White Coat, Black Hat

Adventures on the Dark Side of Medicine

by Carl Elliot of the University of Minnesota

Margaret Soltan Reviews the Book

From University Diaries:

“Medical journals still trust authors; patients still trust doctors; researchers trust subjects; and subjects trust researchers,” writes Carl Elliott in his new book, White Coat, Black Hat: Adventures on the Dark Side of Medicine. “Nobody wants to admit that the world has changed. Nobody is willing to concede that trust may no longer be warranted.”

Chapter by chapter, White Coat, Black Hat systematically considers the way the world has changed. And most of the change, Elliott argues, goes one way: Toward the corruption of each aspect of the drug delivery process by commercial interests.

“Discovery” of new medications may well involve the corporate creation of pseudo-disorders (“‘You are not shy; you have social anxiety disorder. You are not absentminded, dreamy, or fidgety; you have ADHD. You are not moody; you are bipolar.’ Each diagnosis comes with a prescription. The need for medication becomes part of your identity.”); testing can mean sloppy, industry-run exploitation of guinea pigs, poor and desperate people who present themselves as human subjects in one trial after another because they need the money; the publication of results can mean corporation-controlled ghostwriters whose “articles” are warmed-over advertising.

Then there’s the aggressive selling of meds to doctors by salespeople in the field, and by drug lobbyist/physicians at Continuing Medical Education junkets; there’s also the sophisticated advertising of the new pseudo-disorders:

Pharmaceutical companies have been joined by advertising companies, publishing companies, public relations firms, medical education agencies, and university CME offices, each with its own set of skills, services, and financial incentives.

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Elliott looks beyond outward evidence of corruption. He’s good on the deeper motivations underlying, for instance, academic physicians who sell out to pharma. It’s not just money that draws once-respectable researchers into corporate thralldom:

The real appeal of being a [Key Opinion Leader] is that of being acknowledged as important… It is a hunger for status that motivates many academic physicians to work for industry…

Pharmaceutical companies, David Healey tells Elliott, pick KOL’s “based on their psychology and things like that, to suit their needs. They pick the kind of people who would like to have on their CV that they have written eight hundred articles. When in fact they have written ten or twenty, and the other seven hundred and ninety have been written by medical writers.”

Why does industry want to attach itself to people associated with universities? “[B]ecause pharmaceutical companies are so widely distrusted by the public, they need academic physicians to front their research and give it a patina of legitimacy.”

Among university faculty, professors who sit on bioethics panels oversee, and usually approve, various trials. Originally independent, bioethicists, argues Elliott, now increasingly serve to legitimize many of pharma’s bastard offspring. “Since they are paid by the companies whose protocols they review, commercial [bioethics review boards] have a financial interest in keeping their clients happy.” He quotes Jonathan Imber calling bioethics “the public relations division of modern medicine.”

Indeed at universities, “Bioethicists teach ethics to college students … who generally do not suspect that the professors may be getting a paycheck from the very corporations they are discussing in class.”

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The concept of “university” itself has dulled to the point of vanishing, Elliott suggests, in America’s compromised medical schools. “[U]niversities … must compete in a marketplace dominated by the [drug] industry and its commercial spin-offs. If more academics think like businesspeople now, it is partly because the world in which drugs are tested, developed, and marketed is so completely ruled by business.”

The Barnum and Bailey ridiculousness of professors listing eight hundred publications on their cvs tells us that the ethos of big business has come crashing into our medical schools, elevating ringmasters like Charles Nemeroff and Joseph Biederman (both of whom Elliott discusses) to the top of the profession.

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Trust? Only an idiot would trust these clowns.

Unfortunately, as Donald Light details in his much-discussed recent paper about the drug industry having become a market in lemons, it turns out we are. Idiots. We must be. We’re still buying.

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