by definition…

Posted on Friday 29 November 2013

If I’m not a cardiologist and only an Internist in memory, why does this Statin thing get my juices flowing so [an exempler…, but I should’ve…, risk benefit ratio…]? I know there are people who are going to  take Statins for the same reason a lot of people go to church ["just in case"]. I read the New England Journal article [A Pragmatic View of the New Cholesterol Treatment Guidelines] by the editors which stays mostly neutral. I didn’t want them to be neutral. And every time I read one of these Statin articles, I judge it from the title, not the content. I think it’s because it’s a straw man – a surrogate – for something else I feel, and it doesn’t take a psychoanalyst to figure out why I might react that way. It’s the 4½ pages on the right from the American Heart Association Guidelines. I’ve colored in the members of the Task Force who area connected with companies who make Statin drugs. It’s too much – simply too much. So I shouldn’t hide my real motives behind these complaints, I should talk about them directly and get my nose out of a battle where I’m really not terribly informed. And there’s a point to this bit of personal introspection. I have a Conflict of Interest just like many of the people on that AHA Task Force. I can’t read about the Statin controversy without bias – the emphasis is on the word bias. I can say my opinion is scientific, and it is – but don’t you believe  for one minute that’s why I’m writing it [by the way, you already knew that].

I don’t have much flexability in my views about conflict of interest, mainly based on my own internals. I can feel bias inside. It’s part of being a therapist. I can certainly be wrong about myself, but if I pay attention, I’m fairly accurate in being able to monitor when a patient is getting into an area where I need to be careful about what I say. We call it neutrality, an unachievable goal but a worthy standard to shoot for. And I’ve become biased about this issue of bias. When somebody says that they can transcend the fact that a company is paying part of their salary and paying to keep their lab and lab·rats going, I balk for two reasons: first, I couldn’t do that, and second, they always say that as they endorse their sponsor’s product. You just don’t hear people coming down on the other side very often [if at all...].

I think this is something the lawyers have gotten very right. If the Lawyer for the Plaintiff can be shown to have a Conflict of Interest, or if the Prosecuting Attorney has a Conflict of Interest, the case can be thrown out of court or the verdict can be overturned. There’s no gradation in Conflict of Interest, it’s digital, not analog. The operative saying is, it’s like being a little bit pregnant. I’m not usually so dogmatic as this, but I suppose I’ve come by it honestly. I’ve seen a lot of psychotherapy cases that have gone south because of an unacknowledged bias in the therapist. I’m sure I’ve done it too, but at least I worked hard not to, and have sent patients for consultations or referred them on when I wasn’t sure. I’m not totally in love with the legal profession, but I think their vigilance in this area is a decided strength.

So, from my perspective, those pages up there a deal-breakers. I think it’s inevitable that academics will do drug evaluations and they should fight for their independence [but they rarely do]. But having done that, they should be barred from that panel by definition. Rigid rules. The actual American Heart Association Report, has a real go at trying to play things straight. I just think it’s impossible
  1.  
    Annonymous
    November 30, 2013 | 12:58 AM
     

    “‘There are statin believers, and when you hear these experts talk, they’re talking emotionally, not scientifically,‘ Abramson added. ‘The experts are using emotion, not science‘…”
    I suspect it is this bias, even more so than the commercial influence, that is driving the distortion in this instance. Pharmaceutical companies choose to sponsor these individuals. But they may very well have still been “statin believers” even without the sponsorship.
    Perhaps the attempts at these sweeping guidelines themselves are the problem. The imposition of belief, by these few, on a huge number of their colleagues.

  2.  
    Bernard Carroll
    November 30, 2013 | 1:10 AM
     

    There is also something called assortative mating. The Pharma marketing guys keep their eyes peeled for academics who have the emotional commitment, aka therapeutic zealotry. The marriage is made by signing these academics up as KOLs.

  3.  
    Annonymous
    November 30, 2013 | 2:42 AM
     

    Yes, exactly. It seems that this point is sometimes missed.

  4.  
    November 30, 2013 | 2:00 PM
     

    The trend in medicine is to replace diagnosis and treatment with mass-market prophylactic chronic drug therapy.

  5.  
    Annonymous
    November 30, 2013 | 3:02 PM
     

    Googling “assortative mating” and “key opinion leader” brings up this:

    At first it didn’t seem relevant to Dr. Carroll’s point as they used assortative mating in a different context. But right after the article notes this:

    ‘Kiki Chang, director of the pediatric bipolar-disorders program at Stanford, has embraced the kindling theory. “We are interested in looking at medication not just to treat and prevent future episodes, but also to get in early and — this is the controversial part — to prevent the manic episode,” he told me. “Once you’ve had a manic episode, you’ve already crossed the threshold, you’ve jumped off the bridge: it’s done. The chances that you’re going to have another episode are extremely high.”

    Oh boy. Preventive psychopharmacology.’

    Turns out the idea that “The Pharma marketing guys keep their eyes peeled for academics who have the emotional commitment, aka therapeutic zealotry” did come up after all.

    Re Altostrata’s post:
    http://www.huffingtonpost.com/bruce-a-barron/million-hearts-program_b_1096029.html
    http://circoutcomes.ahajournals.org/content/5/4/587.full

  6.  
    Annonymous
    November 30, 2013 | 3:03 PM
     

    Sorry, here is the link the Google search brought up:
    http://clinpsyc.blogspot.com/2008/09/bipolar-overawareness-week-new-york.html

  7.  
    wiley
    November 30, 2013 | 6:21 PM
     

    That was interesting Annonymous. I’ve been looking for explanations other thatn bipolar disorder being “jump-started” by antidepressants. If you see anything like that, I’d love to read it. It seems that the field of psychopharmacology would be very interested in learning why some antidepressants do nothing for a person, while another one somehow “reveals” a bipolar disorder. Perhaps there is something to learn by studying desipramine bipolars versus Prozac bipolars.

  8.  
    Steve Lucas
    December 1, 2013 | 7:45 AM
     

    In a more general context this link may be of interest showing how drug reps dealing with sympathetic doctors may drive drug cost out of proportion to their practice size.

    http://brodyhooked.blogspot.com/2013/11/generic-prescribing-and-conflicts-of.html

    Steve Lucas

Sorry, the comment form is closed at this time.