Friday, June 20, 2008

The medical Thought Police target Medscape

In my post Tuesday about the growing assault on industry supported CME I briefly mentioned Daniel Carlat’s attack against Medscape. Characterizing Medscape in general as “nothing more than a CME industry voicebox” he cited a drug company supported activity titled Managing Schizophrenia in a Patient with Alcohol Abuse and Hepatic Impairment. Noting that the CME article was sponsored by the makers of one of the drugs in question (Janssen’s Invega) he pointed out that the information presented was (gasp!) favorable to Invega. After quoting at some length from the article and ranting about Medscape’s corruption Carlat made this interesting observation: “Has Janssen--I mean, Medscape--said anything inaccurate in this puff piece? No.”

What, then, is Dr. Carlat’s issue? It’s promotional (read: positive towards the drug in question) we’re told. Somehow that makes it irrelevant that the information happens to be true. I left me struggling to find a way to see his argument as anything other than an ad hominem attack.

If Carlat’s post was interesting this post at Health Care Renewal by former Duke psychiatry chairman Bernard Carroll was jaw dropping. Full of invective (Medscape’s content is “tacky” and “pedestrian”) and unsubstantiated allegations (“Some items are academic wallpaper, non-promotional pieces designed to create an appearance of commitment to education”), the post offered no examples of inaccurate CME content in Medscape. At the end, though, we got this tease:

We will examine that trope in my next posting, which features the poster boy for compromised KOLs in psychiatry, Charles Nemeroff, MD from Emory University’s
department of psychiatry. In that example, Medscape joins forces with Nemeroff to promote an entirely new level of sleaze. Stay tuned.

The sleaze, we learned in Carroll’s next post, was a Medscape expert interview with Nemeroff. In what reads like an attack piece against Nemeroff Dr. Carroll did cite some objectionable content from the interview. But this whole discussion is about CME. The problem with the example cited is that it’s not a CME offering. It is what it is---an expert interview in which the expert delivers his opinions. It makes no pretense at being anything else.

In the comment thread of his follow up post on Medscape CME Dr. Carlat said:

But regarding your opinion that most of Medscape's content is "editorially uninfluenced by sponsorship," this is an empirical question. I can't accurately scrutinize their CME offerings in say, cardiology or endocrinology, but on casual inpection they are as saturated with industry sponsorship as the psychiatry section. Hopefully, there's a cardiologist and an endocrinologist out there who has the time to put the "biascope" up to those activities as I have done in psychiatry.

If Dr. Carlat will indulge the observations of a non-academic hospitalist I’ll offer my take. First some disclosures. I have no financial ties to the pharmaceutical industry. I have written a few (non industry supported) Roundtable Discussion pieces for Medscape. I have no financial interest (as Dr. Carlat does) in providing industry free CME.

Medscape’s content spans multiple levels of scientific objectivity ranging from video rants and blog type entries to peer reviewed journal articles. Most are not offered as CME. The demarcations between these content areas are clear. I have written many blog posts with links to Medscape CME activities in the areas of cardiology, critical care and hospital medicine. These articles, by and large, are accurate and scientifically rigorous. What qualifies me to make that claim? As my readers know I regularly check the content against primary sources and, in most cases, link to those sources.

Of course I am judging Medscape’s content on its own merits. Where did we get the mindset that educational content must be judged primarily on the basis of who paid for it? If you can’t understand what’s wrong with that thinking I highly recommend Thomas Stossel’s recent commentary or, better yet, KJ Rothman’s important but long forgotten article on The new McCarthyism in science.

16 comments:

Slosco said...

Whatever.

WOW. So much of what you have written falls into the “half-truth” type of commentary. It’s really kind of funny.

Now go off and write a post about the way in which GSK falsified results in Paxil trials. Overwhelming evidence, and overwhelming evidence of harm. Or are your posts as selective as stultifyingly dull corrupted CME.

The world is just fine.

Anonymous said...

I don't know.

I've seen many, many sponsored CME events/courses/etc. that, while technically being accurate, spin information in subtle yet meaningful ways to influence physicians in ways to potentially favor a branded product.

Example:

I was doing a self study test on heart failure sponsored by an ARB manufacturer. There were a surprisingly high number of questions on the side effects of spironolactone and ACE inhibitors, to the point of it being obvious what the message was: "those two drugs have a lot of problems, and when you look for and identify them, you can then switch to an ARB easily." there was also a lot of questions about positive findings in ARB trials, not so much on the positives of ACE's and spironolactone.

Technically, all the info was true, but it was presented in a skewed and very selective way. The skew, spin, etc. is the issue here, and sponsored CME is full of it. And that is a problem.

R. W. Donnell said...

Slosco,
How carefully did you read my post? It was about Medscape CME and the need for Carlat, Carroll and others to shoulder the burden of proof for their assertions. If you can help them out by citing overwhelming evidence of harm attributable to Medscape CME or any industry supported CME, for that matter, I'd be glad to examine it.

Anonymous,
There is some selectivity of content in industry supporter CME. The same is often true for non-supported activities. That is a problem if one insists that CME activities be comprehensive. For industry supported activities, transparency of funding source combined with a modicum of intelligence and critical thinking on the part of the reader addresses the problem pretty well, I believe.

Supremacy Claus said...

The mind set is that of the left wing ideologue gotcha technique. I spent a month on Carlat's blog demanding an instance of inappropriate patient care attributable to sponsored event. I gave up. If the criticism persists in the absence of a fact of harm, that has a name. Bias. Hate speech.

The response will ultimately be legalistic. The AMA considered a ban on sponsored events proposed their ethics council.

They were promised an injunction and a class action lawsuit. They saw the light.

Carlat may serve on an APA committee to review the question of industry sponsorship for psychiatrists ethics. If they do not back off, they get the same as the AMA.

The parties on the left all have conflict of interest and hypocrisy problems. Carlat, the AMA, Harvard, the NEJM, med schools all provide CME and would be enriched by a ban. Senator Grassley is a paid off running dog attacking drug company sponsorship on behalf of his masters, Independence Blue Cross.

The opposite of this mindset is freedom. No one is forced to be in a sponsored program. No one is forced to avoid a sponsored program. This is not normative. This is the law. The First Amendment Free Speech Clause is a coin. There is the freedom to speak. And, there is the lesser known, but established freedom to hear speech.

Roy M. Poses MD said...

Absence of evidence is not the same as evidence of absence.

I presume Dr RW keeps asking for evidence that MedScape CME or commercial CME harms patients knowing just how difficult it would be to do credible research testing this hypothesis, how little support there would be for such research, and how few medical academics (given the majority seem to have significant financial arrangements with industry) would be willing to do such research.

But let me ask Dr RW: what is the evidence that MedScape CME, or industry funded CME has any benefit for patients?

R. W. Donnell said...

Dr. Poses,
To answer your question, there's no evidence that *any* CME benefits patients.

Concerning your point that absence of evidence does not equal evidence of absence, it seems to me that's shiftig the burden of proof. Shouldn't those who make the claims and call for harsh measures (which will have unintended consequences)shoulder that burden?

Roy M. Poses MD said...

I am confident that there is a fair amount of evidence, albeit indirect, and logic behind the concern that physicians' financial ties to for-profit companies that supply medical products and services affect their clinical practice, teaching and research.

I guess my colleagues and I will have to go about doing a better job marshaling it. The comments space on a blog post may not be the best place to do so. But I promise I will be writing more about this.

Keep in mind, though, that not so long ago most clinical research was sponsored by not-for-profit organizations and government agencies, and most CME was paid for by physicians, and done mainly through medical societies and academic institutions. It is only recently that most CME has come to be paid by drug/biotech/device companies and most clinical research sponsored by such companies.

So, in the recent past, the burden of proof ought to have been on those companies to show why their takeover of clinical research and CME sponsorship was a good idea. But no one was asking such questions back then.

R. W. Donnell said...

Dr. Poses,
As recently documented in a just released ACCME report there's no evidence that sponsored CME influences doctors' prescribing in any meaningful way.

On the other hand there is evidence that non-accredited promotions such as detailing and sponsored meals influence prescribing. If we ban sponsored CME I belive drug companies would divert more resources to such non-accredited activities as well as DTC advertising---one of the unintended consequences I mentioned.

Whether the influence on doctors is good or bad for patients is another unanswered question. It's as plausible to assume it's good as to say it's bad, given that some promotions are for clearly under utilized yet evidence based therapies.

Supremacy Claus said...

Dr. Poses may have missed this point from fifth grade. Or it has been erased by left wing indoctrination at some awful, Hate America, elite school.

This is America. We do not chill speech ahead of time. I refer you to Cuba, Venezuela, and the American academy, where they do that.

We punish criminal speech and compensate for tortious speech after the plaintiff has proven harm. Take your left wing, PC pre-chilling where it is welcome, but not here, in America.

Bernard Carroll said...

HARM TO PATIENTS

RW Donnell and Supremacy Claus are demanding documentation that patients have been harmed by KOLs spinning products for their corporate handlers. Documentation is not hard to come by. An excellent example is the wave of tardive dyskinesia cases that occurred in the 1970s and early 1980s among mood disordered patients who were treated unnecessarily with first generation antipsychotic drugs like perphenazine (Stelazine) and haloperidol (Haldol).

Though there was no evidence base for treating NONPSYCHOTIC mood disordered patients with antipsychotic drugs, the corporations pushed them as broad spectrum psychotropic agents, especially in primary care. The primary care docs didn’t know any better, they listened to the paid KOLs (who had no compelling evidence base) and they used these drugs liberally. Pharma marketing departments even came up with the truly stupid idea of combining an antidepressant drug with an antipsychotic drug in one compound preparation, and pushing the combination product in primary care. KOLs did their part in getting this foolish idea past the FDA. Thus were the infamous Triavil and Etrafon hatched. These contained fixed doses of amitriptyline and perphenazine.

In practice, these combinations ensured undertreatment of any significant depression, plus many cases of severe and persistent tardive dyskinesia among NONPSYCHOTIC patients with bipolar disorder and recurrent unipolar depression. We later understood that mood disordered patients and the elderly are at increased risk of this terrible side effect, as compared to young patients with schizophrenia diagnoses. In 1980 I appeared as an expert witness for the plaintiff in the first major litigation on this issue.

Now we have the spectacle of highly paid KOLs pushing second generation antipsychotic drugs for NONPSYCHOTIC depressed patients, and we have the same foolish talk from paid KOLs like Mark Rapaport about "broad spectrum" psychotropic drugs. See my recent entries on Roy Poses’ Health Care Renewal blog [http://hcrenewal.blogspot.com/2008/01/antipsychotic-drugs-for-depression.html; http://hcrenewal.blogspot.com/2008/01/variations-on-theme-of-sleaze.html; http://hcrenewal.blogspot.com/2008/06/medscapes-cme-ethics-part-ii.html.] We even have the spectacle of the Eli Lilly Company pushing the fixed dose combination called, cutely, Symbyax -- fluoxetine plus olanzapine (Prozac plus Zyprexa).

As Santayana says, those who do not learn from history are doomed to repeat it, and once again it will be the patients who are harmed. The benefit of second generation antipsychotic drugs in depression is underwhelming, while the risks of tardive dyskinesia, though less than with the early antipsychotic drugs, are nevertheless very real. That is why I chastised a lazy and compromised KOL like Charles Nemeroff so strictly last week, especially for his disease mongering (expanding the market for antipsychotic drug use to augment antidepressants) and for his reckless promotiion of the early and broad use of these drugs in NONPSYCHOTIC depressed patients. In doing so he serves his corporate handlers, whose marketing goal is the widest possible use of these problematic agents.

R. W. Donnell said...

Dr. Carroll,
I have made no attempt to defend everything the drug companies, or their opinion leaders, do. My post was about industry supported, accredited Medscape CME.

If you want to discuss the larger issue of industry support of CME I would submit that opinion leader spin in the 1970s and 80s has little to do with industry supported CME under today's policies and safeguards.

Supremacy Claus said...

Dr. D: You may not know this. Dr. Carroll is a very famous psychiatrist. He was a great leader who worked on a very early biological marker of depression, the dexamethasone suppression test. Sad to see such an eminent psychiatrist, of historic importance, involve himself in this crass partisan dispute, mucking around with the pigs. I include myself among the pigs.

Dr. Carroll does not understand the real sequence of advances in clinical care, perhaps by his inexperience treating patients to spend time in loftier pursuits.

A desperate clinician faces a desperate patient. Some innovative off label application or combination works. Word of it goes around the world in weeks. It becomes the standard of care in months. Off label uses of approved medication represent the deepest most gold laden vein of innovation at almost no cost. That we are not studying all meds for all conditions systematically represents a tremendous waste of potential for medical advances. Think of a baby aspirin, a headache pill, for the treatment and prevention of heart disease.

The best indicator of the standard of care is at Verispan, the company that tracks all prescriptions. Because doctors are most driven by patient outcomes, this data base represents the independent and simultaneous discovery of drug benefits for patients by 10's of 1000's of doctors at the same time.

Three years later, inexperienced academics decide to bet on this sure thing, run a pilot study, get a grant, carry it out, publish it. This is already 7 years after the long established and widely used discovery.

Guideline makers, textbook writers and drug companies then collect these and proceed with their agendas. However, this is now the medicine of 7 years ago, and almost no one is still doing it.

Clinicians lead, the rest follow. Neuroleptics sure are a great, long term treatment for bipolar disorder. And any suicidal depressed patient not on a neuroleptic to slow down impulsivity and intense urges has an irresponsible clinician who will prescribe these after his first suicide.

Dr. Carroll is still expressing a biased left wing opinion without a fact of harm. Has he treated a bipolar patient with tardive dyskinesia? I await his real world example of harm of a person. Even if the person has severe diaphragmatic dyskinesias, my reply would be, is patient alive or dead from the hard outcome of bipolar disorder? Thank the sophisticated, advanced clinician that kept him alive with neuroleptics for bipolar disorder.

Perhaps, I am completely wrong about neuroleptics for bipolar disorder. I suggest rebuttal with data, or even with anecdotal examples. I waited a month on Carlat. I am prepared to wait another here or anywhere else. The combination drug treatment came from the loud demands of the doctors, and not the other way around. But let's argue about it.

What is totally unacceptable is oppressive, regulatory suppression of free speech, and oppressive regulatory suppression of listening to free speech. That tyrannical approach is the way of the left. The facts deserted the left 100 years ago. Tyranny and attacks on the person are all that remain for the left wing ideologues.

Supremacy Claus said...

This point is missing from the discussion. CME itself is garbage. It does no harm. It has no demonstrable benefit. Demanding an example of a benefit is as valid as demanding an example of harm. I could not name a specific fact of benefit, just as Carroll cannot name an instance of specific harm.

CME is an unfunded mandate imposed by the clinician hater lawyer oppressor running the medical licensing boards. There is no evidence of any benefit to any patient from this massive waste of time and paper shuffling. There is no evidence the academic windbags presenting these programs know anything of value to patients. There is no evidence anyone remembers their trite, narrow, useless technical points 5 minutes after walking out. There is certainly no evidence anyone changes any practice after these programs.

This is the alternative.

A patient has some condition that puzzles the doctor. The doctor researches this condition either by looking things up, by speaking to others, or by trying a new approach. He looks up a drug interaction he has no knowledge of. What he tries makes things worse. He blogs the results so others avoid his mistake. What he does helps. He shares those results.

Because patient outcomes are compelling, memorable, and have impact on other clinicians, new knowledge taught by patient experience is the sole CME with validity.

Whether the doctor spends 1 hour a year on this process or 100 hours is no one's business. The one hour may change the course of medical history. The 100 hours may be a waste of time. Clock punching does nothing to assess the quality and impact of learning.

None of the left wing ideologues even understand what I am describing. Why? Their agenda is big government oppression to be administered by them.

R. W. Donnell said...

Supremacy Claus,
Thanks for the last comment. I have written a separate post on that topic today.

Lily said...

All these DTC ads are pushing new drugs when the old drugs or the generics are much, much less expensive. I’ve seen ads on TV for Caduet. It has two ingredients. One is Amlodipine and the other is Atorvastatin. With my RxDrugCard I can get 30 tablets of Amlodipine for $9 and 30 tablets of Simvastatin for $9. I’ll bet they are charging more than $18 for this new drug! The unthinking public is going to pressure their doctors into giving them something just because it’s new, when something old or generic would do the job for cheaper.

Supremacy Claus said...

It took 48 hours to get expelled and banned from Pharmalot, a left wing propaganda blog. I demanded the revenue of the newspaper that owns it from health insurance company advertising.

I suggested that Grassley and drug company hate sites were racists. They do not want dark skinned people on Medicaid to get better brand name drugs.

If docs used generics, there would be no campaign of destruction. When the patient is white, the dispute disappears.

Gone, with almost my messages deleted.

Reporters have no licensing bodies to receive complaints of unprofessional conduct.

I also suggested that instead of a relentless list of paper work gotchas, the left ideologue might look into the biggest story of this century. The success of medication at extending life and health, reducing surgery, and revving up the economy. No dice.