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Wednesday, May 26, 2010

Tough Questions

It’s no secret that one of the tough questions in American psychiatry—and at this meeting—is how psychiatrists can interact with the pharmaceutical industry without compromising their integrity or the interests of their patients. Over the weekend, the APA Assembly rejected several proposals that would have provided guidance on which relationships can be problematic and are best avoided. (Full disclosure: I chaired a workgroup appointed by the APA Board that wrote of one the documents that was voted down.) Instead, the Assembly adopted a vague statement that psychiatrists should be aware of their conflicts and manage them, without any guidance on how to do either.

I had two interactions this evening, however, that underscored just how important it is for American psychiatry to provide clearer guidance—and just why that may not be easy to do. On the street outside the Hilton, I was approached by someone who asked if I came to the meeting every year. When I said I did, he wanted to know why there were so many fewer sessions this year. “We used to be able to go to sessions from 7:30 in the morning to 10 at night.” I told him that APA had made a decision to phase out industry-supported symposia, both to protect the objectivity of the program and to reduce APA’s dependence on industry funding. He was puzzled by my response. “I come to get education. [He appeared to be referring to CME credits.] Whether it’s good education or bad education, it’s all education.

Good information or bad, so long as we get CME credits, that’s all that matters? As I was pondering the implications of that interaction, I headed over to one of the ubiquitous receptions, where a prominent member of the APA Assembly came over to talk. She wanted me to know, she said, that she’d thought the report of the workgroup I’d chaired—which she’d voted against—was really quite good. There was just one problem. It had recommended that psychiatrists not give talks when they don’t control the content of their presentations. When physicians give promotional talks for industry, they are handed a slide set created by the company. Our workgroup thought it was inappropriate for a physician to be dispatched to mouth the words written by the company that was signing the check. “I give a lot of those talks,” she told me. “They pay my mortgage. There’s no way that I can stop.” Then she smiled, as though she knew I would understand.

I don’t know, of course, how many psychiatrists will listen to just about anything so long as they get CME credits. Or how many are so dependent on drug company money that they can’t imagine living without it. But for this psychiatrist, it was a troubling evening in the Big Easy.

Paul S. Appelbaum, M.D.
APA former past-president


  1. Wonderful 4 days at apanola. On way home to Albany GA. Much to keep my interest with practical value too. That is what I came for!

  2. It's saddening to know that even an apex body can not do much about the growing interference of pharma industry in psychiatric practice. As a young psychiatrist trained in India, I have experienced this to some extent and heard bigger stories. What are we going to do Sir? An attempt to refuse the pharma at individual level does not seem to help in the bigger scheme of things.
    At the same time, its encouraging to know that APA had made a decision to phase out industry-supported symposia in this annual meeting.
    Congratulations for that!!

  3. I am unable to sit through something that doesn't make sense to me, especially if I have options. There have been many options for me here at APANOLA-2010. On one of the four days I attended I got got up and left four sessions before I found one that had both practical and aesthetic value for me.

    It wouldn't be right for me to accept money or anything else from a pharmaceutical company in exchange for being their mouthpiece.

  4. The author Paul Appelbaum, MD missed the point. When he referred to the physician who asked about the session “I come to get education. [He appeared to be referring to CME credits. (added by Dr. Appelbaum)] Whether it’s good education or bad education, it’s all education.
    I don't know who he talked to, but would bet that the physician wanted to attend educational sessions so he could learn to treat his patients better. Those pesky symposiums that Dr. Appelbaum despises provide value to physicians in their practices. They often are more comprehensive and usable education than the general sessions.
    It is arrogant for the writer to infer that it is only about the credits. Physicians including psychiatrists are smart people, and can weed out good information from bad, and we have learned that throughout our education.
    On the proposed ban on canned talks, Dr. Appelbaum once again is using a simplistic write off to a complicated question. Companies are required by the FDA only to present “on-label” information in their promotional talks, which is why they have to control the slides. If he would prefer non physicians educating physicians about new treatments than all that clinical knowledge will be lost when explaining how the therapy is used in a practice setting.
    Congratulations to the APA members for voting down those proposed rules and standing up for their rights!

  5. I am a resident member of the APA's Assembly and I cannot express the degree of my sadness in witnessing the Assembly voting down the Workgroup's report during this session. We are now one of few organized medicine associations without a stated guideline in regards to this important issue as passed by the membership representative body. The document in question on this blog was the most thought out, detailed, and in line with other established documents such as those from IOM and ACGME and AAMC. It lists a set of guidelines that membership is encouraged to follow. It does not make ethical standards nor does it instruct membership to act in a certain way. As the organization setting the agenda and leadership to our profession, by voting down these documents and accepting a vague language of general "principle," we have not led the profession but acquiesed to vocal minority. In time, the vision and spirit of the guidelines set forth in documents like Dr Appelbaum's workgroup paper will certainly win out but during this session of the APA Assembly, we did disservice to our profession.

  6. Paul S. Appelbaum is severely mentally ill with Asperger's disorder and malignant narcissism. These psychiatric diagnosis are not in dispute: they are easily observed and represent a disqualifying disability, and, I would assume, a "conflict of interest" when it comes to opining about mental status issues, ethics, dangerousness, criminality, capacity to consent to treatment, etc. Blah, blah, blah...

    Appelbaum lives in a flat two dimensional world full of paper with lots of "facts" and figures: this is why he is obsessed with research. He is unable to grok the real 3D world of human mind-space, a space not perceived by the systematizing approach alone. Simon Baron-Cohen: "[people with autism] are hyper-systemizers, best able to cope with logical, lawful systems and not with systems of “high variance or change (such as the social world of other minds)". Hmm. Mind-blind.

    Appelbaum should never have been allowed into medicine, let alone psychiatry, with such grave deficits. Only through intimidation, political malfeasance and criminal interference does he yet rise. And rise he does: is there any position to which he does not aspire and to which he is denied by his mentally ill, destructive, corrupt, co-conspirators in medicine, psychiatry and the APA?

    Any work product,including clinical care, forensic consults, legal opinions, and academic decisions, produced by Appelbaum is void on its face.

    That's some conflict.