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29th May 2016
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The Persecution of Heretics

Tuesday 23rd September
Dissenting doctors are being intimidated into silence. Here's how it happens.
David Healy | Professor in Psychological Medicine, critic of lack of neutrality on psychotropic drugs

Crucifixion

Behind medicine's apparent Biblical authority lies an inquisitional apparatus aimed at silencing dissent. It is run by corporate PR and scientific planning agencies, backed by academic expertise, and its aim is to ensure that prescribing doctors keep on prescribing. The heretic ends up in the broad light of day, but the persecutor hides in the shad...

Behind medicine's apparent Biblical authority lies an inquisitional apparatus aimed at silencing dissent. It is run by corporate PR and scientific planning agencies, backed by academic expertise, and its aim is to ensure that prescribing doctors keep on prescribing. The heretic ends up in the broad light of day, but the persecutor hides in the shadows.

I should know. In a lecture for IAI, I outlined some of the many things that can be done to intimidate doctors – especially those who suggest that a brand-name drug might have significant adverse events. At the time the talk was being given I was being referred again to the General Medical Council (GMC). Further details of this will be announced soon. Readers will be invited to work out who is attempting to commit the murder, with what, and why.

In this case is it the local health board, clinical colleagues, the relevant Royal College, the GMC itself, one of the major pharmaceutical companies, or even the Government?

 

A brief history of medicine

For millennia we have struggled with death and disease. In the 1950s there was a huge increase in the number of truly effective medicines, and this has played a part in improving life-spans and quality of life, in particular among children. These new drugs supported the creation of the National Health Service: effective treatments make populations healthier and more effective at work, so the provision of services offering such treatments makes a country better able to compete with others.

Although most new treatments emerged without a clinical trial in sight, following the thalidomide crisis in 1962, clinical trials were put in place as a way to evaluate treatments. The established wisdom now is that clinical trials reveal the truth about medicines – they are the gold standard method of evaluation – and that once a trial confirms that a drug works, doctors should prescribe it. Guidelines should enforce it, and health systems should make these treatments available at whatever cost as, if effective, they essentially pay for themselves.

Another safeguard put in place was the the creation of a prescription-only status for medicines. This was designed to control addicts, but eventually all new drugs became available on prescription only. This puts doctors very clearly centre stage.

The view that medicine should be evidence-based and that doctors should adhere to the evidence has become increasingly solidified in recent years. Linked to this, an ever increasing proportion of the population is on an ever greater number of medicines for ever longer periods of time. Meanwhile, treatment-induced death has become one of the three leading causes of death.

It now takes decades before doctors recognise a link between life-threatening events and treatment, where such recognition used to be much quicker. Randomised controlled trials have become the gold standard way to hide adverse events and their blind adoption is arguably a mistake of historic proportions. Latterly with the realisation that clinical trial data has been concealed there has been more of a push for access to clinical study reports – a company’s account of what its study shows. Doctors and researchers apparently don’t want to or can’t be trusted to have access to patient level data for reasons of confidentiality.

The medical literature has become ghost-written. Close to the entire literature stemming from clinical trials of on-patent drugs is ghost-written and the raw data from those trials is inaccessible. Nobody – not even the regulators – gets to see it.

The National Health Service, meanwhile, is on its way to being transformed into a system to deliver clinical trial patients to pharmaceutical companies.

 

Physician, heal thyself?

In the face of such observations, the standard response from medicine has been that the problems lie within the pharmaceutical industry. The only issue for doctors, they say, is one of occasional conflicts of interest, and this problem can be solved if doctors declare any conflicts they have. Doctors are good people who are trained to make sure you get the right treatment and the GMC takes care of those few doctors who might pose a risk to your health.

In fact, it is extraordinarily easy to intimidate doctors. One simple clinical misstep can lead to a complaint and an action against a doctor. And clinical practice inevitably gives rise to missteps. Once it does, the GMC can be used as a weapon to silence dissent. Wonderful though the GMC can be, its role is asymmetric. It will not take action against doctors working for pharmaceutical companies who put out grossly misleading information about the lethal hazards of the latest blockbuster drug. It won’t take an action based on its own Good Prescribing Practice against doctors who without seeing the data put their names to articles that encourage doctors to prescribe drugs that are ineffective and dangerous.

Far from being trained in one of the major realities of clinical practice, doctors have no training in how pharmaceutical companies market drugs, no knowledge of how to investigate adverse events and they are becoming ever less able to hear awkward messages coming from patients.

The pressure on doctors is vastly greater than they are aware and this can make them not very nice people. Faced with someone questioning whether treatment is likely to have caused them an adverse event or not, from cognitive failures on statins to suicidality on antidepressants, doctors are liable to turn nasty. Try it and see.

 

Image credit:  Krisztina Tordai

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Susan Thrasher on 25/09/2014 10:25pm

Doctors are really the meat in the sandwich: pharmaceutical companies use them to promote and sell their products, and a willing public turn to them for assistance and advice. I've explored this idea in my new book "Reframing Mental Illness" (available at Amazon) and touch on the role of doctors as trusted-authorities-with-limited-time and drug-promoter in my recent blog "Mental Health Drugs are Big Business" at http://susan-thrasher.blogspot.co.nz/2014/09/mental-health-drugs-are-big-business.html

John Tucker on 25/09/2014 5:46pm

I don't know if I believe that there is an organized pattern of persecution, at least not of rank and file practioners. Certainly there is information in the public domain that companies have set out to discredit their most high profile critics, but this sort of thing is commonplace in the rough and tumble world of scientific debate, and certainly not unknown behavior between academics of differing viewpoints. Its not attractive, nor ethical, but the assertion that general practioners seeing patients in the community are afraid to address patient's concerns about side effects seems a little over the top.

Randomized trials, in spite of their shortcomings, allow us to examine the effects of varying only a single variable, if only on an averaged basis. We can look at the data in the Prozac package insert and see that while 28% of OCD patients on Prozac suffered insominia, so did 22% of those on placebo. In the absence of a control group we would conclude that Prozac caused insomnia in a very high percentage of those taking it. The control group allows us to see that insomnia is a feature of the disease state.

Similar considerations apply to attributing more serious putative side effects, such as disabling withdrawals syndromes, acts of extreme violence, and the like, based on case reports. Using this reasoning, we would conclude that one should avoid the hospital under all circumstances, because death is much more common among those who are hospitalized than among the population as a whole. But one really needs to look at why they are in the hospital in the first place.

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