"As an aspiring doctor, reading Overdosed America was incredibly motivational"

On 6/13/07, William Carroll wrote:

Dr. Abramson -

I saw this article today in the New York Times and thought of you. It speaks to the downfall of continuing education being funded by drug companies

http://www.nytimes.com/2007/06/13/opinion/13carlat.html?th&emc=th

Diagnosis: Conflict of Interest

By DANIEL CARLAT

Published: June 13, 2007

To be honest, my main reason for writing is simply gratitude. I am a year out of undergrad from Davidson College, North Carolina and will be applying to medical school for fall 08. As an aspiring doctor, reading Overdosed America was incredibly motivational albeit discouraging. I think medicine in this country owes you tremendously for all your efforts to put together statistically sound information comprehensively that was so shrouded to begin with. I can't even imagine how laborious that must've been, as I used to get all hissy just reading journal articles for my human genetics seminar.

Your book reinforced my whole-hearted belief in the importance of preventive medicine, which seems unfortunately in the minority these days. After reading I spoke to numerous adults on statins, etc and I urged them to not only read your book (take it or leave it) but to seek medical knowledge themselves. My girlfriend recently made an interesting comment while we were eating dinner, and watching television. She said, "You know, it used to be cars and beer. Now every other commercial is for a prescription drug."

I have a couple of questions for you:
1. What was the predominant reaction from patients, drug companies, fellow physicians (all parties) upon the release of your book? (If you have a publication regarding this and could refer me that'd be great)
2. How much do you integrate this material into your teachings at Harvard? What do students think?
3. Do the recent changes in the FDA seem promising to you?

Once again, thank you.

Will Carroll

***
Will, Thanks for your e-mail--it's great to know that committed people like yourself are out there thinking hard about these issues. Responding to your questions:

The research for the book was certainly time and energy consuming--about 2 years of living and breathing this project, before even beginning the equally challenging task of translating the findings into readable English. But it was a wonderful 2years of intellectual engagement and discovery, like being a detective on a number of very different but related cases. This did involve throwing personal caution to the wind. In my mind I had granted myself a one year sabbatical after working more than 20 years as a family doctor. One turned to three, but I could not possibly be more gratified with the process. And e-mails like yours confirm that, while the medical system has not changed significantly for the better as a result of the critical scholarship that has emerged, awareness of the core issues is growing and people like yourself will, hopefully, carry this mission forward.

My fellow physicians thought I was truly psychotic--writing a book with the primary thesis that the medical "knowledge" that they believed implicitly was really being produced with the primary mission not of helping them to help their patients, but increasing corporate profits. And they continued to think I was nuts after the book was published. That is, for the first nine days after the book came out, until Vioxx was withdrawn from the market for causing exactly the harm that I presented in Chapter three of the book. Then things changed. I lecture all over the country, primarily to doctors. They get it when I am presenting the real scientific evidence, but I fear that as soon as I am gone and the drug companies bring in their speakers to convince them that their products really have the scientific basis that conforms with their paradigms of good medical practice, the effect of my critique has a relatively short half-life.

A central problem, that I did not address strongly enough in Overdosed America, is that what we take as "knowledge" in areas with commercial potential is far more often determined by the inherent tendency of the marketplace to maximize short and intermediate term financial return on research investments. The end result is that what we naively accept as a Platonic kind of knowledge (a little piece of divine truth) is much more likely to be a market-driven perspective that has primarily a short-term business goal rather than advancing knowledge or the well-being of humanity.

Harvard medical students are interested in these issues, but there does not seem to be much interest in integrating a critical and reflective look at the fundamental structure of medical knowledge production into core of the educational experience.

And finally, the strikingly public failures at the FDA are creating an environment where some greater caution seems to be the order of the day. But I fear this is more smart politics than real change. The legislation does not free the FDA from financial dependence on the drug industry, nor does it set up an independent office of drug safety that is not under the administrative authority of the office of new drugs. This leaves a fundamental conflict of interest: the office of new drugs is not going to be thrilled to learn about the mistakes it made in approving unsafe drugs. There needs to be a separation of power here--but this has been carefully legislated out. Ironically, the best Senator on these issues is conservative Chuck Grassley (R-Iowa), who completely understands the public disservice of drug industry influence at the FDA. There is just too much money and influence from the drug and other medical industries available to politicians. I fear that the Democrats will only be slightly better than the Republicans on these issues--any greater than a perceptible difference will create a backlash from the drug industry and be counter-productive in terms of getting elected, which is the primary job of a politician.

All that said, the future is in your hands. So please do everything to protect your ideals and your integrity. And understand that this requires enormous skill and intelligence, often demanding great self-discipline to get your training and credentials without offending the powers that be too much.

Wishing you all the best. Please keep me posted on how your career is progressing.

Sincerely,

John Abramson MD