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One US doctor has severed all his ties to drug companies and come out in a blazing public attack on industry funding of medical education. Jeanne Lenzer and Shannon Brownlee report
A US psychiatrist has vowed to go on a “march of shame” for payments he received from a drug company in return for medical education talks he gave to other doctors. He now promises to give free “undrug” talks to reverse the effects of the “inappropriate prescribing” he may have caused.
Writing in the New York Times (www.nytimes.com, 25 Nov 2007, “Dr Drug Rep”), Daniel Carlat, assistant clinical professor of psychiatry at Tufts School of Medicine in Boston, has given a candid account of his role promoting the antidepressant venlafaxine (marketed as Effexor XR in the United States by Wyeth Pharmaceuticals). Carlat was flattered when a Wyeth drug representative asked him in 2001 to give talks to doctors about the drug for the treatment of depression. It didn’t hurt that he would be paid $500 (£250; €350) for a one hour talk over a free lunch—and $750 if he had to drive for an hour.
Carlat, who specialises in psychopharmacology, says he didn’t believe at first that he was doing anything wrong when he agreed to give the talks. He was familiar with studies showing that venlafaxine, a dual reuptake inhibitor that increases concentrations of serotonin and noradrenaline (norepinephrine), might be more effective than the selective serotonin reuptake inhibitors. As he had already prescribed the drug to a few patients with some success, he reasoned that he would be doing nothing unethical by talking about the drug’s benefits.
The company flew Carlat and his wife to a “faculty development” programme in New York city, where they were put up for two nights at a luxury hotel. They were given tickets to a Broadway show, and he was paid an additional honorarium for attending. Carlat quickly discovered that some of the biggest names in psychiatry were also attending—and benefiting from Wyeth’s largesse. While there Carlat ran into an old colleague, who mentioned that he was giving talks promoting gabapentin (Neurontin) for Warner Lambert—a drug he said was “great” for some patients with bipolar disorder. Carlat was surprised by his old friend’s claim, because of his own experience of prescribing the drug, and because a study of gabapentin for bipolar disorder showed that the drug failed to perform better than placebo. In a comedic moment Carlat, seemingly oblivious to the process he himself was undergoing, wondered whether his colleague’s “positive opinion had been influenced by the money he was paid to give talks.”
After the faculty development programme Carlat was off and running, teaching doctors about venlafaxine. Fortunately, he doesn’t try to put a pretty face on his own behaviour. His account in the New York Times is well worth reading for its close-up look at how drug companies bring doctors into the world of industry sponsored “medical education”—and how doctors may embark on such relationships without any intent of harm or deceit but can nevertheless be slowly seduced into questionable behaviours, such as making pumped-up claims of drugs’ effectiveness while failing to give full weight to side effects. Carlat doesn’t put his readers at arm’s length—he allows them to see his warts. You can almost smell his sweat as he quivers before a fellow doctor who, he fears, sees him for what he is: “a drug rep with an MD.”
But Carlat’s moment of truth is yet to come. After deciding that he needed to be frank about venlafaxine’s side effects, no matter what the reaction of his sponsors is, Carlat gives a more balanced presentation during his next lunchtime talk. Sure enough, his minders at Wyeth take notice of the change. A Wyeth district manager is dispatched to follow up with Carlat. He lets Carlat know that he is aware that his last presentation was less “enthusiastic” than usual. Then, in a moment that would prove to be the grenade under Carlat’s feet, the manager asked Carlat, solicitously, “Have you been sick?”
Although Carlat says it is possible that the district manager’s question about his health was a genuine expression of concern, it was this question—and its timing—that brought everything into focus for him. It made him realise, as he told the BMJ, that “something I would never, never have predicted happened: I ended up being a cog in their marketing machine.”
Carlat immediately resigned as a speaker for Wyeth, and two months later, in January 2003, he launched the Carlat Psychiatry Report (www.thecarlatreport.com). The report is now an eight page monthly newsletter, published online and in print, about psychiatric practice. Its website states, “We receive no corporate funding, which allows a clear-eyed evaluation of all available treatments.”
Industry influence over medical education continues to bedevil and concern Carlat, despite his departure from Wyeth. By publishing his report he hopes, he says, to take claims of effectiveness and put them “under a microscope,” so that he can give readers “the real story about whether they were true or false.” He is outraged that much of the education material that comes to his office is “so utterly biased in favour of the funder’s product, even though it is supposedly accredited.”
Accreditation for continuing medical education is granted by the Accreditation Council for Continuing Medical Education. Despite the council’s oversight a 2007 US Senate Finance Committee investigation found that “pharmaceutical companies were routinely using educational grants to help build market share.” The council determined that $2.25bn was spent in 2005 on continuing medical education accredited by the council, “of which $1.12bn represented commercial support.” Carlat wants to end industry funding of medical education.
It has been several years now since Carlat left Wyeth and founded the Carlat Psychiatry Report. But the problem of biased medical education isn’t going away, he says, and voluntary guidelines about industry funding of medical education have merely created a “veneer of respectability.” So, Carlat decided to offer his own story as a cautionary tale—a way to encourage other doctors to kick their addiction to drug company money. The response to his story has been mostly positive, says Carlat, and a number of doctors have told him that they had similar experiences giving talks for drug companies.
But Carlat still has some dues to pay. He began thinking about the $30000 he received from Wyeth and decided that “the best way I could pay the money back is to give my own services.” So, he decided to go on his “march of shame,” in which he will give free “undrug talks” to any group that asks.
By “coming clean” with his story, Carlat hopes that he might pave the way for other doctors to end their ties to industry. “I haven’t been sued,” he says. “There have been no death threats. These are things that people worry about.”
Carlat says, “I’m hoping to convince doctors to give up their addiction to industry money. Ultimately, our professionalism is at stake. We want our men and women to come in from the dark side.”
By “coming clean” with his story, Carlat hopes he might pave the way for other doctors to end their ties to industry.