Sunday, August 22, 2010

More Tidbits from White Coat, Black Hat

I recently announced Carl Elliott's new book, White Coat, Black Hat:

What follows here is a set of brief quotes gleaned from my now having read the complete volume, and then I will end with some summary comments.

  • On ghostwriters who work for medical communications companies: Carl quotes a biology PhD who went to work for a medical communications company and quit after a year, on being asked when exactly he decided "there was something ethically dubious going on at the agency": "The first day I was there."
  • Objecting to the idea that what's wrong with ghostwriting articles is that the putative author, who did hardly any work, gets credit for having written the paper, and quoting the same former ghostwriter: "The moral crime that I was being asked to commit was to do with truthfulness." That is, the problem is the "spin" that the article contained, not whose name is on the paper. Notice that this is a mirror image of the defense of the practice of ghostwriting offered by pharmapologists, who say that so long as the paper is accurate, who cares whose name is on it?
  • Carl's interview with psychiatrist David Healy of the University of Cardiff, on the latter's extensive insider's view of the psychology of physician "KOLs" or opinion leaders shilling for industry: Healy argues that most of these so-called "leaders" are distinctly second-rate intellects. They and the industry need each other. These guys realize after getting to a certain point in their early careers "that they're not going to get the chair at Harvard or Yale, but [they] enjoy the lifestyle of being courted by industry, and having [their] articles written for [them], of having articles in JAMA or NEJM, which [they] wouldn't otherwise have". They realize that the only way they are going to advance in the field commensurate with their ambition is to jump in bed with industry. Industry in turn needs people with this psychological weakness in order to have a gang of bought physicians who will reliably do what the industry wants.
  • How a person who had worked all his life in pharmaceutical marketing came to have his career-changing moment of epiphany: "I was in the exam room waiting for my doctor...[Seeing the room filled with industry knickknacks and brochures, he immediately thought:] I hope he's getting his information from the medical literature and not from people like me....That's when I realized that I was part of a big scam..."
  • Quoting from the same former marketer, Joel Roselin: "When Joel worked in medical advertising, he used to schmooze with one of his bosses over coffee. The two of them got along well, and Joel felt comfortable joking around with him. One day Joel asked, 'If someone asked you to promote a product you thought was dangerous, would you do it?' His boss paused and thought about the question for a while. Eventually he came up with an answer: 'I'd like to think we wouldn't.'" (Talk about a clarion call for ethical behavior!)
  • Carl, reflecting on his visit to Western IRB in Olympia, Washington, the most successful and prominent for-profit research ethics review board: Carl was invited by the founder of WIRB to visit, so that he'd see that his criticisms of for-profit IRBs were misplaced. Just before his arrival he was sent a detailed confidentiality agreement to sign, basically gagging him from telling anyone, ever, a single thing he saw during his visit. He arrived at WIRB and told the staff person who met him that he would not sign the form, nor any modification of it. This caused considerable consternation, but eventually the leadership decided that Carl could stay and visit, so long as he did not actually sit in on any ethics reviews of any actual research protocols. All through his visit, Carl heard a steady refrain: if only he could have actually seen the way WIRB reviews protocols, he would finally see why it had such a good reputation and why for-profit IRBs could function in a highly exemplary way. "As I drove away from the WIRB campus, it struck me that this obsession with secrecy was the hidden perversity of putting research oversight into the marketplace. Once such competitive pressures are instituted, there is no reason for any commercial IRB to share techniques to improve oversight. In fact, there is every reason not to share, because each commercial IRB has a competitive interest in the failure of other IRBs. ... Even if the members of any given commercial IRB sincerely want to protect the research subjects they oversee, they do not have any financial reason to want other IRBs to protect them, because every IRB that fails represents a potential business opportunity for the ones left standing." This contrasts markedly with university-based IRBs that routinely share their technques for improving their reviews of protocols--assuming that they ever develop any such techniques, which critics of IRBs commonly wonder about.
Summary comments: I have offered these tidbits from Carl's book because the majority of his content is already well known to regular followers of this blog. What, then, is the advantage of his book? One advantage is the nice way he was organized the material, running down the list of actors in the drama, and not sparing our own fellow bioethicists. The other, as illustrated here, is the great set of interviews that he has done and his lively presentation of what he learned.

No comments: