1 Boring Old Man

“I’m just tired…”

aren’t we all… the corruption of the medical practice has wreaked untold carnage upon all of humanity.

Me, too… so much s**t to shovel.

Maybe that’s the goal– to make us all tired so that we don’t care anymore and just give up.

(1.) On the chemistry, I am not a chemist, but my fiance is and works for a drug company, (not in CNS research), and he does scale-up now rather than med chem, i.e. all he is paid to do is design more efficient ways of making a molecule before it’s tested. I showed him the molecules, because they looked so similar to me. He said that he couldn’t comment on those molecules at all or how they would work, but that frequently the removal or addition of chlorine or fluorine was the difference between a drug that worked and one that didn’t. He had frequently seen very different results in the lab (and this was creating new molecules) with differences in structure that were less than those here.

(2.) Everything else you said is spot on.

EastCoaster,

Thanks!! Good info.

Glad I finally caught up with Abilify Month at 1BoringOldMan HQ! I think you’re right about all of this: “Brexie” is most likely a monster of a Me-Too drug. It’ll probably be marketed mainly to depressed people, and once it is, everyone will be expected to forget all about abili… abili what was that stuff called?

RxISK ran a column last week by “DG”, a young man who was given Abilify for Tourette’s syndrome with really disastrous results. The initial group of Abilify reports we got had made me think this drug might look better from the outside than it feels from the inside … DG brought that to life in a really nightmarish way. He & his mom followed up with an account of their earnest efforts to alert the FDA to what they’d gone through — which of course went nowhere.

http://wp.rxisk.org/category/stories/

It’s pretty clear Otsuka’s eleventh-hour Tourette’s Campaign had nothing to do with helping TS sufferers or even capturing their market! I’m thinking the reason they waited so long was that they knew Abilify was a very dicey, unpredictable drug to give to people who had a problem with tics and spasms to begin with; it could work for some but totally backfire for others. People with Tourettes (kids first and foremost) got utterly, cold-bloodedly used, I think, in a high-priced patent lawyers’ game. It’s sick.

Money is not the root of all evil.

The love of money is the root of all evil.

All of medicine has a money problem.

And yes, wearing people down, over burdening them with too much information, and then exploiting any error is the new norm in medicine and many other professions.

Steve Lucas

That’s an old saying that really isn’t true although it may be true in a certain situation.

Money had nothing to do with the Killing Fields or Ted Bundy.

The love of money can also lead to great things and human progress. The HIV cocktails made pharma a lot of money. So did penicillin. So did all the devices we are using to post message on this board.

I understand that simplifying makes things easier to understand but as Dr. Caroll would say, it doesn’t move the ball forward.

Anyone here working for zero salary simply to do good including Steve Lucas please raise your hands. Bueller? Yes, I thought so.

Anyone born in the US in the latter half of the 20th century is one of the luckiest people to be alive. And that’s mostly because people were chasing profits for the last 200 years.

James,

The problem is not economic gain. The problem is when economic gain out weighs any sense of ethics or moral obligation. I would say that the KOL’s are driven by a desire for money, often at any cost. The venture capitalist now buying private medical practices are driven by the love of money. They have no moral feeling towards that practice or the people served.

Many decades ago I was introduced to the concept of the perfect sale person. They and their spouse were shallow, petty, and driven by money. This model was in reference to the perfect drug rep.

The problem is not profits, but when profits become the only endeavor in an economic interaction. Pharma has time and time again shown a willingness to promote products with a higher risk than reward profile.

In terms of moving the ball forward understanding that some will do anything for a buck, include lie and cheat, is an important concept to remember when dealing with medicine as a whole. Not remembering that profit, and profit alone, has been the driver in the issues reviewed by Mickey makes all of his writing moot, since they all then become either business as usual or simple data errors.

There are limits in business and medicine.

Steve Lucas

I agree with all of that.

So the problem is sociopathy, not money.

BTW, the KOLs and academic heads I remember well. They would often grouse about how greedy the private practitioners were and preach altruism. Honoraria as it turns out was their version of the Clinton Foundation.

I agree with Steve Lucas and Dr. O’Brien. The love and pursuit of money has indeed made for great advances in technology and certain areas of medicine and I for one am glad to be alive in this part of the century. I do wonder why the love of money has NOT produced breakthroughs in psychiatric treatment on the order of what we have seen in the treatment of HIV, infectious disease, and cancer. And I think one reason– aside from the undeniable fact that people and their emotional misery are very complex matters, is that CRONY capitalism (as opposed to “regular” capitalism) seems to have characterized the behavior of Big Pharma and certain KOL’s in our field.

Tom,

Great post. Bingo.

james,
the problem is that much of medicine’s (as you may know) talent is chasing money.

i knew many people applying/interviewing for medical school solely because of the salary they PERCEIVED it paid. once they get in, it’s not like they have any other avenue of opportunity; many have useless bio sci degrees that merely serve as a vehicle to fulfill their high-GPA requirements for applying to medical school, althewhile ensuring some form of ‘achievement’ is attained in the process.

if medicine stopped saying ‘we only want the best measured by GPA & MCAT’ (less so the former), and made a better effort to measure the competence and ‘headiness’ of a good doctor, we’d be a lot further.

compassion, rationality, prudence, temperance, and preparedness are hallmarks of some of the best doctors of all time. hippocrates, sir charles sherrington, and sir john eccles come to mind. there are many others i’m sure, but i can only recite those of which my heritage is familiar

The saying might be better phrased “The lust for money is the root of all evil.” Just as desiring sex, which is healthy, is different from lusting after sex, desiring money is different than lusting for money. The former is tempered by consideration of moral and prosocial factors. The latter causes morality to be thrown out the window.

Unfortunately the lust for money is now rewarded and honored in some circles (see the Health Care Renewal blog for examples) and so we have not a prosocial capitalism but a parasitic capitalism that is destroying its host societies.

Hey, how many of you looked the other way when the majority of people got away with framing medical care as taking care of clients or customers?

“the business of medicine”, seems to have been prophetic, eh?

Welcome to the customer is always right!

I remember stating that attorneys, accountants and prostitutes had clients. I had patients.

I still have patients, not clients or customers.

Greed is universal. In the private sector, it is somewhat controlled through supply/demand, competition, lawsuits unless there is a monopoly or rent-seeking situation, which is unfortunately becoming more normal. An example of this would be electronic health records. Or the big five insurance companies.

However, we do not have angels working in the public sector either. Did you know that Congress is exempt from insider trading laws? These people are absolutely addicted to lobbying junkets and for that reason the people who are supposed to be regulated capture the government with what are essentially bribes. Wall Street and Dodd-Frank would be a perfect example.

Anyone who thinks Washington is the solution for greed is not paying attention.

These academic psychiatry departments are not run by the Koch Brothers or the Chamber of Commerce or the Duck Dynasty clan, but mostly by people well left on the political spectrum, and some who claim to be overt Marxists. But who have no problems accepting conflict of interest money when they think no one is looking.

Comes back to that wonderful adage, “if pro is to Pro-Gress, then what is con? Con-Gress?” Nobody still talks about it, but wait for it, IPAB will be happening soon. Then we can see how wonderful Obamacare is for the country.

Psychiatry and the Business of Madness by Bonnie Burstow is just out. The bookstore in Oslo, where I order new books from afar, called today to say it’s in, and not just my copy. Next order is Psychiatry under the Influence – by Lisa Cosgrove and Robert Whitaker – in September there is Peter Gøtzsche’s new book, Deadly Psychiatry and Organized Denial. The end may not be close, but a paradigmatic shift is advancing, I think, I hope. My inbox contains an invitation for a CME course in better communication skills for doctors and health providers, … an obligatory starting course would be even better – to separate the wheat from the chaff.

James Davies’ Cracked: The Unhappy Truth about Psychiatry, is less new, but most relevant. His terse statement that psychiatrists do not prove things, they decide them … exposed during the trial of Anders B. Breivik, when the consensus model the psychiatric guild depends on shredded in front of the eyes of everyone everywhere with an interest in psychiatry and forensic psychiatrists

IPAB?

“…has the explicit task of achieving specified savings in Medicare without affecting coverage or quality.”

(…has the explicit task of getting a specified amount of blood from an orange without reducing weight or volume.)

1. Pay service providers less (and not notice when the talent base decays) (and let P.A.s perform some surgical operations).

2. Negotiate with suppliers; advocate as equivalent, and offer cheaper drugs and supplies that might or might not be as good as what they replace.

3. Eliminate “unnecessary/ineffective” interventions and reduce “waste” (both subject to trade-offs and ideology).

4. Close facilities and increase subsidized transportation and telemedicine.

5. Promote hospice options over intervention in late stage disease and old age (but don’t say d**** p****).

6. Leave buckets of Seconal where depressed people will find them.

Can’t wait!

“I do wonder why the love of money has NOT produced breakthroughs in psychiatric treatment on the order of what we have seen in the treatment of HIV, infectious disease, and cancer.” The impact of crony capitalism is certainly felt in medicine and far beyond, and for a long time I felt like this was also the reason why the quality of news journalism has declined, why the space program has lost direction, and why I don’t feel comfortable owning a car built after about 2005.

Over the past couple of years, and since I’ve been reading this blog, I’ve begun to think I was wrong about that– and not just because I’m a Luddite, curmudgeon, or crackpot. (Though in some contexts, that may be true.)

I think that in disciplines where the low-hanging fruit has been picked, we’re becoming frustrated with the slow pace of innovation. We’re having an emotional rather than a rational response to our limits as a species, and this has insidiously warped our ability to solve complex problems.

The fact that so many of us are half-blasted on drugs, from ETOH to cannabis, SSRIs, and Adderal, isn’t helping our cognitive clarity, either. Neither are rising CO2 levels, particularly for those of us who work indoors, and the cumulative insults of a hell’s-brew of environmental toxins, and we should probably stop distracting ourselves constantly with little gadgets that have lots of brightly colored, flashing lights. To push beyond our current limits, we must become very, very healthy and focused little monkeys.

I think it’s great to expose snake-oil salesmen, and I love that dimension of this blog. At the same time, I feel that there’s a real danger in polarized, us-versus-them thinking. That’s why I really like the analysis of common pitfalls in statistical analysis, and I love posts about chemistry, even if I’m still a long way from understanding them.

And I passed my first licensing exam– the one that covered so much of the DSM 5. Thanks to all for helping me retain my sanity while I studied, and providing a larger context for an otherwise incomprehensible document.

Dr. Rosenbaum, author of the Connecting the Dots, etc. is associated with has no concrete ties to a UPENN center that conducts drug maker-funded studies on statin compliance.

A slick one, this Dr. Rosenbaum.

She’s a national correspondent for NEJM. But who is she when she’s at home?

She’s a cardiologist who spent 2014 as a Robert Wood Johnson Clinical Scholar at the University of Pennsylvania.

Robert Wood Johnson is not to be confused with Robert Leroy Johnson,
the bluesman who is said to have sold his soul to the devil.

They have different middle names, and only one was a bluesman.

J&J’s McNeil division brought Haldol to the US from elsewhere. Approval, final in 1967, was apparently difficult, But I have not found out why.

Back to Dr. Rosenbaum. She has a column on The Health Economist, the online health policy periodical of the Leonard Davis Institute of Health Economics at UPenn.
Currently, her name and photo decorate a graphical banner atop a page of links to her writings for NEJM, The New Yorker, and Huffington Post. The banner, along with her photo and name, says:

“ON MEDICINE TODAY.”

I assumed she was, and admire her candor.

What’s LDI for? Research, policy analysis, and education in health systems, housed here:
http://chibe.upenn.edu/research
(Chibe is not a town in Kenya. It is an acronym for Center for Health Incentives and Behavioral Economics.)

(It would be nice to know what Health Incentives and Behavioral Economics are.)

“CHIBE researchers apply concepts from the field of behavioral economics to design, implement, and evaluate interventions that improve health and build knowledge about efficacy, cost and effectiveness.”

CHIBE is funded by NIH and divers others. Merck stands out.

First study listed on CHIBE’s active research page:

http://chibe.upenn.edu/research/2013/09/09/using-social-forces-to-improve-medication-adherence-in-statin-users-with-diabetes
Funder: Merck & Co.

100 diabetics, who currently take the statins prescribed to them less than 70% of the time, will get fancy pill bottles that buzz and glow to remind. The bottles also transmit data about cap openings to the patient or a caregiver. 100 additional diabetics will serve as a control group.

Second:

http://chibe.upenn.edu/research/2013/09/09/using-social-comparison-to-improve-medication-adherence-in-statin-users-with-diabetes
Funder: Merck & Co.

This study will use peer pressure to encourage adherence to statin prescriptions. Not only that, it will mess with subjects’s heads, like so: “This study’s interventions will study the effects of feedback and information about others by varying what individuals are told about their medication adherence and how it compares to other people in the study.”

Third:
http://chibe.upenn.edu/research/2011/07/11/impact-of-medicare-part-d-cost-sharing-on-cardiovascular-medication-adherence
Funder: Pfizer, Inc.

Fourth
This study aims to evaluate the impact of Medicare Part D cost-sharing features on statin and antihypertensive use.

http://chibe.upenn.edu/research/2011/07/11/collaboration-to-reduce-disparities-in-hypertension
Funder: Pfizer, Inc.

All studies funded by drug makers were on statin compliance; all stain compliance studies were funded by a drug maker, Merck or Pfizer

Note: I veered over to this project while composing a verbal assault on the mind-feekery Dr. Rosenbaum employs in Connecting the Dots. Her manipulations and spurious logic made me dotty and I had to disconnect.

So, maybe CHIBE at U Penn is the inspiration for those inane ads that a corporation called OPTUM is running on TV – you know, the ones that tell us to fight illness with wellness, using their deep and powerful, purpose-built solutions?

The situation with statins makes Paxil for depression seem as rock-solid as appendectomy for appendicitis:

http://www.thennt.com/nnt/statins-for-heart-disease-prevention-without-prior-heart-disease/

Not to excuse psychiatry, but IT ISN’T ONLY PSYCHIATRY with this problem. In fact it isn’t only medicine. There is a lot of bad research out there. Most of it.

I saw the OPTUM wellness ad…it’s all pushing on a string.

There is a simple and effective way to promote wellness and save trillions of dollars at the same time…end the damn farm subsidies that produce cheap corn based junk food.

But we won’t do that —why? Because of the cronyism that benefits big Ag. And to be honest, because people who don’t eat right are in a state of mental inertia and would probably raise hell if local vegetables were cheaper than McDonalds.

Here is photo of a University of Alabama pep rally from the 1960s:

http://acumen.lib.ua.edu/content/u0001/2007001/0002554/u0001_2007001_0002554_2048.jpg

What don’t you see in that crowd that you would certainly see today?

If they didn’t smoke, they would be the picture of health.

So sad to see this great nation that once produced great research and great things ruined by kleptocracy.

Besides, OPTUM is so Madison Avenue. It’s a nonsense branding word that came out of a focus group, you know, like Paxil did. The sly implication of excellence is based on nothing but the corporation’s fantasy – pushing on a string, indeed.

I think the disconnect is this:

When you and I hear vapid happy talk, we cringe, but we’re a small minority. Most people eat it up.

If you go to Psych Times, you will see my reaction to the happy talk by the APA about how exciting and wonderful everything is due to all the new amazing discoveries. But I’m apparently the minority there too. Even doctors (WHO SHOULD AS SCIENTISTS BE SKEPTICS–why is this even controversial?) seem to like the happy talk.

As tough as I have been on the APA, I will give them credit for finally coming around on All Trials. I’m a curmudgeon, not a perma-curmudgeon.

Positive Psychology? Grab a beer. I stumbled on to this over the weekend.

Humiliating, you’d think.
http://blogs.discovermagazine.com/neuroskeptic/2013/07/16/death-of-a-theory/#.VVMPxH-9KSM

Apparently not.
http://blogs.discovermagazine.com/neuroskeptic/2014/08/27/false-positive-psychology-genomics/#.VVMQzH-9KSO

Thank you NIH. This is why we can’t have nice things.
(Posted by one of the de-bunkers)
http://www.homolog.us/blogs/blog/2015/01/22/horror-nih-is-now-funding-loving-kindness-meditation-of-positivity-lady-through-multi-year-grant/

Fredrickson and Cole earned doctorates as Stanford.

Bonus: Keltner, also out of Stanford, finds causality too one-dimensional
http://well.blogs.nytimes.com/2015/03/26/an-upbeat-emotion-thats-surprisingly-good-for-you/

Nit-picking on the NEJM statins piece. I didn’t want to make another 2-foot tall post so it’s in pastebin.

http://pastebin.com/Vagk9Jug