On August 20, 2014, Psychiatry Advisor published an article on its website. The article was written by Leslie Citrome, MD, a professor of psychiatry at New York Medical College in Valhalla, NY, and a member of the Board of Directors of the American Society of Clinical Psychopharmacology. The article is called Is Bias Against Pharma-Funded Research Fair? This is an interesting title, because bias, by its very definition, is unfair. So the very wording of the question begs the question – which strikes me as unfair. But let’s put that aside.
Dr. Citrome begins by introducing the term “pharmaism” (anti-pharma prejudice). He tells us that:
“Pharmaism includes the implicit belief that people associated with pharmaceutical companies are more likely to be intellectually and morally dishonest than others.”
He provides two examples of pharmaism:
The fact that medical journals insist on independent statistical analyses of research submitted by pharmaceutical companies.
“…the lay media singling out health-care professionals who earn money by contracting with pharmaceutical companies for professional services…”
Dr. Citrome predicts, with apparent misgivings, that the media’s activities in this area will increase when the Physician Payments Sunshine Act’s provisions take effect on September 30.
So, as you can see, the article is off to a good start. Medical journals that insist on independent statistical analyses of pharma-conducted research are displaying prejudice against pharmaceutical companies. And we even have a name for this prejudice – “pharmaism,” akin, presumably to racism.
But, wait! There’s an important difference. Racism refers to prejudice or discrimination against another person, or group, based solely on race or skin color. But medical journals that insist on independent statistical analyses of pharma-conducted research are basing this policy decision on the fact that, in a compellingly large proportion of cases in the past, the statistical analyses of pharma-funded research was flawed. And, by an extraordinary coincidence, was always flawed in a direction favorable to the company!
What Dr. Citrome is trying to do is rescue both pharma and the psychiatrists who accepted their largesse, from the consequences of their venality. Psychiatry maintained its corrupt relationship with pharma for decades. The dynamics were simple. Pharma provided the money; psychiatry provided the fraudulent research, the medical licenses, and the prescription pads.
But now the hoax has been exposed, and corrective measures have been taken. And Dr. Citrome is crying: foul! You people are just pharmaists! A nice piece of spin, which, incidentally, in prison populations is called “flip the script”.
To find a psychiatrist using a ploy that is popular among prison inmates is not all that surprising to me. But, you see, I’m a pharmaist – so what can you expect?
Incidentally, the term pharmaism was actually coined by Dr. Citrome, himself, and James Karagianis, MD. Here’s a quote from the June 2014 issue of The International Journal of Clinical Practice editorial Pharmaism: a tale of two perspectives, by L. Citrome, et al.
“The term ‘pharmaism’ (or ‘pharmism’) has been used informally by two of us (JK and LC) and we were both surprised and pleased that another person has used it in an editorial…and to the best of our knowledge, marks 2013 as the year that this word has first been used in a scholarly publication.”
So Dr. Citrome and Dr. Karagianis are clearly pleased with themselves for this lexicological invention, and, presumably, with the verbal chicanery that it entails. Or perhaps they’re blinded by truthism, a prejudicial aversion to facing facts.
Incidentally, Dr. Citrome’s and Dr. Karagianis’s full definition of pharmaism is given in the IJCP document quoted earlier. Here it is – read carefully:
: a belief that being associated with a pharmaceutical company is the primary determinant of human traits and capacities regarding scientific discourse and that not being associated with a pharmaceutical company produces an inherent superiority regarding moral and intellectual standing free from bias
: prejudice or discrimination
This is doctoral level spin, without a doubt. They begin with the notion that many people are distrustful of pharma-funded/conducted research. They convert this distrust, which incidentally is well-deserved, into a prejudice, and – and this is the rabbit in the hat – they give it a name and a definition. But note how the phenomenon of warranted distrust has morphed into something truly obnoxious by the simple expedient of inventing a word and a definition to go with it. Warranted and appropriate distrust has now become a belief,
“…that being associated with pharma is the primary determinant of human traits and capacities regards scientific discourse…”
Has anyone on this side of the debate said this, or anything even remotely like this? What we do say is that pharma influence and money has in the past corrupted a great many psychiatrists, in both academia and clinical practice, and that it is prudent to be cautious and skeptical of pharma-funded research and advertizing. Note that Drs. Citrome and Karagianis don’t dispute this. Instead, they create this inane caricature of our position, and critique that, as if it reflected the position on this side of the issue.
And the second part of the definition is even worse:
“…not being associated with a pharmaceutical company produces an inherent superiority regarding moral and intellectual standing free from bias”
Again, has anyone said this, or even suggested it? Certainly pharma’s deep pockets, and their willingness to spread largesse, has created an environment in which a great many psychiatrists have been corrupted. But the notion that a lack of contact with pharma will produce the opposite result is simply absurd.
But back to the Psychiatry Advisor article. Dr. Citrome concedes that:
“Some of the attitudes behind pharmaism have origins in the sins of the past. This includes the deliberate withholding of data, questionable promotional tactics, and rewarding high-volume prescribers. Despite substantial changes in how pharmaceutical companies do business, there is much in the way of lingering suspicion that deceptive practices continue unabated.”
Let’s take a look at that last sentence and the embedded link. Despite “substantial changes in how pharmaceutical companies do business” there is still suspicion of deception.
I suggest that most people reading this would presume that the “changes” mentioned were of the cleaning-up-one’s-act variety. And, I further suggest that most people on opening the link would expect to find some account of this clean-up, e.g. publishing the results of all trials, rather than cherry picking those with favorable outcomes, making all relevant data available to outside scrutiny, etc…
But actually, this is not the case. The link is to a brief article in HealthDay News titled Pharma Sales Reps Finding Access to Physicians Increasingly Difficult (author unnamed). The gist of the article is that according to a report from ZS Associates, a New York-based marketing consulting firm, there has been a steady decline in drug reps’ access to physicians. The only changes on the part of pharmaceutical reps mentioned in the article is greater reliance on “digital communication channels.” Rather than on face-to-face visits, which were the norm in the past.
In particular, there is nothing in the article that might be expected to allay the lingering suspicion concerning pharma-funded research.
So what Dr. Citrome has done is imply that pharma has cleaned house, pretended to provide a supporting reference, and then directed criticism at us pharmaists for retaining – in typically bigoted fashion – our lingering suspicions concerning the integrity of pharma researchers and those psychiatrists who sup at the same table.
And then the Crown Jewel:
“Separating the facts from the rhetoric takes some effort…”
Dr. Citrome, that is, indeed, the case!
He then refers us to “…an excellent summary of the issues…” This links to an article by Thomas Stossel, MD, et al in the June issue of The International Journal of Clinical Practice, After 20 years, industry critics bury skeptics, despite empirical vacuum. Dr. Stossel is a professor of clinical medicine at Harvard, and a division director at Brigham and Women’s Hospital.
Here’s the conclusion section of that article, quoted in full:
“As this review reveals, the conflict of interest movement has failed to substantiate its central claim that interactions between physicians, researchers and the medical products industry cause physicians to make clinical decisions which are adverse to the best interests of their patients. After 20 years of impugning the motives of industry and demeaning the professional judgment of physicians, the instigators have failed to produce solid evidence of harm commensurate with their extravagant allegations. At the same time, they have diverted resources away from more worthwhile pursuits, such as basic and applied medical research, clinical care and medical education towards onerous compliance exercises and obtrusive laws and regulations. They have propagated an availability cascade that projects the superficially plausible message that the medical products industry is coopting patient care by corrupting physicians and researchers. Perhaps worst of all, they have made it respectable to ignore the epistemological foundations of medical science, diverting attention away from the scientific merit of the information presented and focusing it instead on the identity and motives of those who present the information.”
A full critique of this article would take us too far afield, but the essential points of the piece are:
- The conflict-of-interest (COI) movement has not proven that physician ties to industry have actually harmed patients.
- The COI movement has created an environment where information is judged more by the motives of the presenter than by its actual merits.
It’s an interesting, if one-sided, article. Note some of the language in the conclusion:
- the “instigators” [in the COI movement];
- their “extravagant allegations”;
- “onerous” compliance “exercises”;
- “obtrusive” laws and regulations;
- the “superficially plausible” message.
And the image of the COI movement “diverting attention away from the scientific merit of the information presented” is a far cry from the reality – at least in the psychiatric field –where an eminent researcher at a prestigious university is actually on record as promising a pharmaceutical company a positive result for their drug if they would pony up at least $700,000 for a center on pediatric bipolar disorder at Harvard’s Massachusetts General Hospital.
And incidentally, according to an Editorial in Endocrine Practice, November/December 2009:
“Dr. Stossel is a founder and director of, consultant to, and owns stock options in Critical Biologics Corporation to which his employer, Brigham & Women’s Hospital, has licensed his inventions; he is a director of and owns stock options in Velico Medical Corporation to which Brigham & Women’s Hospital has also licensed his inventions; he currently serves as a consultant to Pfizer.”
But getting back to our psychiatrist, Dr. Citrome, it is clear that he loves the article and he finishes with an upbeat quote:
“Consulting for and collaborating with industry to facilitate the development of new treatments, informing practitioners about new treatments, assisting in conducting clinical trials are all activities that can ultimately benefit patients.”
The most notable feature of Dr. Citrome’s article is the fact that it got written at all. Psychiatry’s corrupt relationship with pharma has been a dominant feature of the profession for the past 40 years. It is a legacy of the most profound shame and ignominy, which psychiatry made no attempt to correct, until outsiders such as Senator Chuck Grassley, of Iowa, who is probably a pharmaist, began to expose these practices. Pharma-psychiatry corruption was widespread, and existed in both academia and in clinical practice. Deliberately tainted pharma research was promoted, not just in professional circles, but also to the general public. Tawdry pharma adverts in psychiatric journals and in the general media promoted the chemical imbalance lie, and turned dangerous psychiatric drugs into blockbuster products. For instance, between 1997 and 2007, the number of Americans taking neuroleptic drugs increased from 2.2 million to 3.9 million, bringing the promise of brain shrinkage, tardive dyskinesia, akathisia, and an assortment of other adverse effects to an additional 1.7 million people! Most of this increase was the result of cooperative psychiatric researchers “discovering” new uses for these products, especially among children and older people.
As in so many areas, psychiatry has no answers to the criticisms it faces. So it resorts to spin; in this case, vilifying the conflict-of-interest movement.
For decades, psychiatry went unchallenged. Those few of us who drew attention to the spuriousness of its concepts, and the destructiveness of its “treatments” and its corrupt ties to pharma, were marginalized and ridiculed. We were parodied, and asked if we also believed in witches!
Psychiatry had the backing of pharma dollars, and seemed unassailable. They neither listened to, nor cared about, voices of dissent. Theirs was the arrogance of the true believers, and they had the pharmaceutical cash register receipts to prove that they were correct.
Then something happened. The bubble burst. The scales fell from the eyes. The Emperor’s nudity was recognized, and psychiatry has no response other than spin. And that’s what we’re seeing in Dr. Citrome’s article: the COI movement is doing more harm than good!
And, incidentally, at the end of the article, the disclosure states:
“In the past 36 months, Citrome has engaged in collaborative research with, or received consulting or speaking fees, from: Alexza, Alkermes, AstraZeneca, Avanir, Bristol-Myers Squibb, Eli Lilly, Forest, Forum, Genentech, Janssen, Jazz, Lundbeck, Merck, Medivation, Mylan, Novartis, Noven, Otsuka, Pfizer, Reckitt Benckiser, Reviva, Shire, Sunovion, Takeda, Teva and Valeant.”
And just to make my epistemological position clear, I do recognize that a person could have all these ties with pharma and still be objective on these issues. That’s logic 101. But I also recognize that there are strong incentives not to bite the hand that feeds us. That’s psychology 101. Actually, it isn’t even that. It’s just common sense.