Q&A with Dr. Daniel Carlat: Biting the pharma hand that fed him

Dr. Daniel Carlat is a medical curiosity.

After establishing a psychiatry practice in Massachusetts and publishing some popular textbooks, including The Psychiatric Interview, he was courted in 2001 by Wyeth, the pharmaceutical maker, to educate doctors about depression treatment as part of their Speaker's Bureau. After about a year of pitching for Wyeth, he quit after he started to question the ethics of the enterprise. Since that time, he has become one of the most forceful critics of industry-sponsored Continuing Medical Education. He publishes a monthly newsletter called The Carlat Psychiatry Report that is part of an effort to offer CME without industry sponsorship. In 2007, he wrote an influential piece that was published in The New York Times Magazine called "Dr. Drug Rep," which detailed his work for Wyeth and his change of heart.

I reached him at his office in Newburyport, Mass. The first part of our conversation is below. It has been edited for space and clarity. The second part will be posted next Friday.

Q: You chaired a meeting at the American Psychiatric Association in 2006 called "Pharmaceutical Industry Influence in Psychiatry." You have written that you were expecting very few attendees but ended up with a packed room. What was going on at that time that drove that interest in your talk?

A: I think that was just at the very beginning of the sort of sequence of revelations that many psychiatrists were on the payroll of the pharmaceutical industry. And more came out subsequent to that. At that meeting, we had Jerry Kassirer who had recently published his very popular book On The Take, and he was sort of a big draw. He wasn't talking primarily about psychiatry but about cardiology and lipid-lowering drugs. During his talk, in the front row, was sitting Gardiner Harris from The New York Times, and he put up some slides based on work that Harris and others had done into the industry ties to physicians. There was an expert consensus group of cardiologists who were recommending the use of statins, and these slides showed how many of those experts had ties to the pharmaceutical industry. It was very interesting to hear Jerry's perspective. He has a lot of credibility, being the former head of the New England Journal of Medicine.

Q: And you spoke, too, of course.

A: Yes. I spoke about a study I had done that I had never published looking at CME newsletter articles and the number of times that the sponsor's product was mentioned positively versus mentioned negatively. I had found a very strong correlation between industry sponsorship and the promoting of that company's product.

Q: Was it widely known at that time that you had worked for Wyeth? Or did that not really become public only after your article in The New York Times Magazine in 2007?

A: I had published a little blurb about it in my newsletter before The New York Times article, maybe a couple of years before. The newsletter was founded in January 2003. Maybe a year or so after that we put out an issue looking at industry influence in medicine. And in that issue, I mentioned in an anecdotal blurb that I had worked for the industry in CME.

Q: What was it about you, do you think, that attracted Wyeth?

A: It's hard to know, but they certainly knew that I was prescribing Effexor. I never found out how much I was prescribing, but they knew what percentage of the drugs that I was prescribing was Effexor versus other drugs.

Q: How did Wyeth know that?

A: They get that information from pharmacies. It's a practice that has been more and more prevalent. It used to be before we had all this high technology that drug reps would sort of hang out at pharmacies and hover over the pharmacist's counter and check out what patients were getting prescribed and try to figure out which doctors were prescribing what medications. But now it's becoming much more systematic. The major pharmacies themselves will sell the data to information aggregating companies like IMS, and those companies, in turn, will sell reports to the pharmaceutical companies. And this information is essentially in real time. If you want to know how many prescriptions for Effexor Dr. Carlat has written in the last few months, last week, last day you can find all that out and that allows you tell how effective you have been in selling your product.

Q: But just being a good prescriber wouldn't make you a good teacher. What else did they know about you?

A: They had seen that I had written books. I had written a fairly well-known textbook on interviewing. I went to Mass General (Massachusetts General Hospital) and I was articulate about things when they visited me. They recruit their speakers based on a number of things. Like Adriane Fugh-Berman has said, I think it is true that one of the reasons they hire promotional speakers is to encourage them to prescribe more of their product and to reward them for prescribing more of their product. My abilities as a speaker or writer were just part of the equation. They also saw me as someone who could create a lot of new customers. They paid me about $30,000 over 2002. They may well have felt that a $30,000 investment just to get me to prescribe more Effexor to a few patients would have recouped their investment. If I only started an additional 5 or 10 people on Effexor over that year, over time, they would have made a bundle of money on that investment.

Q: At first it seems like you felt you were performing a necessary and beneficial service. What was it, initially, that you liked about teaching these classes?

A: I enjoyed getting out of the office, having conversations with other physicians, being the center of attention, feeling important, feeling that I was chosen to be an expert speaker to other doctors. You get appreciation from the doctors you are talking to. Medicine is hard work, and the doctors get a little entertainment break in their day. Some of them see it, cynically, as a free lunch and a chance to listen to another doctor who is clearly going to be biased toward the supporter's product.

Q: In that case, why is there anything wrong with it? What's the difference between a doctor with drug company ties giving a talk about a drug and a politician giving a talk that the audience knows is going to hew to the party line?

A: I said some of the doctors are savvy. Not everyone is savvy. Some know that they are hearing an expert who is following the party line. But then there are others who don't really think about it that way. They see me as a true expert. If I come in there and highlight Effexor, one part of their mind might say, "This guy is hired by the company to say these things," and another part of their mind might say, "Gee, I hadn't thought about that drug much and maybe I should prescribe more of it." That is kind of the way advertising is effective, from car commercials to billboards for beer.

Everybody who sees a commercial knows that the reason so many good things are being said about the product is because of the company producing the commercial, but that doesn't prevent those ads from being extremely effective in persuading people to buy Car A over Car B. Same with pharmaceuticals. Doctors can know hired guns are hired guns but it doesn't make them ineffective. Particularly if there is repetition involved. They could have me come in one month and hire someone else another month. Several different hired gun experts, all following the same marketing pitch. Eventually, that sort of weasels its way into your unconscious and affects your prescribing decisions.

Q: Again, though, why is that bad? Nobody is forcing these doctors to sit in the same talks over and over, right? If they are commercials, the doctors can ignore them the same way people ignore commercials when they are watching TV.

A: The only reason that it's bad is that these marketing pitches are not based on objective science. They are typically slanted in favor of those studies that push the supporter's product. I think it's much better for doctors to get their information from other sources. I'm biased in that I have my own financial conflict of interest here because I publish and make money off my own CME newsletter. There are others, like The Medical Letter. It's foolish for doctors to think they are getting unbiased information from the manufacturer of a particular product.

Q: You actually make an interesting disclosure on your blog. You say, "I have the following conflict of interest: since I make (a little bit of) money by publishing an industry-free CME newsletter, I stand to benefit financially if drug companies were not allowed to fund my competitors." This seems tongue-in-cheek to me, but I'm wondering if you have had accusations from drug companies that you are trying to steal their business.

A: Not from drug companies. I have certainly had accusations from industry-funded CME providers, most of whom are not MDs but are usually business people who hire medical writers to write CME. There is a fair amount of distrust of me from that community. From that standpoint, not only am I a direct competitor in some ways with their business, but, even more to the point, if my political agenda comes true, then the pharmaceutical industry would no longer be involved in accredited medical education and all those people would go out of business. Rockpointe Corporation is the most famous. There is now a longstanding blog-versus-blog animosity between the head of Rockpointe, Thomas Sullivan, and me.

Q: What changed your mind about teaching industry-sponsored CME?

A: It was both a gradual process and a sudden process. I was doing these talks once a week or every couple of weeks. Over time you realize you are saying the same thing over and over again. And what you are saying is not necessarily something that you want to say or you really believe is important. What you are saying is what the drug reps who are watching you speak want you to say. In some ways you might say, "Dr. Carlat, isn't that obvious. Isn't that what you signed up for?"

Q: OK. Isn't that what you signed up for?

A: Yes. But it's not really until you are in the trenches doing the talks over and over again that you get it and you start to feel the subtle pressures that are in the looks of approval or disapproval from the drug reps sitting in the room. The awkward silences or the big smiles lighting up. Those are the pressures that you feel as promotional speaker. I think anybody in that racket eventually notices that and feels uncomfortable with that. And once you feel uncomfortable with it, you have to think about your own ethics and think about if you really are beginning to slant what you're saying in a direction that is inaccurate or overly biased. I felt that was happening to me.

In the article I wrote about it, I portray the breaking point, where I said in one of the lectures that I talked for the first time about some of my own doubts about the efficacy of Effexor. The next day, I got a visit from the regional manager for Wyeth wanting to know what was going on because he had heard from his reps that I wasn't as enthusiastic about the product as I had been. At that point it reaffirmed what I already know on some level: that I was not there to provide a medical education service. I was there to provide an advertising service for the company. That was the kicker for me. I can still hear the line, "Dr. Carlat, you didn't seem as enthusiastic about the product." The hair was raising up on the back of my neck, and I thought, "There is no way I can continue to do this is. It is completely unethical."