In the past few months, books about the medical profession have moved onto my reading list for a couple of reasons:
- Although ObamaCare is on life-support, America will need to replace it with something, and no one seems to know what that replacement should look like.
- My son Mikey will become an M.D. next month, and I want to understand what he’s getting into.
I was hopeful that White Coat, Black Hat would improve my understanding of modern medicine, and I wasn’t disappointed. The book, which is subtitled Adventures on the Dark Side of Medicine, is a current look at bioethics.
Bioethics is the study of controversial ethics brought about by advances in biology and medicine. The author Carl Elliott, who has a medical degree and a doctorate in philosophy, is well qualified to expound on the subject. The book consists of six chapters, each of which discusses an issue that troubles Dr. Elliott.
Chapter One – titled The Guinea Pigs – concerns the subjects of medical research. Most of the chapter focuses on (a) the economics involved in getting people to submit to becoming guinea pigs and (b) the sometimes inadequate protections to ensure their safety. The chapter included an interesting history on a group of WWII conscientious objectors who volunteered to (a) gargle pneumonia-infected sputum, (b) wear lice-infested underwear to contract typhus, (c) allow mosquito-filled boxes to be strapped to their bellies so that they would get malaria, and (d) be placed on semi-starvation rations for six months in order to understand how to treat malnourished citizens in liberated countries in Eastern Europe. Talk about taking one for the team.
Chapter Two – titled The Ghosts – concerns the fact that most academic papers are authored by ghostwriters working for pharmaceuticals, with the role of the academic person limited to editing and signing. This practice is widely accepted because the writing is so technical, with no real pride in authorship. Dr. Elliott seems more concerned that these ghosted papers play a large role in the professional advancement of the academic person working under the adage of “publish or perish.”
Chapter Three – titled The Detail Men – concerns the role of the pharmaceutical representative. The term “detail” is a historical term that means to give a doctor information about a company’s new drugs with the aim of persuading the doctor to them. I was especially interested in the discussion of whether the detail man’s freebies are effective – the possibility of which doctors reject out-of-hand because there is no possibility “that physicians are so weak and lacking in integrity that they would sell their souls for a pack of M&M candies and a few sandwich and doughnuts.” Of course, as the author points out, the pharmaceuticals wouldn’t be giving away things if the gifting wasn’t effective, and studies confirm this.
Chapter Three also contains a description of the improved reporting on each doctor’s prescribing habits. This information is widely available to pharmaceutical reps, and this prevents doctors from inaccurately assuring the reps that the doctors are or will prescribe the rep’s drugs.
Chapter Four – titled The Thought Leaders – concerns the role played by key opinion leaders (KOL) “in managing the discourse around a given product – a discourse that is equal parts scientific study, commercial hype, and academic buzz.” As I was reading this chapter, I started thinking about Malcolm Gladwell’s book, The Tipping Point, and sure enough, the author inserted a quote from The Tipping Point – “Ideas and products and messages and behaviors spread like viruses do.” This chapter focuses on the pharmaceutical practices for identifying, cultivating, and harvesting of KOLs. The author does not use the analogy of a whore and her pimp.
Chapter Five – titled The Flacks – concerns the role played by the public-relations person. The author uses the analogy of the Volkswagen flack who was charged with selling a $70,000 luxury VW Phaeton to VW constituents who generally are “creative, environmentally sensitive liberals who are concerned about social justice… read the NY Times, listen to NPR, and shop at Whole Foods.” Not that there is anything wrong with any of that.
I especially enjoyed the author’s discussion of branding – no, not branding of the drug, but branding of the patient’s disease. Among the flack’s techniques:
- Portray the condition as common, yet underdiagnosed. For example, clinical depression.
- Destigmatize a shameful condition. For example, urge incontinence becomes overactive bladder.
- Direct-to-consumer (DTC) advertising. The AMA reversed its opposition in 1992, and in 1997 the FDA relaxed its warning requirements that had essentially precluded TV ads.
Chapter Six – titled The Ethicists – discusses the author’s fear that ethicists like himself are becoming whores to the pharmaceutical industry. Much of the chapter concerns institutional review boards (IRBs), which are “the committees responsible for overseeing the ethics of medical research in the United States.” Historically, IRBs have been academically based, but now many are for-profit, and they seem plagued with the same conflict-of-interest that caused the rating agencies like Moody’s to contribute to America’s financial meltdown in 2007-8.
Although the book contained an Introduction and a “Coda,” there is essentially no beginning or end; only six distinct chapters. My conclusion is that pharmaceutical industry is analogous to the energy industry in that its immense profits are being lavishly deployed to ensure that those profits keep coming in. The difference is that the pharmaceutical industry must work with the medical profession, and maximizing profit should never become the number one objective of a profession. But sometimes it becomes a close second.