In my Internal Medicine days, I read the New England Journal of Medicine from cover to cover every single week. I still pick it up in the doctor’s lounge and read it just like I used to. And when I changed to psychiatry, I lamented that there was no NEJM-analog. So my comment, "What is this doing in the New England Journal of Medicine?" in my last post about the Drazen/Rosenbaum articles [wtf?…], was as a long time reader.
Well, I reread the editorial and series this morning, and if anything, they were worse – bordering on polemics. I tried to cut them a little slack because they’re internists and not psychiatrists. Psychiatry has been on the leading edge of the kind of problems COI can lead to for decades. Maybe, I thought, they’re just naive and not so in touch with the kind of fire they’re playing with here. They’re civilians, whereas we psychiatrists are veterans – knowing first hand how this COI thing can grow into a metastacizing cancer. But then I was alerted to this story about the Vioxx debacle by Bioethicist Arthur Schafer [University of Manitoba]. Editor Jeffrey Drazen should be a veteran after Vioxx [see also in Wikipedia]: Fortunately, rescue from company “spin” was at hand. Some alert scientists discovered that the VIGOR authors had failed to report several heart attack deaths in their NEJM publication even though they had supplied the correct data to the FDA… Even worse from the company’s point of view, the Vioxx deaths which had been suppressed from the NEJM article were deaths which occurred in patients with no history of heart disease. This fact kicked the legs out from under the company’s specious claim that only those with a history of heart disease were at elevated risk from taking Vioxx.The investigators did not correct the scientific record. Their failure to do so was compounded when Dr. Jeffrey Drazen, esteemed editor of the NEJM, declined an opportunity to publish a letter submitted to the journal by independent scientists which would have alerted readers to the misleading nature of the data originally published. Years later, when the full extent of the harm done to tens of thousands of patients became undeniably clear, Drazen and his fellow editors at the NEJM justified their refusal to publish a timely correction with the intellectually [and morally] feeble excuse that it is the responsibility of authors, not journal editors, to correct data…
In sum, almost no one emerges with much credit from the saga of the Cox-2 inhibitors. The drug companies which massively marketed the drugs, both to doctors and directly to consumers, made billions of dollars; but, when the facts eventually emerged, the companies experienced a serious loss of public trust. Merck, in particular, is now facing a staggering number of expensive law suits. The company continues to insist that it took all reasonable measures to determine whether Vioxx carried undue cardiovascular risks and is defending its conduct in all of these law suits. Medical journals and their editors, in particular the NEJM and its editor Dr. Jeffrey Drazen, were seen by some critics as being incompetent at best and collusive at worst in what turned out to be a terrible human tragedy…
“The University as Corporate Handmaiden: Who’re ya gonna trust?”, by Arthur Schafer in The Universities at Risk: How Politics, Special Interests, and Corporatization Threaten Academic Integrity, ed. Jim Turk. James Lorimer and Co, Toronto, 2008.
Note: Schafer’s chapter is well worth reading in toto for a thoughtful in depth look at this whole issue of the Corporate invasion of Academia.
by Relman AS.New England Journal of Medicine. 1980 303[17]:963-970.[partial text here]
The most important health-care development of the day is the recent, relatively unheralded rise of a huge new industry that supplies health-care services for profit. Proprietary hospitals and nursing homes, diagnostic laboratories, home-care and emergency-room services, hemodialysis, and a wide variety of other services produced a gross income to this industry last year of about $35 billion to +40 billion. This new "medical-industrial complex" may be more efficient than its nonprofit competition, but it creates the problems of overuse and fragmentation of services, overemphasis on technology, and "cream-skimming," and it may also exercise undue influence on national health policy. In this medical market, physicians must act as discerning purchasing agents for their patients and therefore should have no conflicting financial interests. Closer attention from the public and the profession, and careful study, are necessary to ensure that the "medical-industrial complex" puts the interest of the public before those of its stockholders.
by MARCIA ANGELL, MDNew England Journal of Medicine. 2000 342[20]:1516-1518.In 1984 the Journal became the first of the major medical journals to require authors of original research articles to disclose any financial ties with companies that make products discussed in papers submitted to us. We were aware that such ties were becoming fairly common, and we thought it reasonable to disclose them to readers. Although we came to this issue early, no one could have foreseen at the time just how ubiquitous and manifold such financial associations would become. The article by Keller et al. in this issue of the Journal provides a striking example. The authors’ ties with companies that make antidepressant drugs were so extensive that it would have used too much space to disclose them fully in the Journal. We decided merely to summarize them and to provide the details on our Web site.
Finding an editorialist to write about the article presented another problem. Our conflict-of-interest policy for editorialists, established in 1990, is stricter than that for authors of original research papers. Since editorialists do not provide data, but instead selectively review the literature and offer their judgments, we require that they have no important financial ties to companies that make products related to the issues they discuss. We do not believe disclosure is enough to deal with the problem of possible bias. This policy is analogous to the requirement that judges recuse themselves from hearing cases if they have financial ties to a litigant. Just as a judge’s disclosure would not be sufficiently reassuring to the other side in a court case, so we believe that a policy of caveat emptor is not enough for readers who depend on the opinion of editorialists.
But as we spoke with research psychiatrists about writing an editorial on the treatment of depression, we found very few who did not have financial ties to drug companies that make antidepressants. [Fortunately, Dr. Jan Scott, who is eminently qualified to write the editorial, met our standards with respect to conflicts of interest.] The problem is by no means unique to psychiatry. We routinely encounter similar difficulties in finding editorialists in other specialties, particularly those that involve the heavy use of expensive drugs and devices…
Dr. Dawson’s review seems to support Dr. R’s viewpoint.
http://real-psychiatry.blogspot.com/2015/05/bias-cuts-both-ways.html
We can add Jerome Kassirer to the list of former NEJM editors who raised this alarm.
http://www.amazon.com/On-Take-Medicines-Complicity-Business/dp/0195300041
This is not naivety.
Sandra,
Thanks for the note. I joke about having lived a cloistered medical life after exiting the University in the mid-1980s. I guess 1999 would have been a year or two before I decided to retire, and by then, I was in full Rip Van Winkle mode [asleep]. I didn’t even know that Jerome Kassirer had been fired as editor of the New England Journal around these very issues. Speaking of naivety, this post is an example of my own. I thought [or wanted to think] that the cancer-that-ate-psychiatry was localized. It’s increasingly apparent to me that was naivety on my part.
Hi Mickey,
Thanks for your comments. I can imagine Dr. Relman, former editor of the NEJM who first raised the warning flags on COIs rolling in his grave. These articles are stomach churning, really twisted in their thinking. When the editor of Health News Review asked me to comment on their blog, I jumped all over it. When Dr. Rosenbaum questioned the harms caused by COIs, I wanted to use one example from psychiatry. Oh which of the multitudes to pick. Since she’d mentioned child abuse in one her articles I chose the Biederman fiasco & tragedy of overdiagnosis with serious mental illness & overtreatment w/ antipsychotics.That she mentioned the Vioxx business was quite amazing as Mickey mentioned, as and I noted in my first blog, which Mickey provided a link to. As he says, what is going on at the NEJM? I for one have been reading the BMJ the last couple of years.
Susan,
I read the BMJ now too. In fact, even though I have faculty access, I pay for a subscription to suport their work and Fiona Godlee’s courage. She really belongs up there with Relman, Kassirer, and Angell. For those who don’t know, Susan wrote those two articles up top in Health News Review. Good show, Susan…
Monke,
I have nothing but respect for Dr. Dawson. We rarely agree on this kind of thing, but he’s a prodigious and right-thinking clinician – and that’s what really matters in the end. We also share an acquired revulsion for “Managed Care.”
On a humorous note, after Marcia Angell’s editorial appeared (Is Academic Medicine for Sale?) the NEJM published several letters in reply. First prize went to this succinct response: “No. The present owners are very happy with it.”
Slightly Off Topic: It’s bad enough that psychiatry and medicine are being devoured, but I wish that was where it ended. This all seems to be part of a larger, cornucopian cultural meme that I’m still struggling to understand. Maybe it’s some kind of anesthetic an “intelligent” species administers to itself when faced with overpopulation, declining natural resources, and other existential threats, but there’s a lot of wild, crackpot, big money, high-tech fantasy that’s being peddled in what I used to consider our most venerable bastions of high culture.
Check out John Colpatino’s fawning profile of Karl Deisseroth in the May 18th New Yorker, page 75. It’s not optogenetics itself that freaks me out– for oncology or neurosurgery, the technology itself sounds like it has great promise, at least to someone who knows almost nothing about either of those fields. Sure, it would be great to map the human brain– we’ve heard this song many, many times before– but people are quoted as comparing this guy to Galileo.
And the clinical applications described in the piece make my blood run cold. The piece begins with a case history about a patient who is being treated with direct vagus nerve stimulation to attempt to control depression, and seems to cast repeated and complex treatment failure– “going pancake” and the craving for greater voltages–as stumbling blocks on the road to some great new breakthrough. “Cells outside the targeted treatment area can be roused,” Colpatino notes, in an unintentionally chilling and morbid attempt to offer balance.
Am I missing something? This sounds like a combination of ECT and trepanning. I know it’s not NEJM, but it’s not Wired, either– it’s The New Yorker!
Dr. N., I like to hear that Dr. Dawson is a “prodigious and right-thinking clinician.” That is how he comes across on his blog.
I’m not sure it’s relevant here, but he and others, including Dr. Rosenbaum, cite a 2012 study by Kesselbaum et al. as evidence that internists have bias against pharma-backed drug trials.
I spent quite a while poring over it when Dr. R first cited it, and believe its method was flawed and data analysis overly fancy. I graphed the means for the data in various conditions of the experiment (provided in an appendix), and they can hardly be distinguished. I can’t say the study’s wrong, because I don’t know what this means:
“a hierarchical proportional-odds regression model, using the appropriate Likert-scale response as the outcome. This model included a random intercept for each physician to account for within-physician correlation of responses across abstracts.”
If anyone has a clue or any interest, please have a look at my graphs of the means, and the graphs the authors generated for the odds ratios they calculated. I provide some background and a link to the study, and there’s a place for comments underneath the post.
http://unmitigatedcrap.blogspot.com/2015/05/wot_23.html
Back to full relevance, Dr. Dawson posted a third installment today.
http://real-psychiatry.blogspot.com/2015/05/moral-bias.html
P.S. B. Caroll: Good one.
hi catalyzt,
i have many reservations about optogenetics, not withstanding that its protocol has had reproducibility problems for over a year and they have nto been fixed.
https://pubpeer.com/publications/23575631
the person who said karl deisseroth’s optogenetics is akin to what galileo did for physics is none other than dr christof koch. dr koch is being forced to say this because he was one of the first to review my work, which has yet to be published. i chose him as a reviewer because of his very impressive body of work and collaboration with the late francis crick.
dr koch’s role in reviewing my work over 16 months ago was critical. it gave me confidence that what i was doing was correct, and that the results weren’t the issue. instead it has been politics because i patented teh methodology (but will allow FREE usage for publication, just not commercialization). deisseroth has been in optogenetics for many years and has yet to produce the result that was reviewed by dr koch.
expect the media surge and prestigious journal double-talk to continue for the near future. this is frequently referred to as the ‘run-up’ before the big crash, i.e.- they try to convince everyone with compromised ‘professionals’ that the current unethical practices/bunk results are acceptable/correct. it allows them to continue along the unfruitful path that we’ve been set on for the past decades.
soon it will all come crashing down.
Warning – Long comment and a perhaps off the topic turn at the end.
One problem with how the conflict of interest (COI) issue is discussed is that COI is looked at as an either-or phenomenon. I think Dr. Dawson’s reviews may have been motivated by that. Painting any physician who has received any funding from a drug company with the same brush is easy, but it is stereotyping, and that stereotyping is just as destructive as other forms of stereotyping that are done in our society.
The relationship between what is received and how that will bias a physician’s actions is extremely complex, and involves factors which cannot be enumerated. Money is not the only currency that can be exchanged, there are others, some sleazy such as sex, but others as innocent as the enjoyment of a friendly relationship. Here is an example of the latter.
When I started my own practice in the late 90’s I banned anything that came from a drug company. No gifts, no trinkets, no lunches. Reps would still stop by and leave samples, some of which I would give out. They didn’t come by too often, probably because I did therapy and saw 1 patient per hour, and wasn’t prescribing lots of medications. I do remember that when Lexapro came out I tried some samples with my patients and it seemed to have decent results with a low side effect profile. So I began using it more. The Forrest rep came by a few times and I would give out the samples she left. I integrated meditation into my work with patient. I had written a book on meditation and wrote an article on that topic for one of the trade magazines, I think it was the Psychiatric Times of all places. She was interested in mindfulness and we talked more about that then Lexapro. But we clearly had a friendly relationship and I liked talking with her when she stopped by which was about every three months or so. Now did that influence my decision-making about Lexapro? Was she coming by solely in order to increase my prescribing? Those questions are impossible to answer. Given that I may have had 10 patients on Lexapro I doubt that there was much incentive for her in my prescribing pattern. But who knows.
I did get asked by Forrest if I would do some speaking about Lexapro, but when I learned that they would provide the slides I declined, knowing that I would be used to advertise the drug if I accepted.
My point here is that any human interaction is going to cause bias. The only way for a physician to be unbiased is to have no contact with anyone or anything. Treating every physician who receives anything from a drug company or does any research that is funded by a drug company as if they are a KOL or signing their name to ghostwritten articles is prejudice. The NEJM article are going to be received at least somewhat positively by people who experience those inveighing against COI as having moved past a point of reason. Dr. Dawson may be an example of that, though I hesitate to speak for him. When a group is perceived as going on a crusade, they will tend to lose the support of the people in the middle.
Warning – Philosophical tangent
My own thinking as I type this is that the root problem is too many people have lost their moral compass. First, the idea that “the love of money is the root of all evil” has been replaced by “greed is good.” Second the idea of chivalry, that those with power have an obligation to protect those without it, is dead. Whether it is a hospital administration abusing its workers, a drug company raising prices on medications that people can’t live without, a municipality such as Ferguson extorting money in the form of fines tacked upon fines upon fines to those who cannot pay, the process is the same. Those who are defenseless are not people to protect, but prey.
Unless we regain a moral compass nothing is going to get better. But we don’t achieve the moral high ground by stereotyping.
I’m with Dr. Dawson on this one. COI doesn’t exclude good results:
http://www.bloomberg.com/research/stocks/private/person.asp?personId=4017072&privcapId=6411354&previousCapId=36367670&previousTitle=INSYS%20THERAPEUTICS%20INC
Dr. Ho developed the triple therapy cocktail for AIDS. I could give a damn about whether he got pharma money. I do care if some who contributes nothing to science by lying, spiking or not using sound methodology gets pharma money.
I find it interesting that people who decry COI from pharma have no problem with climate scientists (who have been caught red handed “hiding the decline”) getting government or UN grants to support the government agenda. Again, this stuff cuts both ways.
But then again we could just bet the farm on genius archangels doing perfect studies in a world without money producing pixie dust that would eliminate all mental illness and extend our life spans to 800 years. But I prefer real solutions.
Dr. Arpaia (or anyone else),
Can you give me an explanation for why escitalopram is functionally different from citalopram? Can you you explain why it is anything other than a method to substitute a new on patent drug for one that is about to go off patent? Those samples are the in road to get people on the new patented version of the drug.
Joseph,
Many decades ago I took a class taught by the sales manager of a drug wholesaler. One major point was it was the job of the sales manager (management) was to keep the sales people on the reservation. This took the form of making sure the sales people stayed on script, which is why they are called detail people, did not focus on one doctor, and kept their expenses in line.
This was all part of a vetting process that continued through out their employment. Business followed the same pattern until about 1980 when we saw the “greed is good” mind set take over.
I am not concerned about the doctor attending a convention and accepting the free meals given as part of the program, or the pens and bags given out as you sign in. The problem becomes when the doctor in order to receive those free pens must speak with the drug rep. This is what the drug rep wants as they are trained to use even passing in the hall as a selling opportunity.
Interestingly a doctor friend was quite upset when their practice started a no gift policy because their concern was where they were getting their pens. Two pharmacists’ friends were equally concerned about their pens when the drug store they worked at did the same.
Your invitation to speak was the part of a grooming process to turn you into a drug sales person. The drug company had built a model of your practice and knew what you made and how they could enhance your income, resulting in you relying on speaking fees for those extras you wanted.
No person is as pure as the driven snow and a fair doctor/pharma relationship can produce positive results. The problem is pharma will always try to pervert this relationship to their advantage. You did the right thing in not accepting the speaking opportunities and had a positive relationship with the drug rep.
The issue becomes what is an incidental business relationship with the drug companies and what is a relationship where the prescriber relies on the drug companies for additional income or economic gain.
I remember one doctor proudly stating he did not eat the lunches provided by the drug reps while part of his pay package included daily gourmet lunches for his staff. This doctor had in my mind crossed the line between incidental and relying on the drug companies for a service not related to their practice.
I cringe when I hear the term “maximizing income” or “economic gain” spoken by people who really do not understand the terms and are using them as a cover for personal or corporate gain. The vetting process of old would not have allowed a drug company to pull a drug and replace it with a higher priced similar or a large company to buy a small company and then triple the price based on a ROI or marketing calculation.
Arm’s length relationships with drug companies can be beneficial, but you must keep a constant eye out to make sure you keep your arm.
Steve Lucas
@cardiobrief aka Larry Huston tweeted the link to “No, Pharmascolds are not worse…”
“So here’s my semi-epic rant against Lisa Rosenbaum’s epically misguided series on conflict of interest”
The replies are epic, too.
https://twitter.com/cardiobrief/status/601400173613420544
Steve or anyone else,
Can you speak about doctors giving patients coupons for prescribed meds? A specialist gave me one and I didn’t think anything of it since I was stressed out about upcoming surgery even though it was minor. But later, I realized the possible COI and was curious about this.
Also, due to adverse reactions to this med, I ended up in ER so that is another reason I was curious. 🙂 All jokes aside, I am not blaming the possible COI for my problems but of course, it is an understandable reason why I would be wondering.
Thanks!
I’m pretty much with Dr. Arpaia on this. When taken to the point of stereotyping and guilt by association, our criticism of industry has gone too far. Equally, when legitimate concern is refuted, e.g., when Dr. Rosenbaum holds up extreme and unreasonable examples, that’s not sensible either. We don’t declare pollution a sham because fringe groups of radical environmentalists exist. We don’t defend nuclear war even if we disagree with the tactics of some protesters. Likewise, I’m not ready to defend the too-cozy relationships of physicians and industry even if the rhetoric gets overheated and unfair sometimes. COI is smoke, not fire, but it still shouldn’t be ignored.
Sandra Steingard: Citalopram is a racemic mixture, equal parts of two enantiomers, only one of which is psychoactive. Escitalopram contains only the active enantiomer. Functionally, this means that 10 mg of escitaloprm has exactly the same psychoactive effect as 20 mg of citalopram. The argument is that this halves the side-effect potential, as the total dose is less. I don’t know whether this is true or not. However, since escitalopram went generic, I’ve prescribed it preferentially over citalopram.
Winge,
Dr. Weiss who defends Dr. Rosenbaum regarding the Cardiobrief post has an interesting background as he is associated with UCSF, which has had issues with COI’s in the past.
Per HCR:
After Firing Dean, UCSF Stalls Release of Audit
http://hcrenewal.blogspot.com/2008/01/after-firing-dean-ucsf-stalls-release.html
Conspiracy Theory” Proven – Taking UCSF Private
http://hcrenewal.blogspot.com/2012/01/conspiracy-theory-proven-taking-ucsf.html
Abort, Retry, Fail? – Lancet Avoided Much Recent Unpleasantness in Reporting on New Gates Foundation CEO (Including Her Defense of $55,000 a Year for Bevacizumab)
http://hcrenewal.blogspot.com/2014/05/abort-retry-fail-lancet-avoided-much.html
What these links point out is UCSF is an institution that has had several questionable issues with regard to financial conflicts and leaderships relationships with industry.
It may also be of interest that Janet Napolitano now leads the California University system.
Steve Lucas
Maybe we ought to take some of the heat off pharma and put it on Elsivier:
http://retractionwatch.com/
Steven Reidbord (and others),
I guess I was not explicit enough. I am aware that citalopram is a racemic mixture and that escitalopram is the active enantiomer. So why would the inactive enantiomer have side effects? Isn’t it inactive? I am aware of how it was (effectively) marketed but this always struck me as a typical marketing slight of hand to get more patent time for the drug company.
Sandra,
I admit to being among the gullible. I knew Lexipro® was a patent extension gimmick, but the logic made sense. I later thought better of it when I realized the cost difference and changed everybody to Celexa®. They all [actually only the few] said they noticed no difference. I was in my naive period, and hadn’t yet “caught on.” Actually, it was the beginning of my realizing how much sleight of hand was being played…
Sandra, good point. Apparently I’ve been gullible too. Although this was neither my rationale nor Forrest’s marketing pitch, apparently there’s some animal model evidence for escitalopram’s superiority. (All by the same researcher I think.) My preference for prescribing generics led me to choose Celexa over Lexapro for almost all patients while Lexapro was still on patent.
Sandra,
My experience was that the “inactive” enantiomer seemed to cause more of the sedating side effects that my patients on citalopram complained of. Maybe that was placebo effect, but since the main difference between SSRI’s is side effects the fewer side effects that my patients had the better, whether I could explain that or not.
The R-enantiomer also seems to have more of the QT-prolongation effect, so now that Lexapro, or S-citalopram is generic I only have one person on citalopram, who insists that her depression responds much better to that than to S-citalopram.
I read this thread and was ready to just bail, but then I read about the issue between lexapro and celexa and was truly compelled to comment.
The ratio is really 10 milligrams lexapro to at least 30 milligrams celexa, so where the hell do people get off writing for 20 or more milligrams of lexapro that’s equivalent to 60 milligrams or more of Celexa, and think about it, 30 milligrams of lexapro equals about 90 milligrams of Celexa, so do you as providers write that amount of milligrams of these dosages?!
Anyway as other people got off topic, so will I. Frankly this blog I can’t follow anymore. And these run on posts that just talk about numerous issues just lose me. I do like to talk about the issues about Psychiatry being inappropriate and clueless, but these pontifications about studies and editorials just lose me.
Therefore I know I’ve said it before, but at this point I am ready to take a long nap from this place.. Some of you might be happy to know I am not going to be around anymore, but it’s really a shame that the point of these issues get lost with all of this extrapolations?
Anyway, appreciate the opp to comment, good luck to all with your interests.
Joel Hassman MD
@Steve Lucas
Forgot to say “Thanks” for the insight on the way drug reps are trained.
Dr. Arpaia, the Forrest drug rep was indeed bonding with you to increase sales of Lexapro.
I was involved with designing systems for drug rep training and management. As Steve Lucas indicated, all of their interactions are choreographed. She was going back to her supervisors reporting on your level of doneness and discussing when to turn you into a KOL.
Yes, Lexapro is very frequently overdosed as though it was Celexa or Paxil. From patient reports, it does indeed have adverse effects even at a “low” (but nonetheless powerful) 10mg dosage — to what extent in comparison to citalopram is impossible to say.
@Allostrata
Any drug rep is doing what they do to sell their product. The question is not that they are doing that, but whether their methods are ethical.
Conversation is a legitimate means of conveying information and attempting to influence decisions. Offering treats, money, gifts, etc is not.
If I read your materials online and that influences me to avoid prescribing that is no different than talking with a drug rep.
@Joseph Arpaia
Precisely the same kind of thing goes on in defense marketing. In my day the process was openly called ‘G-2’, the military designator for intelligence staff roles (as opposed to, e.g., ‘G-6’ for signals). The process truly is best understood in terms of intelligence-counterintelligence.
I assume clinical psychiatrists are skilled at noticing absence of forthrightness. Ask a pharmaceuticals sales rep directly about what intelligence about you he compiles and tracks in his CRM (‘customer relationship management’) system. (He may have a super-CRM system specialized to grooming KOLs.) Pay attention to the psychological indicia of his response. Repeat several times, with several reps, striking without warning. You may conclude that the process is not adequately characterized by the term ‘conversation’.
(By the way, it’s significant that in defense contracting — in my day at least, but hopefully still — government purchasing officers were prohibited from accepting so much as the gift of a fast food lunch.)
Joseph Arpaia,
It is the content of the conversation and whether the data one receives is a fair representation of the data that is the point here. There is ample evidence that the information provided by the rep is portrayed as educational but it is primarily designed to promote the drug.I think there is also good evidence that physicians are not terribly good at making the distinction.
Zealotry comes in many flavors and the lust for pharma money is but one.
Rigid ideology is another cancer in academia. The Gruber tapes are a perfect illustration of that. He’s bragging about how he deceived people to promote himself and his agenda. Unfortunately, there are a lot of Grubers in academic medicine, not just in psychiatry.
Most of the researchers I knew from training loved their pet theory and hated it being challenged. This is not the proper scientific mind set. And most of these ended up as dead ends.
Like all salespeople, drug reps deliberately strive for a personal bond, an emotional connection, to make what they say even more influential. This is different from simply providing information.