Friday, May 28, 2010

A Hot City, an Empty Exhibit Hall, and a Stern Mina Dulcan

The annual meeting of the American Psychiatric Association was held in New Orleans this past week. The weather was hot (in the mid-90s) though the meeting was somewhat tepid and under-attended.

The exhibition hall in particular had an empty and echoey feel that I had not seen in years past. I talked to one exhibitor, my friend Dr. David Robinson, the prolific author of several books and the owner of Rapid Cycler Press, who told me that ever since the drug companies had stopped giving out free gifts, the attendance at exhibit halls was down. “In the past, they used to line up before the hall opened in the morning. No more.” This is not terribly good news for the publishers, but on the other hand publishing is undergoing unrelated and much more far-reaching changes with the advent of e-books, and the ritual of carting tons of paper to exhibit halls will eventually end.

Another attendee, a noted researcher in mood disorders, told me that he noticed fewer psychiatrists from other countries this year. Most such psychiatrists typically receive travel funding from drug companies. But this year, because of the APA's decision last March to phase out industry-funded symposia, fewer companies were willing to pay the travel expenses of our foreign colleagues. What's the connection, you might ask? In the past, companies justified these travel expenses because they knew that the sponsored psychiatrists would be attending their CME symposia, which are infomercials in support of their latest drugs. There were only two such symposia this year. So the ROI (return on investment) of funding foreign attendees is no longer robust enough to justify the marketing expense.

Nonetheless, there were still plenty of exhibitors, including mega displays by Merck to push their antipsychotic Saphris (ALL the effectiveness, plus a numb mouth and a metallic taste!), Shire for Vyvanse (proud sponsors of drug diversion for college students since the 1990s), Lilly for Cymbalta (depression is painful, depression is painful, depression is....), and several others. And they were still giving away things, but not the disposable cameras, personalized business cards, or emblazoned clocks of old. Now, the only things they can offer are "educational" items such as textbooks, and here Stephen Stahl was the superstar, doing book signings for various drug companies (you can see one of the announcements here) who have found that his faith in molecular psychopharmacology dovetails nicely with their marketing messages. The man's a great writer, I'll give him that, and he works the pharma angle with the energy and creativity of a Barnum and Bailey circus hawker. He's obviously making some serious cash from industry, but frankly, I'm a little embarrassed for him.

However, I'm the one who should really be embarrassed. Sauntering through the APA's official book publishing area, I came across Dr. Mina Dulcan, Chair of Child Psychiatry at Northwestern Medical School. She was signing copies of her various textbooks. She's a bigwig in the field, having been the editor in chief of the major journal in child psychiatry (the Journal of the American Acacemy of Child and Adolescent Psychiatry) until recently. (The photo above was apparently taken after the events outlined below. It was published in the APA's daily meeting bulletin--and yes, they spelled her name wrong).

Anyway, I went up to her to introduce myself in order to show her a copy of my new newsletter, The Carlat Child Psychiatry Report, edited by Dr. Caroline Fisher from UMass Worcester.

"Hi Dr. Dulcan," I said, "I'm Danny Carlat, nice to meet you."

She took a look at my name tag, and said, "Oh, I've heard about you."

Since her expression was somewhere between stern and outright hostile, I queried, "In a good way or a bad way?"

"In a bad way, to tell you the truth." And then she was off on a high volume rant that went something (if memory serves) like this:

"How DARE you write an article in the New York Times saying that your therapy training at Mass General was terrible, and then later having this GREAT AWAKENING that"--she made a religious hand waving gesture--"'Oh, it's important to understand my patients,' and then you write an article in order to sell your new book and your newsletter. How are you any different from the drug companies? I was outraged by your article and showed it to my colleagues. What a disservice you have done to psychiatry." And it went on from there.

Her argument was not new to me, certainly has its merits, and I am generally happy to engage in constructive debate. But this was not debate, it was simply a very angry person yelling at a colleague with dozens of other psychiatrists looking on in jaw-dropped amazement. I decided not to prolong this awkward encounter (to the relief, I'm sure, of the leaders of American Psychiatric Press who were nearby), and slunk out of the booth, passing along the way a psychiatrist who smiled at me and whispered, "I subscribe to your newsletter and love it!"

Psychiatry--truly, a House Divided.


Marilyn Mann said...

Let me get this straight. She is sitting there signing and promoting her books and she is outraged that you wrote an article that might cause someone to buy your book? Outrageous! How dare you, indeed!

Anonymous said...

Dr Carlat- I love reading your posts- you offer a much needed view into the world of psychiatry- I look forward to future posts- thay are refreshing!!!
Katie- Psych NP in NY

Ronald Pies MD said...

Hi, Danny--

Sounds like quite an experience with Dr. D.--sorry you had to endure that! The Talmud tells us that any rebukes should be delivered in private, and that humiliating someone in public is akin to "spilling blood." It's a shame we are not more respectful of our colleagues, particularly in public.

By the way, your readers may be interested in an article by my Upstate Medical colleague, Dr. John Manring, that will soon appear in Psychiatric Times [disclosure: I'm still Editor in Chief for a few more weeks]. Dr. Manring's piece is a kind of commentary on your NY Times piece, but more broadly, it is a description of the intense psychotherapy training our residents receive at SUNY Upstate Medical University in Syracuse [my alma mater, so yes--I'm a tad biased, and quite proud of the place!].

But Upstate is not the only psychiatry residency where psychotherapy training is still alive and well. I believe, in fact, that a recent study showed that such training has increased or at least been maintained in a majority of programs. That is good news!

Best, Ron Pies

Pharma Analyst said...

Dr Carlat - as a Pharma analyst, I love the blog and the work you do but have to throw in that Vyvanse is a genuine step forward in the treatment of ADHD - there are many pharmacological advantages it has over the competition.

In fact, it is much harder to abuse than traditional stimulants. So I agree with you in the skepticism towards drug companies but not to the barb at Shire =)

Anonymous said...

Hmm, I think Dr. Dulcan has an anger problem and needs a mood stabilizer. Yes, I am being sarcastic but if a patient had acted that way in her office, that is exactly most likely what her reaction would have been.

By the way, Dr. Dulcan is on the advisory board of Eli Lilly.

Thanks to the Soulful Sepulcher blog for pointing this out.

Anonymous said...

Let's see, whose perspective would I respect more, a revered, endowed academic professor and chair of a major department, former editor of a gold-standard journal with a squeaky-clean pedigree of unimpeachable integrity--or a "celebrity" wannabe who is polemicizing the current situation in psychiatry for self-aggrandizement?

The "house divided" is pretty much the profession of psychiatry vs. the wannabe.

pacificpsych said...

In some ways it's better that she yelled at you in the open. The hostility towards critics is often much more insidious and veiled. Look at what happened to David Healy in Toronto.

I agree, though, that self promotion is evil.

pacificpsych said...

To Anon: I respect the one who speaks the truth. I respect the ones who point out the flaws in conventional wisdom and who fight the good fight against the deterioration of this profession, a fight against entities much larger than themselves. This type of fight often comes at great professional cost. It is far more likely to be deleterious to one's professional life than to lead to any advancement. If Dr. Carlat will manage to sell a few books as a result of all this shameless self promotion :) , more power to him.

moviedoc said...

Her anger is misdirected, Dr. C. Don't take it personally.

SteveM said...

Re: The Rage of the Great and Powerful Dulcan!

Hah! I hope someone got that on video.

Danny, I can' believe you slunk out of the booth. You should have calmly noted to Dr. Dulcan that she was experiencing an HA, (Hyperbolic Academic) Conniption and advised her to breathe into a paper bag until it passed.

Anyway, to mend fences with the revered, endowed professor, suggest you send her a personal copy of your new book, "Unhinged" and in the inscription, thank her for her melodramatic validation of its title.

Supremacy Claus said...

Your encounter with Dr. Dulcan made my day. Both of you are morally superior, supercilious fatheads.

anonymous (but reg reader) said...

Saw your book in the bookstore this evening, skimmed through it and hope it sells well per your expectations.

That said, here is my little epiphany about our older colleagues, the ones who should consider retiring sooner than later. It seems that there is such a level of pathological paternalism with our senior colleagues, and I am quite tired of dealing with their outdated and intrusive attitude of "I know what is right for you, the patient, and for you, the junior colleague, so do not challenge me, do not debate me, and do not cross me, or there will be consequences!"

Well, this attitude and expectation is outdated, colleagues, and it does no one, especially themselves, to cling to this misguided notion and just alienates everyone who has to be in earshot of it, much less have to be incovenienced by it. And now that the gravy train of pharma perks has left the station and the train ain't picking up passengers here on, I guess those of you dependent on something for nothing, well, withdrawal is due!

As to Dr Carlat, I still strongly disagree with your take that the training needs to be totally revamped. No, it needs to be restored. Just an opinion.

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

If someone of Mina Dulcan's stature can react to what you have written with such ignorance, then you are obviously doing something right. And why shouldn't you market your book? That's a really dumb thing for Mina to have said, since it says nothing about the validity of your arguments.

Anonymous said...

I love reading your posts but have to confess that I've been so sad about the passing of a much respected psychiatrist who had the "audacity" to treat me without drugs, believing back then (1969 or so) that talk therapy would do the job. And it did. His confidence and patience helped me find a strong sense of self.

It took 18 months but I gained so much insight and I STRONGLY believe that if drugs had been a part of it, I would never have felt so empowered, so sure that I was the source of the eventual strength and courage which I found. A part of me would have wondered, "Was it just the meds?"

Of course, there are pros and cons to any therapist (no one is perfect) and this doctor was anti meds, unless everything else failed first. Of course, he'd treat schizophrenic or psychotic patients with meds and even used shock treatment on severely depressed people.

But I have been wary of meds ever since. I did suffer one severe depression as I faced the loss of my old psychiatrist as well as my parents.

SSRIs caused abdominal discomfort beyond endurance, even though I stuck it out for weeks. Other meds all have side effects that are distressing. I know that if I had a trusted therapist I could get through even depression without meds. I have done it before. I don't care if it takes longer.

I do not understand why psychiatry changed the way it did. It is so bad for patients, who see one person for therapy, another for meds. One person should do both. That is my sincere take.

Joseph P. Arpaia, MD said...

To the lastest Anonymous poster: Your ignorance of the current issues in psychiatry is extreme if you think, as you seem to imply, that Dr. Carlat is the only opposing voice.

Bruce Wilson said...

To Anonymous,

Let me point you to one "revered, endowed academic professor and chair of a major department, former editor of a gold-standard journal with a squeaky-clean pedigree of unimpeachable integrity" who is doing pretty much the same as Dr. Carlat -- in your words, "polemicizing the current situation" in medicine.

Marcia Angell.

The polemics are needed. Why? Medicine has sold its soul to moneyed interests. It's time to bring it back.

As for "wannabe" and "self-aggrandizement", those pejoratives that have no place in this debate.

Bruce Wilson
(soon to launch)

Dr John said...

Give you 3 to 1 odds in 10 years you have half the exhibitors and half the attendance. Not only is industry funded symposia being phased out but so is psychopharm research by some major pharmaceutical companies. How tragic for psychiatry to be without Saphris, Cymbalta and Vyvanse exhibits. How will our intellectual integrity survive such a loss? How will humanity endure?

I don't know this Dr Dulcan but she sounds like she takes herself pretty seriously. Out with the old. In with the new Dr Carlat!

Joel Hassman, MD said...

I thought about this after reading this current post and then a couple of prior ones: why did you go to the APA in the first place, having to know your book would not go over well with at least the hierarchy of this growing irrelevant organization no respecting, committed to care psychiatrist would be a member of as of 2010? A bit of a masochistic tendency, sir?

Come on, man, these entrenched, power hungry, greedy, lack of clinical focused elitists and their dumbed down lackies are what is left, basically, of this group.

And yes, there is a minority who I think just join or keep their membership to not risk alienating the alleged powers that be, but, really, now that the word is out there are no more freebies and literal free lunches/dinners, people will scatter for what is left for little effort and minimally invested committment.

Sorry, Dr Carlat, I'm sure you had a good reason, but, you are a leper now, and as far as I am concerned, good for you, and unfotunately, welcome to the club. But, I like what Groucho Marx once said, not representing me, but the APA: "anyone who is in a club that has me as a member is not a club I want to belong to!"

Harsh, but the reality I witness these days. And sorry to the few members of the APA who know me and know I respect their collegiality.

SteveM said...

Re: Supremecy Claus - "you are morally superior, supercilious..."

Supercilious? Really? If Dr. Carlat called himself, "The Great and Powerful Dr. Daniel Carlat" and imperially popped off at colleagues, perhaps.

But he self-describes as "Danny", and unfortunately slinks away from academic gasbags. Which is anything but supercilious.

edgar said...

Mina Dulcan rages as she signs the flyleaf pages
Of her treatise on disorders to which kids are prone.
When she scolds at Danny does she think that she’s so canny
That the rest of us won’t see her for an academic crone?

Anonymous said...

Egomania and wealth are dangerous M.O's for health professionals of all stripes, at the sake of their patients. There is a real danger is mental health reinforcing victim mentality and learned helplessness, even when intentions are good, rather than based on guaranteeing a repeat 'consumer' be they Psychiatrists or non-MD Psychotherapists.

It's disgusting that all these smart people don't look at research bias and poor constructs. Again, why did Pharma companies quit funding "Active ingredient placebo's" in their research? Dr. Ader's new research on how potent the Placebo effect and learning theory is on medication is very interesting and something to keep an eye on as well. If active ingredients (placebos that provide side effects that make consumers "feel like its working" and thus believe in the efficacy more) show no statistical difference for many would think this would be researched further. Although, I suppose Pharma companies need to figure out how to make billions off of active ingredient placebo's, otherwise some of their drugs which are about worthless won't rake in the $$.

In the last 20 years, I've seen a significant reduction in respect for Psychiatry, and this is without many being really aware of how many money grubbers and amoral folks are involved in promoting "diseases" that are purely fiction at time's merely to get their big Pharma consultation fees.

Uma said...

I braved depression for 3 years because I was paranoid about getting addicted to the meds. It got so bad at one point that I was constantly reminding myself not to hurt myself. When I came out of it I thought I could have achieved the same in months with meds. But only now I realize, after finding real answers to my problems and putting my plans into action, that meds could never have done this for me. I did get an MRI scan to make sure it was not a tumor (I have hyperprolactinaemia).

Carolyn Thomas said...

Is it just me, or does the spectre of that big empty exhibit hall and vacant conference seats say more about the psychiatriatic profession than it does about the recently-forced demise of Big Pharma-funded perks like free trips and swag at these meetings?

Docs don't go into the exhibit halls because they're not getting the freebies they are used to? Foreign shrinks don't bother attending conferences unless Big Pharma picks up the tab for them?

These are psychiatrists, right? By any definition, these folks are at the near-top of the income food chain when it comes to those who can certainly afford to pay for things like flights, hotel rooms, and their own business cards and plastic ballpoint pens.

I like Australian psychiatrist and researcher Dr. Peter Parry's recent summary of his study published in the Journal of Bioethical Inquiry:

"While evidence-based medicine is a noble idea, MARKETING-BASED MEDICINE is the current reality."

The Ethical Nag: Marketing Ethics For The Easily Swayed

Uma said...

I think what Supremacy Claus is trying to say is that as long as you're anonymous you can call anybody anything and feel the most superior of them all.

Anonymous said...

Those of us who were around Emory when Dr. Dulcan was there would quickly reassure you. Don't let it get to you. She's that way as a baseline - a true nast-i-crat of the first magnitude. You should see her on a bad day...

Anonymous said...

Nice. How dare you not go along with the masses? How dare you not be a lemming? How dare you question the status quo? How dare you attempt to heighten public awareness about the problems with your specialty and profession? How dare you encourage your colleagues to take a hard look at themselves and the motives behind what they do? How dare you?

This woman is a walking example of why so little progress is ever made in healthcare quality improvement and patient safety. How dare anyone question the way things are already done? So many smart people developed the current methods, so there can't POSSIBLY be any flaws or weaknesses in those processes/products. After all, doctors went to medical school. People who go to medical school are perfect. People who go to medical school are even immune to sales pitches. They are invincible.

Anonymous said...

I really really love your blog, but I am shocked and somewhat disappointed that you allowed a post from "Pharma Analyst" through moderation when the post is nothing more than a not-even-thinly-veiled drug advertisement.