Showing posts with label Rosenbaum. Show all posts
Showing posts with label Rosenbaum. Show all posts

Saturday, May 23, 2015

Moral Bias



Lisa Rosenbaum's final installment of her three-part conflict of interest series in the NEJM is out and full text is available online for free.  My associations and observations in response to the first two can be found here and here.  As a student of bias and rhetoric, reading Dr. Rosenbaum's series has been a breath of fresh air both on its own merit, but also relative to the grim anti-industry and anti-physician bias that permeates the popular press and medical settings these days.  The hypocritical nature of many of these comments was always obvious to me, but there was only very qualified support for anyone who did not see all physicians (especially psychiatrists) as tools of the pharmaceutical industry.  But the types of moral and ethical biases that Rosenbaum highlights goes far beyond the issue of free lunch from a pharmaceutical rep.  It shakes the very foundation of a system of evaluation based on weak empirical evidence or pure politics as I have pointed out many times on this blog.  At some level it is such a stunning expansion of many of the old NEJM editorials, it seems surrealistic that these articles have been published.  But on the other hand, the page below this last article invites readers to participate in a poll on the ".....suitability of three potential authors to review articles for the Journal."  Combined with the fact that these articles have a series editor that suggests to me that this may be all part of a social media-like initiative to attract interest to the NEJM.  On that basis, I expect a full gamut of future authors including the more typical opinions equating the appearance of conflict of interest with conflict of interest and suggesting zero tolerance for contact with industry.

This article starts out with commentary on the medical school "anti-pharma animus".  The organization of American medical students apparently grades medical schools on the basis of how free from pharmaceutical company influence their conflict of interest policies and environment are.  She gives a quote from a medical student to illustrate the mind-set involved in at least some members of this movement, namely the need for "pure" information to medical students.  Some early critics of Rosenbaum's article cite this as anecdotal data but that misses the point.  Her point is that this kind of mind-set exists and it is one of a number of mind-sets that makes the ethical climate around conflict of interest an unreasonable one.  She also points out that the rhetoric associated with this statement clearly indicates that this is a moral argument and at that point the psychology of moral arguments may apply.  From the perspective of medical education, is it better to take an insular approach and suggest that all research can be assessed by looking at the funding source or should medical students be taught to read and critique research independent of funding source?  A study quoted one of Rosenbaum's previous article suggests that internists are able to look at research abstracts and classify them according to research rigor, but that the introduction of funding source forces a re-evaluation with a bias against industry funded research.

The article progresses to talk about the psychology of moral argumentation at that point and a set of arguments that I have summarized in the table above.  I think it is also instructive to address one of the early arguments about the Rosenbaum essays and that has to do with evidence and the use of evidence in arguments.  In order to look at that, it requires a quick look at the type or argument, whether it is a scientific or non-scientific argument and whether the corresponding type of evidence exists.  I think there is no doubt that Rosenbaum's arguments are moral arguments rather than scientific ones.  As such they seek to address the ethical climate around conflict of interest.

There are two aspects of the concept of ethical climate that are missing from Rosenbaum's analysis.  The first is the ethical climate as a way to control physicians.  The best example during my career has been managed care and the research that supported it.  Like today's collaborative care research, the early managed care research was focused on the idea that it was more "cost-effective" than fee-for-service or treatment as usual.  In both cases (collaborative care and managed care), the research was generally done by advocates of the proposed methods.  Thirty years later, any objective analysis on the effect of managed care on psychiatric services will show that it has been devastatingly negative.  Bed capacity has been shut down, the criteria for inpatient care is "dangerousness" rather than any specific medical indication, people are clearly discharged from hospitals based on optimizing meager DRG based payments rather than medical indications, detoxification and addiction services have practically been eliminated from most hospitals,  only a small percentage of hospitals have psychiatric services, state hospital systems have also been shut down, and the only place where psychiatric care has increased has been county jails and prisons.  That entire system wide change for the worse was based on a moral argument of cost-effectiveness rather than scientific research.  Once that ethical landscape was established physicians could simply be shouted down with the slogan: "Times have changed - you are no longer in charge."  I doubt that any physician who heard that slogan was ever in charge of anything.  It was political rhetoric, designed to elicit an emotional reaction in the people taking over and the physicians they ultimately came to control.  Nobody thought that cost effectiveness was the same thing as cost shifting to correctional systems.

The second aspect is the explicit control of physicians by managed care companies and a conflict of interest that greatly exceeds that of any other industry.   Rosenbaum's three articles are all focused on the pharmaceutical or medical device industries.  There is no mention of the managed care industry or its spinoffs, despite the fact that it controls the medical care of over 80% of Americans.  As I have consistently pointed out, the theoretical concerns of the affiliations of authors on research papers about drugs or medical devices is nothing compared with a managed care company that tells your physician that you need to be discharged from a hospital or use a particular medicine that the physician is not recommending.  In the case of psychiatric care, that company is free to make even more life altering decisions such as denying a patient with a drug addiction any functional detox services, deciding that a patient with significant suicide risks can be treated on an outpatient basis, or maintaining a person in a disabled state with minimal treatment options for a complete recovery.  The regulatory environment that concentrates that much power in an industry that can generate profits by denying care is a complex story, but it all started with an ethical environment  that blamed physicians for the high cost of health care.  That physicianscold environment has too many elements in common with the pharmascold environment to ignore.  In both cases there is a predominate moral bias that greatly oversimplifies the problem and at least in the case of managed care leads to clear long term adverse consequences.              

The good news is that these articles have been published along with the evidence that moral reasoning can be seriously flawed and associated with biases.  Rosenbaum's focus has clearly been on the relationship between physicians and the pharmaceutical or medical device industry.  She has discussed her personal experience as a Cardiologist and how it has affected her largely in terms of interventions, statin therapy, and as a potential consultant to the industry.  Psychiatry has been an easier target for the same biases and rhetoric that she lists in her article.  I pointed it out in a Washington Post article where the narrative was clearly skewed to fit the idea that psychiatry was corrupted by Big Pharma and attempting to make it easier to diagnose depression in order to sell more antidepressants.  That article included selected information to make it seem like the American Psychiatric Association was the only professional organization to make advertising profits from Big Pharma.  The suggested quid pro quo for advertising revenue should be absurd to anyone familiar with advertising but it was not to this reporter.  But the real issue was that the DSM does not recommend treatment anyway and the majority (80%) prescribers who treat depression don't use a DSM-5 or even care about what it says.  Less formal approaches adopt a similar scolding moralistic tone toward psychiatry that is possible only by ignoring the deficiencies in other medical fields and idealizing them while devaluing psychiatry.

I think that Rosenbaum's articles are must reads, especially for psychiatrists who may be unfamiliar with rhetoric, moral reasoning, and politics.  That may be why physicians in general have been inept in mounting any kind of a counterattack against political strategies that work by changing the ethical climate.  These articles provide some points for discussion.   Watching the counterattacks will also be instructive.      


George Dawson, MD, DFAPA

1: Rosenbaum L. Beyond moral outrage--weighing the trade-offs of COI regulation. N Engl J Med. 2015 May 21;372(21):2064-8. doi: 10.1056/NEJMms1502498. PubMed PMID: 25992752.

Sunday, May 17, 2015

Bias Cuts Both Ways






















Lisa Rosenbaum's second article (1) in a series of three appeared in the New England Journal of Medicine this week.  It continues the theme that bias is more complicated than following the money (or pens or pizza slices).  It was interesting to note the response to the original article.  On at least one blog a poster apparently Googled Dr. Rosenbaum in order to point out all of her potential conflicts of interest.  It probably would have been more relevant to look at the standard International Committee of Medical Journal Editors disclosure form on file at the NEJM.  But it does provide a good example of one of the references in this week's piece - financial disclosure (or in this case suspicion) as an ad hominem approach to evaluating science.  In a similar vein, one of the authors of a previous NEJM editorial pointed out that the science has to stand on its own merit independent of disclosures or credentials.

The initial part of the article points out a fact that has always seemed pretty obvious to me.  Association is often used to suggest that there are significant meaningful conflicts of interest.  The oft quoted statistic is that 94% of physicians have "relationships with the industry".  This includes counting drug samples or donuts in the workplace as a significant relationship.  One of my previous employers decided that all hospital employees should participate in "donut rounds" and not just the physicians.  I viewed this as a pseudo-egalitarian managed care tactic, but by definition that means that 100% of the employees at that hospital had a "relationship with the industry".  The article also points out that physicians who request drugs be included in a formulary are also more likely to have industry relationships than not.  I have a history of being on two separate Pharmacy and Therapeutics (P&T) Committees of a major healthcare system and a major hospital where the overriding biases were drug cost and deals with pharmaceutical companies.  There were major changes on a year to year basis due to price differences in the cost of commonly prescribed drugs and they were often based on the flawed assumption that all drugs in the same class are equivalent.  On the other hand if an exclusive deal could be made, that company might also be able to combine that with a preferred deal for a more common drug.  It was a curious situation where decisions that were supposed to be science based were not.   The P&T Committee was biased by the managed care industry operating strictly on a cost basis.

I decided to part ways with the P&T Committee on the day we were presented with forms to fully disclose all of our finances to assure there were no conflicts of interest.  The usual hype about how we were all cherished guardians of the public trust was included.  I thought about it for a second and looked around the room.  There were approximately 15 MDs and 4 PharmDs on the committee.  Some of the brightest and most well read staff in the organization.  I ran the hypothetical through my mind: "What are the odds that if I owned stock in XYZ Pharmaceutical that I could convince my 20 colleagues that it was a good idea to put their most expensive drug on the formulary just based on my word?  What are the odds that I could overcome the predominate bias of the financial well being of the company that employed all of us?  What are the odds that if I accomplished those first two unattainable goals that I would actually see a profit in my XYZ Stock?"  I also thought about the drug approvals that we did based solely on public relations considerations.  Drugs that were practically worthless, but that were demanded by advocates for incurable diseases.  The explicit decision was that we did not want to run afoul of some of the very vocal advocates for those illnesses.  It would be bad public relations and press.  I looked back at the 5 page disclosure form and decided that I was not going to play that game.  I was not going to pretend for one second that I needed to be vetted by an organization that apparently saw itself as destined for sainthood.  I walked away at that time.  I had long been familiar with the other bias listed in the Rosenbaum article and how any disclosure at a CME presentation could result in mockery or discreditation.  It is difficult enough to present the pertinent information to an audience who may want to be entertained without being the butt of jokes as a sponsored presenter.  Any way you look at it my behavior was a reaction to a modern day witch hunt mentality and I was not about to be declared a witch.  Even beyond that, I was not the only "clean" person in the room.  Getting heavy handed about a conflict of interest disclosure as a public relations gimmick after many of us had already figured it out 20 years ago was more than a little insulting.

Rosenbaum also discusses a previous study from the NEJM (2) that as far as I can tell has not received press anywhere else.  In this study, the authors designed identical fake clinical trial report abstracts of studies with varying methodological rigor.  The studies had three possible funding disclosures - the pharmaceutical industry, the NIH or none.  In this experiment the internists involved in the study were less likely to read the entire report, less likely to prescribe the study medication, and less likely to see the experiments as rigorously conducted if they were sponsored by industry rather than the NIH.  They were half as likely to prescribe medications recommended in an industry sponsored trial than an NIH sponsored trial.   The authors were naturally concerned that physicians would be skeptical of even high quality but industry sponsored trials and that might slow the acceptance of that information in clinical practice.

In an interesting study done by the industry that same year,  a team (3) at the biotechnology firm Amgen  examined 53 studies that were considered to be 'landmark' preclinical studies in the field of oncology.  The goal was to see if they were reproducible.  The findings could be confirmed in only 6 or 11% of these papers.  The non-reproducible research led to hundreds of secondary articles and in some cases led to research that exposed patients to agents that resulted directly from the original research.  A team (4) at Bayer HealthCare did a similar review of preclinical studies to identify potential drug targets and concluded that only 25% of the work was reproducible.   That same article referenced the general industry rule that up to 50% of published results from academic settings cannot be reproduced in an industrial lab.  The Amgen and Bayer HealthCare studies suggest that is really an underestimate of what amounts to academic bias.  A common criticism leveled by Big Pharma critics is that they have benefited from all of the taxpayer funded basic science research at the NIH.  These studies suggest that there are plenty of problems with that research independent of funding stream and that they are less rather than more likely to lead to drug discovery.

In addition to unique information to examine the issues of bias (the author lists many more),  she also points out the origin of the word Pharmascolds (5) as those who "vilify the medical products industry and portray academics working with it as traitors and sellouts".  The authors here describe an inadequate public response from both the companies and the physicians who were criticized.  The full text of the reference is available online.

This is another highly informative article by Rosenbaum which demonstrates that analyzing conflict of interest is not as easy as some members of the press and some professional critics make it out to be.  She gives a great example of an 85 year old woman who needs an aortic valve replacement and what the considerations might be based on the characteristics and biases of two different Cardiologists assessing this situation.  It is even more complex in a setting where some would be quick to refer the woman to a hospice service.  In my experience outlining all of the potential biases in that situation is a significant task and one that few physicians would attempt.

Some day a more measured discussion of conflict of interest might provide a better approach.  Until then be skeptical of any critics who suggest that it is inappropriate for a physician to have a relationship with the pharmaceutical or medical devices industry just based on the face of it.  And for any physicians out there who want to take the most conservative path to avoid unwarranted criticism, stay out of the Sunshine Act database.

        


George Dawson, MD, DFAPA        
                   

















1:  Rosenbaum L. Understanding bias--the case for careful study. N Engl J Med. 2015 May 14;372(20):1959-63. doi: 10.1056/NEJMms1502497. PubMed PMID: 25970055.

2:  Kesselheim AS, Robertson CT, Myers JA, Rose SL, Gillet V, Ross KM, Glynn RJ, Joffe S, Avorn J. A randomized study of how physicians interpret research funding disclosures. N Engl J Med. 2012 Sep 20;367(12):1119-27. PubMed PMID: 22992075.

3: Begley CG, Ellis LM. Drug development: Raise standards for preclinical cancer research. Nature. 2012 Mar 28;483(7391):531-3. doi: 10.1038/483531a. PubMed PMID:22460880.

4:  Prinz F, Schlange T, Asadullah K. Believe it or not: how much can we rely on published data on potential drug targets? Nat Rev Drug Discov. 2011 Aug 31;10(9):712. doi: 10.1038/nrd3439-c1. PubMed PMID: 21892149.

5:  Shaywitz DA, Stossel TP.  It's time to fight the 'pharmascolds'.   Wall Street Journal.  April 8, 2009.    http://www.wsj.com/articles/SB123914780537299005 accessed on May 17, 2015.