving it up.
Q: Then there’s this huge section on regulations about “charitable contributions.” Does this mean we are going to limit the charity cash that drug companies lavish on us?
A: No. This was another document padding exercise. It just says--in the space of five paragraphs--that you have to use charitable contributions responsibly.
Q: Same deal with corporate sponsorships?
A. Yes, you can still accept as many sponsorships as you want, as long as it is “aligned with the Society’s strategic plan and mission.” We do suggest that you try to seek multiple corporate sponsors for programs so it doesn’t seem too obvious that you are being used as an advertising vehicle for a single product.
Q: Actually, that could be a win-win—more sponsors, more cash.
A: Bingo!
Q: It says no more company logos on tote bags and such. That’s not so great—hey, we made a few thousand bucks at every meeting on that stuff.
A: Sorry guys. That couldn’t be helped. Companies have already promised not to distribute these things to doctors, so it would have been poor form if we tried to do it anyway.
Q: I'm seeing pages and pages about CME meetings. This makes me nervous.
A: Chillax, my friend. We simply copied and pasted all the existing ACCME regulations that we have been required to follow for years anyway.
Q: You mean there’s nothing new here at all? We can continue to take millions of dollars yearly from drug companies to put on accredited CME programs that are focused on drug categories that they market?
A: Absolutely. There are no new restrictions here at all.
Q: Okay, but let’s move on to something more ominous-sounding. Item 7.3 says: “Societies will not permit direct Company support of the development of Clinical Practice Guidelines or Guideline Updates.”
A: Yes, this was a genuine concession to the pharmascolds. But it’s not as bad as it seems. After the initial print run of your guidelines, drug companies are free to pay you muchodinero for “repurposing” guidelines. That is, they can package them up into journal supplements, Internet education programs, whatever they want. They just can’t pay us to actually write the guidelines.
Q: Oh--that’s fine. Basically we still get drug company money to produce clinical guidelines, but the checks don’t actually get cut until after we write and print them.
A: Hey you’re smarter than you look!
Q: One last question. Are these guidelines mandatory?
A: No. Take ‘em or leave ‘em. If you adopt them we’ll throw your society’s name on our website. A little bit of free PR for you. There’s really no downside to adopting them. You’ll get good PR, and you’ll be able to maintain your existing extensive relationships with pharmaceutical companies at all levels of the organization.
In order to ease the critical shortage of primary care physicians, Texas Tech School of Medicine is starting a pilot program which streamlines medical school to a 3 year program for students committed to primary care medicine.
This is an interesting model, and one which I think can be applied to psychiatry as well, since the shortage of psychiatrists is nearly as acute as the shortage of family practitioners. We could create a special track for future psychiatrists which would include early courses in psychotherapy and psychopharmacology, omitting courses of less relevance to our field.
USA Today covers this topic nicely here as well. It turns out many other medical schools are considering similar programs.
For those who don't know, Oregon's Governor Kulongoski vetoed the psychology prescribing bill. I found this unfortunate, not because I'm particularly keen on psychologists prescribing, but because I think the bill would have put needed pressure on my profession to take a closer look at what psychiatrists are and where we should be headed.
In his veto letter, the Governor said he was concerned that the Oregon legislature approved the bill in a hurried fashion during a Special Session which included no public input. He proposed that the legislature come up with a pilot program in 2011 to help to gather more information about how to solve Oregon's crisis of access to mental health treatment. What this means is that in all likelihood we will again be treated to the spectable of America's new blood sport--the vicious turf wars between psychiatrists and psychologists. American Gladiator pales in comparison.
Truly, these last few weeks have not been pretty, and I'll plead guilty to my part in the fracas. I was the first "prominent" psychiatrist to publically proclaim that psychologists with extra medical training might actually be able to prescribe some medications safely.
In doing so, I felt a bit like Salman Rushdie, whose 1988 book, Satanic Verses, so unnerved the Islamic orthodoxy that the Ayatollah Khomeini issued Rushdie a fatwa (a death sentence). My own version of "Satanic Verses" is called Unhinged: The Trouble with Psychiatry (Simon and Schuster, due out May 18, but who's counting?). The book is not about psychologists prescribing, but rather about the loss of psychotherapy from psychiatry. Nonetheless, it will likely enrage more than a few psychiatric jihadists, because in the last chapter I outline my prescription for reform, and it involves a fairly radical restructuring of psychiatric training. In this scheme, psychiatrists will be more competent than they are now, but they will unfortunately lose two crucial letters after their names: an "M" and a "D." I anticipate some resistance.
In the meantime, we are in a preposterous situation in which the two major organizations with expertise on the American mind are locked in mortal combat: the A.P.A. (psychiatric) vs. the A.P.A. (psychological). If they can't figure out how to resolve differences, God help us all.
Governor Ted Kulongoski of Oregon finds himself in the unenviable position of deciding the fate of two professions. And he has to do it either today or tomorrow.
Yes, I hyperbolize...a little. Senate Bill 1046 would not actually hand psychologists prescription pads. Instead, the bill would allow the Oregon Medical Board to issue prescriptive privileges to psychologists who are properly trained. Before any privileges are handed out, however, a task force of psychiatrists and psychologists would have to hammer out final guidelines, including exactly how much training is required, what kind of collaboration with physicians is needed, and which medications psychologists would be allowed to prescribe.
The Governor has put this bill on a list of measures that he is "threatening" to veto. Apparently, this is his invitation to all the stakeholders to whip themselves up into even more of a frenzy in their efforts to lobby him. My wild guess is that Kulongoski was initially in favor of the bill, but as crunch time arrived and he got more and more of an earful from Oregon physicians worried about loss of income, he began to reconsider. These last few days will serve as a quick straw poll to find out how much political damage he might do to himself if he were to sign the bill.
Personally, I support the bill because I believe it requires enough medical training to produce safe prescribers. At least two Oregon psychiatrists support the overall concept of psychologists prescribing, including Jim Phelps, who wrote this editorial in favor of the bill in Psychiatric Times, and Joseph Arpaia, who has commented on this blog. Both Dr. Phelps and Dr. Arpaia are joining with me in forming a multi-disciplinary study group to develop a list of principles for appropriate training of psychologists interested in prescribing. If anybody else wants to join, please e-mail me directly at drcarlat@comcast.net. I suspect there are many more open minded psychiatrists out there who are afraid of "coming out" on this issue because they fear the wrath of colleagues.
Although I have been asked to actively lobby for this bill, I've declined, for various reasons, not the least of which is financial. I get most of my income from psychiatrists subscribing to my newsletters. The more political I become on this issue, the more I fear subscription cancellations. But more nobly, I think there is a far more important underlying issue than this particular bill. There is a critical shortage of psychiatric prescribers in the U.S. The most recent estimates by the University of North Carolina Scheps Center, published in a series of article in Psychiatric Services, documented a shortage of prescribers in 96% of U.S. counties, and estimated that only 50% of the needs of psychiatric patients are currently being met. We must offer more realistic solutions than telepsychiatry, increasing residency slots (which we can barely fill with qualified applicants as it is), and phone call consultation with primary care doctors.
Rather than lobbying for specific bills, I want to get psychiatrists and psychologists together to jointly come up with a position paper on best practices for training, supervising, and monitoring prescribing psychologists. This could then serve as a blueprint for prescription legislation in other states (and in Oregon, which will surely pass another version of this bill next year if the current one is vetoed.)
Yesterday I debated Steve DiFillippo, owner of Davio's and Avila's restaurants, on the WGBH program Greater Boston, hosted by Emily Rooney. The topic? The effect of the Massachusetts Gift Ban law on area restaurants.
On one level, it was a friendly debate on the economic impact of the law on those restaurants that depend on drug company sponsored dinners for a chunk of their income. You can watch the debate here. Please don't comment on my bad hair day.
But on another level, this is a larger and more worrisome issue, which is the trickle-down effect of deceptive marketing practices on the economy, such that very good people unwittingly help to perpetrate deceptive marketing practices.
When you do these news shows you arrive a half hour early and are greeted by the producer, who brings you to a waiting room where all the other guests are sweating it out in preparation for their five minutes of fame. For example, I got to meet House Speaker Robert DeLeo, who was there to talk up his proposal to legalize casino gambling in Massachusetts. I then had a pre-debate chat with Steve DiFillippo. He has created some amazing restaurants, one of which I have a personal connection with. My wife and I had our wedding rehearsal dinner at Davio's when it was in its former location on the Charles River in Cambridge.
Steve is a completely ethical person, does great community work, and was just given the Torch of Liberty award by the Anti Defamation League. Yet, here he was arguing that drug companies should be allowed to wine and dine doctors in order to sell them on their newest drugs. From his perspective, doctors, with all their training, should be smart enough to separate the hype from the truth. But unfortunately our extensive training does nothing to immunize us from the effects of marketing, as many companies have discovered. Merck, for example, found that hiring doctors to pitch other doctors at restaurants and other venues led to four times more Vioxx prescriptions. It didn't matter how much they spent on restaurants, they knew they would get a handsome return on their investment. Unfortunately, a bunch of people who took that Vioxx died of heart disease, and the drug was eventually taken off the market. As patients, we deserve to have our treatment decisions based on the medical literature, and not on the pitches of salesmen who have softened up their clients with cabernet and filet mignon.
I think if Steve and the other restaurateurs didn't have a dog in this race, they would agree with this. But they do have a dog in the race. And when your income stream depends on believing something, it's highly likely that you will believe it.
Steve, like thousands of other business owners, is a victim of "trickle-down deception." It begins with the drug companies, and spreads and expands where the money goes. Other victims include advertising companies, medical education communication companies, publishers, lunch caterers, celebrity spokespeople, etc.... In each of these industries, there are ethical people who believe they are just making an honest buck. But they are unwittingly participating in a system that depends on a basic deception: trying to dress up advertising in the guise of education.
The solution is to simply do what we are doing--keeping a close eye on the industry and reporting their most deceptive practices. Unfortunately, when they just can't behave themselves, we have to expend a lot time and effort to pass laws regulating them. The ensuing trickle down effect of honesty is something we can all support.
I am a psychiatrist in Newburyport, Massachusetts and an Associate Clinical Professor of Psychiatry at Tufts Medical School (but note that the opinions expressed in this blog are not those of Tufts). I graduated from the psychiatric residency at Massachusetts General Hospital in 1995, and am the founder and publisher of three CME newsletters: The Carlat Psychiatry Report, The Carlat Child Psychiatry Report, and The Carlat Addiction Treatment Report.
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