a sticky wicket…

Posted on Thursday 11 July 2013

In her testimony before the UK Public Accounts Committee in the earlier post [goldacre and godlee… ], Dr. Fiona Godlee says [@15:55]:
"Unless we can find a solution to the commercial incompetence problem, we have to recognize that the pharmaceutical industry has an irreducible conflict of interest in relation to the way it represents its drugs, in science and in marketing. And unless we can resolve this in a way that is more in the public interest and in patients’ interest, I would argue that drug companies should not be allowed to evaluate their own products."
While she made this comment as an aside towards the end of their argument for legislation mandating data transparency, she landed squarely on the story’s sticky wicket [in the spirit of the King's English]. There’s been something of an unacknowledged Neurotic Contract with the pharmaceutical industry. "We’ll overlook some improprieties if you’ll be in charge of drug development." In psychiatry, that reached tragic-comic proportions in that a large segment of psychiatry has built itself around the pipeline of new drugs which it duly publicized and prescribed – an unfortunate symbiosis that seems to have had a lifespan of about twenty-five years. Now that the some improprieties and the duly publicized and prescribed is beginning to be seen in the sunlight, that landscape looks a lot different than it did along the way. Again, Dr. Godlee [@15:54]:
"I think secrecy doesn’t serve us well."
Simple and understated – the crux of the problem. Such Neurotic Contracts rely on secrecy, and when the lights come on, they always have this same what-were-they-thinking? look.
    No American I know has ever seen a whole Cricket match. An understanding of the rules alone has been too contaminated by the simplicity of our baseball. Half a lifetime ago, I spent an afternoon trying to follow along in the company of a knowledgeable British neighbor. I couldn’t even figure out when to clap. The one thing I took from that day was his clarifying the meaning of a sticky wicket. It didn’t mean that the little top sticks [bails] wouldn’t fall off the upright sticks [stumps] when they were supposed to, a belief that apparently immediately identifies you as being from beyond the edges of the old Empire. It means playing on a damp field that makes the ball behave erratically. That’s likely wrong too, but it is with that definition that I proceed – playing on a difficult and unpredictable field.
Either data transparency or insisting on independent Clinical Trial validation seems inevitable to me – a reform whose time has come. In psychiatry, that carries something of a unique valence. Our specialty has increasingly migrated its practice to psychopharmacology with a small collection of medications, relying on the promise of new arrivals to make up for disappointments in efficacy and heavy side effect burdens. With the clarity of accurate information, those drugs have a diminishing appeal and the other end of the pipeline supplying new versions from industry is in a state of indefinite suspension. Many of us suspect that the recent revisions of the diagnostic manual were built on that same sandy beach as the over-reliance on inflated medication information and the fantasy of unlimited growth. And our organizations like the APA, the AACAP, and the NIMH seem to be still living nearby. Added to that, during the irrational exuberance of the last thirty years, the traditional tools of the trade were vilified and sent to pasture much to the delight of the third party carriers.

And so to our sticky wicket - we can’t predict our trajectory very well playing on this difficult field. In the coming crisis, where is the guidance, the compass pointing us in the right directions? Dr. Godlee offers us a simple one of immense value, "secrecy doesn’t serve us well." I think another comes from lessons learned in the last crisis if the 1970s. The solutions were built on revolution, devaluing the past, and moving ahead on the wings of fantasy. Besides throwing out the baby with the bathwater, it produced a vulnerability and a hunger that was easily exploited by the pharmaceutical and insurance industries abetted by the zealots within. And that identifies another compass point – being wary about making tempting alliances or following dangerous leaders in the process of finding new directions.

The obvious Anglophilia of this post was intenional – Ben Goldacre, Fiona Godlee, Cricket slang. The UK has our same problems, but operates in a more mature National Health Service and is playing on a less chaotic field. The forces for reform there are more organized [AllTrials, RIAT] and have a greater direct access to the seats of power. And finally, the clearest vision for the future I’ve read comes from the Critical Psychiatry Network centered in the UK [see a long and lonely wait…]. We would do well to listen carefully to the messages from the far side of the pond…

Update: Secrecy Does Not Serve Us Well [BMJ on-line June 12, 2013]
  1.  
    wiley
    July 11, 2013 | 12:17 PM
     

    “…drug companies should not be allowed to evaluate their own products.”

    Bingo! It’s refreshing to hear that stated so plainly by a representative of the field. I’d like to put a “ever” between the “not” and “be”.

  2.  
    annieUK
    July 11, 2013 | 12:25 PM
     

    Hello Dr. Mickey
    You are half-right….wasn’t the second half of the debate so interesting.
    Weren’t they grey, weren’t they ugly, weren’t they ignorant, weren’t they stupid.
    By this I mean those from MHRA, NICE, EMA.
    I think their measure was taken. The chairperson was so on the ball…..

    Would you, in the UK, want these people to look after your best interests.
    I don’t think so.

    Ben and Fiona were bright, sparkling, full of intelligence and it was great to watch them. Smart……

    As an ssri casualty, in the UK. What I am missing is the ability to sue, and this is where the USA scores.

    So, we may be smart, but we cannot sue…….
    I fly along on the coat tails of Professor Healy.
    If anyone wants to know anything about how we operate in the UK, go to David Healy blog or Rxisk.org and all will be revealed….
    Commenting is not really my thing, I love your take but can do without the commenters…..
    Cricket?? I live in Scotland, Shortbread!!
    Come and visit the UK and haver a chat with David……you two have a lot in common.
    Congrats Ben and Fiona…and Dr. Mickey for his research. Thanks from the UK. Enjoy your holiday and why not take a break from all this.
    Clear the head, do some fishing, chill – thanks…….for so much illumination….a quiet fan who does not need to justify her existence with comments which do nothing to accelerate progress.
    Let’s praise David Healy and Dr. Mickey and let some new blood in.
    Comments are becoming tedious and boring and do nothing to help, so far.
    DH and MN are not agony aunts…….. xx

  3.  
    Steve Lucas
    July 11, 2013 | 2:50 PM
     

    When one thinks of government incompetence, one does have to look far to find examples of waste and simply not knowing:

    http://www.foxnews.mobi/quickPage.html?page=38321&content=94870094&pageNum=-1

    Now take this mentality and apply it to medicine and we do not have to wonder why everything is a mess.

    Steve Lucas

  4.  
    Peter Parry, child psychiatrist
    July 11, 2013 | 8:56 PM
     

    Another good post as always, thanks Mickey.

    Glad to see you promoting the CPN – we must organise to save the profession.

    I couldn’t get the video of Godlee and Goldacre to work…

    In my med student days in the late 1970′s with the Adelaide University Cricket Club – we played two-day matches – consecutive Saturdays – against other clubs. One match was gainst Kensington Cricket Club in the leafy eastern suburbs of Adelaide.

    On the first Saturday we (AUCC) fielded whilst KCC batted on a dull hard “batsman’s paradise” of a wicket (aka “pitch” – the 22 yards between each set of “stumps” aka “wickets” too) where the ball bounced boringly true and the batsmen could hit boundaries almost at will (like home runs but you get 4 for the ball bouncing/rolling across the boundary and 6 runs for it sailing over on the full). KCC scored about 220 runs with losing only two “wickets” – in other words just 2 of their 11 batsmen were “out” (ball caught by us fielding side or their stumps/wickets “broken” by the ball bowled by the bowler or thrown by a fieldsman before the batsmen could run the 22 yards etc etc).

    It rained a lot before the next Saturday. The “wicket” (pitch) was “sticky”. This refers just to the hard packed 22 yard strip – not the whole field – which would just be called “wet”. The pitch/wicket was as is typical made of dark clay with thin layer of grass – so that is why it could be “sticky”. The ball bounced very erratically. Us AUCC batsmen had no idea and no chance. I recall the game because I “top scored” with 7 runs out of a total of about 30 runs from all 11 batsmen by the time we were “all out”. We’d been beaten by nearly 200 runs – all because of a “sticky wicket”.

    Big Pharma – Medicine COI has been a very sticky wicket.

  5.  
    July 12, 2013 | 6:14 PM
     

    The Critical Psychiatry Network is a voice of sanity, for a profession that has very little left.

    Duane

  6.  
    a-non
    July 13, 2013 | 8:39 AM
     

    Re:Secrecy Does Not Serve Us Well [BMJ on-line June 12, 2013

    Imagine another research/subject paradigm. Objective science is a plodding mule plowing a row-not a racehorse running the Kentucky Derby.
    http://www.jlaguidebook.org/jla-guidebook.asp?val=10

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