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Anger and Forgiveness"Are You There Alone?"10 Good Questions about Life and DeathA Casebook of Ethical Challenges in NeuropsychologyA Companion to BioethicsA Companion to BioethicsA Companion to GenethicsA Companion to GenethicsA Companion to Muslim EthicsA Cooperative SpeciesA Critique of the Moral Defense of VegetarianismA Delicate BalanceA Life for a LifeA Life-Centered Approach to BioethicsA Matter of SecurityA Natural History of Human MoralityA Philosophical DiseaseA Practical Guide to Clinical Ethics ConsultingA Question of TrustA Sentimentalist Theory of the MindA Short Stay in SwitzerlandA Tapestry of ValuesA Very Bad WizardA World Without ValuesAction and ResponsibilityAction Theory, Rationality and CompulsionActs of ConscienceAddiction and ResponsibilityAddiction NeuroethicsAdvance Directives in Mental HealthAfter HarmAftermathAgainst AutonomyAgainst BioethicsAgainst HealthAgainst Moral ResponsibilityAgency and AnswerabilityAgency and ResponsibilityAgency, Freedom, and Moral 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It was a distinct pleasure to read this book. The Dubovskys' message can be boiled down to a pragmatic and hopeful thesis, a plan for re-forging the relationship between academic medicine and the pharmaceutical industry. Essentially, the reality of the relationship must be acknowledged, the nature of the relationship as one of influence must be accepted, and the relationship needs to be professionalized so that genuinely useful information is exchanged. I'll explain the Dubovskys' recommendations in due course. Before proposing their solution, the authors describe the lay of the land facing psychiatric prescribers (and, might I add, all medical prescribers), in their first chapter. This is worth unpacking in some detail, since the authors appear to have distilled the essence of the problem in as clear a fashion as I've ever seen it described.
Industry, not the university, produces, tests, and markets pharmaceuticals, although at times, industry allies with academic medical departments. Principally, however, the pharmaceutical industry is a profit-driven enterprise, and it relies on marketing to achieve its aims. Prescribers are a key source of these marketing efforts, primarily through the efforts of drug detailers, who are employees of the companies they represent. To pretend that this relationship is not one of influence is naïve.
The authors also describe typical responses within academic psychiatry to the detailer-prescriber tension. The most common response has been to insist that the relationship can exist without the influence. "We prescribe based on evidence, not free chardonnay," is a common claim uttered in the halls of academic medicine, and the relationship is seldom examined more deeply than that. Medical students and residents are left to forge their own relationship with industry representatives, with little opportunity to critically reflect on the nature and purpose of that relationship. On the other side, an increasingly common, more reactionary response is to shield medical students and residents entirely from contact with industry representatives.
Both of these responses are rather astonishing in their inadequacy. As the Dubovskys explain, industry's influence is pervasive, and it is not going away. The real task before the pragmatic and conscientious prescriber is to examine this relationship, recognize its multiple purposes, and manage it to maximize its effectiveness. The physician-industry relationship is neither a symptom of all evils in the hyper capitalistic age, nor is it a benign, ultimately non-influential source of free meals and drug samples. It is a relationship, based on marketing theory, designed to positively dispose the physician toward a product. Fortunately, knowing this gives the physician the opportunity, together with the industry representative, to fashion the relationship in a professional manner. Its benefits and limitations can be recognized and managed, and it can be a factor in improved patient care. This is the Dubovskys' hopeful thesis.
The book is divided into two parts, "Fundamentals," and "Practice." Part I examines the current role of industry in academic medicine and how this came to be. Next comes a concise but thorough review of research design, including an explanation of all relevant metrics to arm a consumer of academic literature with the proper tools to analyze what is presented. A special chapter is devoted to analyzing industry-sponsored trials. The Dubovskys again take a pragmatic and plausible middle course. They do not automatically reject all industry-sponsored research as hopelessly biased and scientifically useless, a common reaction in industry-critical analyses. Instead, they arm the reader with the tools to detect bias and sift out scientifically and clinically useful conclusions.
Part II lays out a practical approach for the prescriber. For better and worse, industry funding has become the primary driver of new research. To ignore all industry-sponsored trials seems far too procrustean. Uncritically accepting them is the path of Pollyanna. The middle course of attempting to separate wheat from chaff is difficult, but it is possible, and the book's final five chapters outline a useful and realistic approach. First, prescribers need to identify and analyze appropriate studies. This is obvious.
What is not obvious is how to re-forge the relationship with industry detailers, and elucidating this is the book's crowning achievement. It begins with recognizing the basic principles of marketing employed by detailers in their relationship with psychiatrists. It is perhaps painful for psychiatrists to face the reality that they are being treated by industry representatives as means rather than ends, but living in denial about this doesn't change it. The Dubovskys outline basic marketing principles at play in the relationship, empowering prescribers through awareness. They also outline sources of influence such as direct-to-consumer advertising.
The goal of Part II isn't to shame psychiatrists or vilify industry representatives, but to encourage psychiatrists to recognize and take their power in the relationship. Seeking information, rather than food, is a good start. Not falling for typical ploys like letting grandiosity get stroked by the detailer's pseudo-deference to psychiatric expertise is another. Making it clear to industry representatives that honest sharing of both harms and benefits of medications would go a long way to improving the likelihood that psychiatrists will extend trust, rather than skepticism, toward industry. This would also benefit patients, the ultimate consumers of medications, since their physician consultants would be able to provide them with more in depth information about risks and benefits of pharmaceuticals. Professionalization of the detailer-physician relationship stands to benefit industry as well, since the crass appearance of influence-peddling with lavish dinners and speakers' fees would be replaced by a more sober exchange of information.
These are all reasonable, pragmatic recommendations. It is the realism of the Dubovskys' recommendations which breathes fresh air into a larger discussion of Big Pharma, too frequently sidelined by an easy retreat into exasperated cynicism or uneasy yet uncritical allegiance. Neither option need carry the day. Industry isn't going away, and neither is academic psychiatry. Uncritical acceptance of the status quo seems untenable, as does over reactive rejection of all efforts at a relationship. The marriage may be an arranged one, but the relationship can and must be improved. The Psychotropic Drug Prescriber's Survival Guide, is a great first step toward a better détente.
© 2008 Robert Tarzwell
Robert Tarzwell, MD, FRCPC, Clinical Instructor, Faculty of Medicine, UBC
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