Focus on real problems in medicine and policy, not the industry affiliation sideshow

Under the headline "Antidepressants good for the grieving?  Panel with industry ties says yes," the Washington Post today offers their version of what by now has to be a Mad Lib template: "Panel ___(pretentious title)____  entrusted to make consensus recommendations for ____(topical medical policy question)____ includes many participants with ____(close/cozy/lucrative - must choose one) ____ industry ties."

The point readers are intended to take away from these sorts of articles is that evil for-profit companies are corrupting medicine and seeking more ways to shove unwanted and unneeded drugs down people's throats.  Most popular coverage of the industry tends to focus on some variation of this view - and full disclosure, of course, this is the business in which I work - proudly.

Let me offer a different perspective on this often repeated, painfully trite storyline.

The real story here is that there are a lot of issues in medicine and policy that are intrinsically complex, for which there really aren't obvious answers, and where significant disagreement exists.  Use of antidepressants in grief is probably one of those topics.

Rather than focus on the intrinsic, deep complexity of the issue, which not only gets complicated, but also usually doesn't provide a clear good guy and bad guy, and hence less narrative direction, it appears many journalists opt for the "pharma polluting the process" storyline, which then at least offers an obvious and easily understood direction to the reporting, a well-trod path for readers to follow.  It seems intellectually dishonest and journalistically lazy to reduce complex medical and policy questions to a scorecard of industry affiliations.

The more interesting story here is the tyranny of consensus recommendations themselves, which stem from a desire to define (more accurately, impose) clear-cut "best practices" even where a clear standard doesn't exist, and where data do not unambiguously support one approach over another - and where the best approach in any case almost certainly depends upon the values and preferences of a specific patient.

Best practices are a vital tool for many businesses processes, and can be vitally useful in medicine to steer providers away from medical practices that are clearly flawed.  But reification of consensus just for the sake of having a standard doesn't intrinsically make sense, even though it's something that many policy makers, healthcare systems, and payors like because it offers a defined set of rules - albeit falsely precise and artificially specific.  This brilliant WSJ article by Groopman and Harzband,  "Rise of the Medical Expertocracy," provides an especially compelling discussion of the topic.

Having critiqued reliance on experts, let me say a word on their behalf.  Industry is routinely pilloried for "buying off" experts, for hiring physicians and scientists who are perceived to be key "thought leaders" in an area.  According to many critics, anyone with such industry ties should be barred from having their views impact the general public - e.g. shouldn't be on consensus committees, regulatory advisory committees, etc., at least in the most extreme view.

Here's another take: if your job was making medicines (an occupation less noble than issuing bioethics proclamations from a university office, perhaps, but still not the least worthy job description in the world), wouldn't you want to get advice from the people who you thought knew best?  Isn't it just possible that maybe industry seeks out experts not to corrupt them but to learn from them?

And what about the view that even if industry's goal isn't to corrupt experts, experts working with industry will inevitably get corrupted/soiled/deserving of an "asterisk" - I've heard this all.

My view - consistently stated (e.g. here, here, here, here) - is that hard problems require teams of the best people, period.  Transparency is essential - and I only wish we had as much insight into the thousands of other factors that could influence expert opinions (such as interpersonal animus, say, or the very real opportunity to forge a professional career as a pharmascold) as we have into industry connections.   Certainly, the view that experts who've not consulted for industry exist on a higher ethical or scientific plane would be laughable were it not taken so seriously by so many. 

My dream would be that we learn to focus less on the sideshow of industry affiliation, and more on the main act, the really important question that deserves to dominate our thinking: how can we all work together to create the best medicines, and define the most informative policies.


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