Welcome to Mind Reading, Healthland’s new series of talks with authors of “brainy” books.
Bioethicist Dr. Carl Elliott‘s new book, White Coat, Black Hat: Adventures on the Dark Side of Medicine, is a relentless exposé of bad doctoring. The book examines the pervasive and often deadly influence of money in the U.S. health-care system, covering everything from clinical trials that compromise patient safety for little scientific purpose to ghostwritten journal articles that serve mainly to market drugs. The result, Elliott argues, is a medical system in which no one is looking out for the patient.
Indeed, just today we saw a new example of this problem: a study published in the British Medical Journal found that the manufacturer of an antidepressant used in Europe (but, interestingly, not approved by the FDA) did not release data on 74% of the patients in its trials, obscuring the fact that the drug was no better than placebo.
White Coat, Black Hat can best be described as simultaneously fascinating and depressing — which is exactly what I told Elliott when I emailed him for an interview. In response, he said, “If you’re depressed, then I’m doing my job,” and added jokingly that he’d provide “free Zoloft with every purchase.”
Naturally, my first question to him was whether he had chosen to mention that brand name deliberately. “Oh yes,” he quipped. “That’s so I can collect from Pfizer.” (Elliott, a professor of bioethics at the University of Minnesota, does not take pharmaceutical company money.)
We talked about that and some other key issues he covers in his book.
Q: Do you think the medical system has become more corrupt than it used to be? There certainly is a long history of quackery and other such problems.
A: I’m 49. I graduated from medical school in 1987. My father was a doctor so I’ve been around it all my life. To be honest, it always seemed bad. But there’s definitely a huge difference between what I saw in medical school and what my father saw in the 1950s. [Mine] was an era in which the entire market-driven corporate ethos seemed to be making big inroads. There was no shame in talking about medicine as a business — and nobody even blinks now.
Q: If science is the best way that we have of knowing the world and if the most effective treatments are evidence based, but if corporate influences on the medical trials designed to provide that evidence lead to hidden or fabricated data, how can I as a health journalist advocate for relying on “science”? If the science itself is unreliable, is it better than quackery?
A: That’s what’s so demoralizing about it. We’ve gotten used to the idea that your doctor might be getting gifts and payments from industry. But once you start to look at the litigation, it turns out that the companies are spinning the data and [some articles are] ghostwritten, and all the best journals are implicated. Where do you go now? I don’t have an answer.
Q: Should we ban all industry gifts to doctors?
A: That would work for me. The problem is that medicine is largely self-regulated. There’ve been professional bodies talking about this forever, [but] it doesn’t stop just because the American Medical Association says that doctors can’t accept a gift worth more than $50.
Q: I read a study once that found smaller gifts actually have a larger influence on recipients than big gifts.
A: That would really surprise me. I have seen studies suggesting that smaller gifts like pens do have an effect but it’s hard for me to imagine that a pen has more effect than $1 million in salary.
Q: I think the idea is that if you are taking a million-dollar salary, you recognize the power of influence and try to work against it, but if you take a pen, you think, “Oh this couldn’t possibly matter.” But you secretly feel obligated to reciprocate.
A: If you talk to pharmaceutical representatives, that’s what they say. The purpose of the gift is not really a bribe; it’s to get in the door. What you want is a piece of the doctor’s time, for them to feel bad about just saying no. Once you get in the door, especially if you walk in with a couple dozen Krispy Kremes, people do feel a lot worse about treating you badly.
Q: Many people discuss pharmaceutical company marketing and “disease mongering” as if they’re always a bad thing. But don’t these efforts it also do some good in terms of de-stigmatizing disorders like depression and letting people know there’s help for them?
A: It’s good and bad. For the stigmatized illnesses, everybody would agree that people would be better off if they were de-stigmatized. On the other hand, de-stigmatizing is a huge marketing opportunity. They’re selling you the drug by selling the disease.
Q: Speaking of which, how did the drug companies manage to sell antipsychotic drugs to so many people?
A: That’s a fascinating question. If you had told me when in I was in medical school that a new version of Haldol, essentially, would become the most profitable drug in America, I would have just laughed. No one wants to take those drugs. They make you feel so bad and have such terrible side effects. I would have sworn that nobody except the most severely [ill] and desperate would agree to take them — but it’s happened.
[There were a few parts to the] strategy. One was to sell the idea of these drugs being a new kind of antipsychotic medication that don’t have the side effects of the old ones. We can now see that that’s wrong from all the litigation and the CATIE study [the Clinical Antipsychotic Trials of Intervention Effectiveness, which compared older antipsychotics to newer ones]. These drugs do have side effects, just as much as the old ones. But if you can spin and tweak and manipulate the literature well enough, as the drug companies did, you can sell that idea.
The other part is to market the drugs for other illnesses that nobody ever really thought of treating with antipsychotics. Bipolar is the big one here. Now, everybody’s got it. It used to be rare, but you can chart the rise and it goes up with the introduction of “atypical” antipsychotics. [They’re also sold] as an adjunct for depression.
Q: It seems to me that it’s also partly the result of the “war on drugs.” People are afraid of drugs like Valium because they worry about addiction, but they don’t have to fear antipsychotics the same way.
A: Yes, they are [even] used for insomnia because they’re not controlled drugs — that’s a really important point. And it’s not just patients who are [scared of addiction]. It’s doctors; they are freaked out about prescribing controlled drugs because the DEA is looking over their shoulder. If you give Valium, you have to be really careful, but you can give Seroquel and nobody cares.
Q: You write about people who make a living as human guinea pigs, going from one medical trial to another and getting paid for it. Wouldn’t that mess up the data, all the drugs they are taking?
A: I don’t know. I think what the pharmaceutical companies would say — though I’ve never actually asked — is that these are safety trials, so they are just looking at basic things [like whether or not it does harm]. As long as there is a long enough washout between trials, one shouldn’t interfere with another.
When I give talks about this, that’s always a question that some pharmacologist in the audience asks. What bothers them is the quality of the data. What *should* bother them is the exploitation of the poor, but, no, let’s talk about data.
Q: You wrote a fascinating article [excerpt] for the New Yorker about a sociopathic doctor named Colin Bouwer who faked his biography and killed his wife. Do you think there’s something about being a doctor that makes a person more likely than others to be sociopathic?
A: Not sociopathic, but narcissistic that’s for sure. I don’t think anyone would disagree, except maybe doctors! I think it has to do with the fact that from a very young age, you are told how brilliant you are and how being a doctor elevates you over ordinary mortals. If you are told that often enough, you start to believe it.