Tuesday, November 30, 2010

Who Writes Medical Textbooks? You Might be Surprised.

Last week, I wrote a post about dental products manufacturers underwriting articles, and even entire issues, in dental practice journals. This week, I get to write about pharmaceutical companies writing whole books.

This does not make me happy.

Today's New York Times carries an article by Duff Wilson about a 1999 textbook on the treatment of psychiatric disorders that was apparently written by GlaxoSmithKline (then SmithKline Beecham).

Pharmaceutical companies and medical instrument manufacturers have in the past been accused of playing too important a part in the writing of articles, but "to ghostwrite an entire textbook is a new level of chutzpah," to quote Dr. David A. Kessler, a former FDA commissioner.

The book ("Recognition and Treatment of Psychiatric Disorders: A Psychopharmacology Handbook for Primary Care") was "written" by Dr. Charles B. Nemeroff (who was at Emory University's medical school at the time) and Dr. Alan F. Schatzberg (then at Stanford's medical school). In the book's preface, the "authors" thanked SmithKline Beecham for an "unrestricted educational grant."

According to Wilson's article, Drs. Nemeroff and Schatzberg insist that SmithKline "had no involvement in content."

But a 1997 letter from the associate editorial director of Scientific Therapeutics Information suggests a somewhat different scenario. The letter was attached to a "complete content outline", notes that "we have begun development of the text", names the primary technical writer (not either Dr. Nemeroff or Dr. Schatzberg), and presents a proposed timeline, which includes dates for drafts to be submitted to "co-authors / APPI / sponsor".

"APPI" is the publishing arm of the American Psychiatric Association, and was the publisher of the book.

Guess who "sponsor" is.

Peer-reviewed medical journals now require full disclosure -- as Wilson put it, "whose idea it was, who wrote the first draft, and who edited."

Don't you think medical textbooks should meet those same standards? Of course you do.

Tuesday, November 23, 2010

Full Disclosure is Better than Full-Body Scans

Pretend, for a moment, that you are a dentist.

If you read an article in the Journal of the American Dental Association that tells you that a "cone-beam CR scanner" would provide a safe and effective way to identify tooth and jaw problems earlier and more effectively than older methods like X-rays, you might consider investing in such a gizmo for your office, right?

In fact, there's an entire issue in the JADA dedicated to the wonders of this new technology. Sounds even better, right?

Now ... what if I tell you that the entire issue is underwritten by a cone-beam scanner manufacturer. Still as interested?

I thought not.

Today's New York Times has a long article by Walt Bogdanich and Jo Craven McGinty on this new technology, and about concerns that children, who are particularly vulnerable to the pernicious effects of radiation, are being exposed to excessive levels of radiation in their dentists' chairs.

Individual scans, properly administered, are not dangerous, but the effects are cumulative, so children (and adults) should not be scanned unless there's a genuine need.

An expert in 3-D technology like the cone-beam scan is quoted as saying that "a cone-beam scan produces no more radiation than a whole-body scan at the airport," while another expert argues that "cone-beam scanners can be several hundred times as powerful." (Never mind that there are questions being raised about the radiation levels to which frequent travelers may be exposed.)

The real question is, Why are we exposing children and adolescents to radiation if it isn't necessary?

According to the Times, cone-beam CT scans produced "significantly higher" levels of radiation than traditional dental imaging techniques, without sufficient scientific data to prove that it provides better results.

That's not to say that traditional techniques are perfectly safe. Dentists have been advised not to use old, slow "D-speed" X-ray film "because it requires more radiation than faster film". But about 70 percent of dentists are still using D-speed film.

The Times offered its readers an important sidebar: "What Patients Might Want to Ask the Dentist about X-Rays". It is important to know why a particular technique is being recommended, and that a proper lead shield is being used to protect you (or your child) from unnecessary exposure.

But an even more important question to ask might be why obvious conflicts of interest keep getting by us.

At the end of their lengthy article, Bogdanich and McGinty point to the continuing education credits that dentists can earn "by reading about cone-beam technology in a new magazine, Orthodontic Practice - US, and then answering 10 simple questions appended to the end."

The article is credited to Dr. Edward Y. Lin, a Wisconsin orthodontist, who is a strong supporter of cone-beam scanning. That's fine; different dentists certainly have different opinions about the value of the technology, and Dr. Lin said that "the company did not pay him to write the article or to appear in its full-page advertisement in the same issue."

What company would that be? Imaging Sciences, a scanner manufacturer. For whom Dr. Lin has been a paid lecturer.

In other words: How many lectures paid for that article?

Tuesday, November 9, 2010

Illegal vs Unethical vs Stupid

Imagine this situation: you have a conflict with your boss. It's not a huge deal, but it's been simmering away for a while, and you're ticked off about it. You're convinced that you're not getting a fair deal -- after all, your boss is your boss, right? So you vent a little to your co-workers in the lunchroom, or around the water-cooler.

Or on Facebook.

Is this a firing offense?

Here's the actual situation: An ambulance service company had asked an EMT employee to prepare a response to a customer complaint about her work, but denied her representation by her union. Later that day (from home), the employee posted a derogatory comment about her supervisor on her personal Facebook page; some of her friended colleagues piled on. She was suspended and later fired for those postings, which violated company Internet policies.

According to the National Labor Relations Board, that was a violation of workers' rights: your right to complain about your boss does indeed extend to social media sites.

"The labor relations board announced last week that it had filed a complaint against an ambulance service, American Medical Response of Connecticut, that fired an emergency medical technician, accusing her, among other things, of violating a policy that bars employees from depicting the company 'in any way' on Facebook or other social media sites in which they post pictures of themselves," writes Steven Greenhouse in an article in today's New York Times.

In addition, the NLRB found "that the company’s blogging and internet posting policy contained unlawful provisions, including one that prohibited employees from making disparaging remarks when discussing the company or supervisors and another that prohibited employees from depicting the company in any way over the internet without company permission." (The complete board release is here.)

I'm not going to rehash all the public details of the case, but it does seem as though everyone involved behaved badly.

And while I agree with the NLRB position, the employee's behavior strikes me as, well, dumb.

Yes, the EMT is ticked off right now and wants to vent with her friends. I understand that, and empathize. That's what water coolers and (after hours!) the neighborhood bar are for. But what happens when she applies for another job, and the prospective employer, in conducting the background check, comes across this posting?

Now put yourself in that employer's shoes: You don't know all the circumstances of the dispute (any more than I do). Maybe the employee is right; maybe her boss is right. But wouldn't her response (the posting) strike you as a little intemperate? Could such behavior escalate? While she may have all the qualifications you are looking for, in an environment of high unemployment, what are the chances you can't find someone who hasn't been posting negative comments about her boss?

How many articles do we have to read about people posting embarrassing pictures or comments about themselves or others before it sinks in that the Internet is forever.