Monday, February 02, 2009

Billy Rubin’s unmitigated gall

One of the blog reactions to our recent Medscape Roundtable on pharmaceutical industry support for CME came from the new pseudonymous blogger, researcher, ID doc and part time hospitalist Billy Rubin. (Not to be confused, mind you, with this Billy Rubin). An ad hominem attack and the straw man played tag-team against me to produce some entertaining reading but, unfortunately, a misrepresentation of my section of the Roundtable.

Before I get to the ad hominem I should note that perhaps I started out on the wrong foot with Dr. Rubin in my choice of words. It was my characterization of the relentless hunt for corporate evil in every nook and cranny of medical education and the associated non-evidence based fear mongering as a McCarthyesque purge. OK, it was a little strong. It was intended to grab the attention of folks on both sides of the debate. I smiled when I wrote it. But it must have pushed Dr. Rubin’s choleric button and released some bad humors. It sent him off him on a rant and apparently so rattled him that, suddenly, all self reference shifted to the third person:

Then comes the whammy: The opportunities for continued learning are now better than ever due to the development of the Internet. Unfortunately, there is a movement afoot to limit those options. A growing McCarthyesque purge seeks to restrict our educational choices by banning industry support of continuing medical education (CME).

"McCarthyesque purge"?! Under the category-heading for inappropriate allusions, Doctor Rubin thinks that this statement may likely not be supplanted from its perch for the remainder of 2009. He would point out in detail the foolishness of the historical comparison, but prefers to think it speaks for itself and he has other fish to fry forthwith.

One more thing before I get to the ad hominem. In his opening section Billy asks this very important question:

So who would you want in charge of ensuring this education?

My personal answer to that question, as should be the answer of all practicing doctors, is I want to be in charge of my own education. With the help of self assessment tools such as MKSAP and Harrisons board review I am in a better position than some outsider from the medical thought police to make the best educational choices. Surveys find that the vast majority of doctors also feel that way.

He goes on:

You would think that professional societies, without any affiliations to for-profit companies, would arrange and direct the overwhelming majority of CME activities, but it just ain't so. As of 2001, drug companies paid over sixty percent of the costs of CME, and it does not appear the number is dramatically declining.

The implied premise is that because drug companies help pay for CME they control content. That premise is simplistic. It was partially true 20 years ago, but is much less so today. Gone, for example, are the one company, one drug topic, one speaker restaurant events (they still take place, but they’re no longer accredited). Given that drug company support does influence content to a limited degree even in today’s tightly regulated environment the person in charge is still you, the user. You make the choice. If you want to base that choice on the litmus test of whether the activity in question has industry funding that’s fine. Better that than outsiders making the decision for you. Be assured, though, that if the purge wins you will not be in charge of your CME.

Now on to the ad hominem attack, which was aimed at all four authors. Dr. Rubin wrote (my bold):

None of the four appear to have any expertise in the matter, at least by what Medscape reported about them. Dr. Rubin has no particular problem with non-expert physicians airing their thoughts on medical matters--he is one such non-expert doing so right now--but he does have a problem when the authors are leading a roundtable discussion on a website read by thousands of physicians around the country. Can I huff and puff in my blog? Sure. But I might not be the best person to speak with authority in a more formal setting, unless I had done a good deal of homework beforehand. And it's quite clear from reading the posts that nobody had done a great deal of homework, pro or con.
Authority? Had Dr. Rubin taken a moment to check the background of the Roundtable and find out what it is and purports to be it would have been clear that the series is little more than a soap box (and a very informal one at that) where doctors, medical students, residents and nurses can air out opposing views. No authority or status is implied. If Dr. Rubin wants to make an issue over whether a bunch of bloggers should huff and puff in front of Medscape’s larger audience, I suppose we can debate that some day.

Having thus (what do these non-expert bloggers know anyway) framed the discussion Dr. Rubin goes on to the straw man. Here are some of the positions I did not take, which Dr. Rubin nevertheless attributes to me, then holds up for ridicule:

There's just no evidence that it influences physician behavior in ways beneficial to drug companies! (“It” being commercially supported CME).

To begin with, I made no such statement. Although the proof that CME has any influence on doctors whatsoever is slim let’s hope CME influences doctors just a bit. Otherwise there’d be no point in CME at all. If, of course, I believed CME was pointless I would never have bothered to write the Roundtable piece in question. Taking for granted my position that CME does influence doctors in some way the strong inference is that at least part of the content would be favorable to the use of drugs in some manner.

Physicians just aren't that credulous!

Well, that’s part of what I said. Here’s what I actually said:

Unable to marshal evidence to support their proposal, the proponents of the ban have appealed to a set of beliefs. One such belief is based on the caricature of a credulous physician incapable of critical appraisal of educational content.

A few paragraphs farther down is where Dr. Rubin’s partial representation of this point deteriorates to the level of the straw man:

His last point, one that Doctor Rubin hears time and time again when he chooses to discuss this matter with various colleagues (though truth be told he has learned which colleagues are like-minded on this matter, and tends to avoid the remainder lest he lose his control in public), is perhaps the most precious of all: I'm not biased! Maybe everyone else is, but not...incredibly smart, skeptical me!

Try as I might, reading and re-reading the piece, I just can’t seem to find that particular “last point.”

What gives Dr. Rubin license to make such misattributions? He tells us in his last paragraph (my bold):

Oddly--well, actually, not oddly at all--the real argument running beneath these rationalizations is virtually never spoken of. It's pretty simple, actually, and Doctor Rubin, despite his immense respect and affection for the vast majority of his colleagues, has heard that silent-yet-powerful argument since his early days in med school. The "argument," such as it is, is this: I am a physician and that entitles me to nice things.

Well, I think it is a little odd that Dr. Rubin can hear arguments that aren’t even being expressed. (By the way, although I am biased and at times a little credulous I do confess just a tad of skepticism regarding that particular claim).

But the pièce de résistance comes not from Dr. Rubin but from one his commenters, who wrote:

The Medscape article critiqued here would not have survived editorial review by the Medscape Nursing editors, in my opinion. Physicians, have you written to the editorial director of the Medscape Internal Medicine Web site to request that the article be removed from the site? If not, here is the editor’s contact information…

Wow. When you dislike someone’s opinion piece just petition the editor for a retraction. Wonderful idea.

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