Ethical Issues in Psychiatry

Discussion in 'Psychiatry' started by Darth Asclepius, May 13, 2008.

  1. Darth Asclepius

    Darth Asclepius Dark Lord of the Sith

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    Hi everyone. I'm going to be taking an awesome class next year. It's an independent study in ethics, focusing on ethical issues in psychiatry. I'm really excited about it. I get to pick the topics I will cover. Some ideas I'm kicking around are the Tarasoff decision, involuntary commitment, and informed consent and research. Do you have any suggestions for things I should make sure I cover as a future psychiatrist or just topics that might be interesting? Thanks for your help. Have a good day.
     
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  3. HCE

    HCE

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    you might want to take a look at the relationship between drug company representatives and some doctors....
     
  4. OldPsychDoc

    OldPsychDoc Senior Curmudgeon
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    Good start.
    I'd recommend you add sexual exploitation of patients and conflicts of interest/industry marketing to your list as well.

    (eh--HCE beat me to it by a couple seconds...)
     
  5. Solideliquid

    Solideliquid Members Only

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    Um, do you include innocent bystanders (cough residents cough) just into the free lunch and pens?

    Swear you guys, I have been to so many Abilify lunches/dinners and really Abilify is the only anti-psychotic I've prescribed about twice in all my two years as a resident.
     
  6. swanny

    swanny Program Director

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    Those are great topics that have had a lot written about them. Newer "cutting edge" issues include genetics and psychiatry (testing/informed consent/counseling; marriage and family planning; direct to consumer marketing of genetic tests; genetic registries; insurance/employer access to information); "cosmetic psychopharmacology" (medication use to improve performance or overall functioning without the presence of a formal psychiatric disorder); and psychiatric assessment of people regarding "the right to die" (in the case of a terminal illness).

    Good luck!
     
  7. whopper

    whopper Former jolly good fellow
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    Here's some topics I can think of, some already mentioned.
    -Gifts from pharmaceutical companies to doctors & other health care practitioners. Is it unethical?
    -psychiatrically medicating children: adults have the right to say no to psyche meds unless they are an immediate danger to themselves or others. Children can be made to take meds by their parents. Some of those parents do not have the childrens' best interest, yet the child psychiatrist is often times only able to use the parents as the ultimate source of information on deciding to medicate that chlid.
    -psychiatric involunatary commitment: how often is it incorrectly applied?
    -Managed Care denying payment: Patients are only covered by managed care for Axis I DOs. Several patients come into the ER after mutilating themselves due to Borderline Personality DO which is not an Axis I DO but at the same time these patients need hospitilization but will not be covered by managed care (and if that's the case often times the institution will not admit the patient or put strong pressure on their doctors to get rid of that patient ASAP) unless the doctor fudges the diagnosis. Unethical? On who's part-managed care? The doctor?
     
  8. MBK2003

    MBK2003 Senior Member

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    How about:
    - Involuntary outpatient commitment
    - Homeless outreach services whose payment/granting is dependent on the percentage of their clients who remain in stable housing. Do homeless mentally ill people have a right to be homeless and mentally ill?
    - Psychiatric advanced directives
     
  9. HCE

    HCE

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    There have been some recent articles on ethical issues confronting military psychiatrists that might be timely and of interest. Here is a general article on some such issues:

    http://www.bordeninstitute.army.mil/published_volumes/military_psychiatry/mpch7.pdf

    For a list articles on the military psychiatrist's conflict between patient vs. military/employer relationships, see the following:

    http://findarticles.com/p/articles/mi_qa3912/is_199812/ai_n8820332/pg_8

    I have no military background, so others with such a background are better equipped to advise on these issues.
     
  10. Darth Asclepius

    Darth Asclepius Dark Lord of the Sith

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    Thanks for the great ideas!

    Another one I have been thinking about is the effect of cultural differences on psych diagnosis and treatment. This was motivated by a patient I had who was a refugee and had some different beliefs and habits. At times, it was unclear how much of his behavior was from his psych illness and how much was "normal". He definitely had some psychosis, but as it resolved it became apparent that some of his "weird behavior" was actually quite normal.

    If anyone has more ideas, please keep them coming. I'm really excited about the elective. I think it's going to be a great experience.
     
  11. Ritz

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    The idea to blame doctors for talking to drug reps is just lame. I guess it is mostly those who do not get the attention complain. If money was everything I am sure most of us could have been Attorneys or Investment Bankers. Psych needs all the advertisement and awareness amongst the Public especially with the Managed care driven health care. Drug companies are amongst the strongest lobbyist against Managed care.
     
  12. OldPsychDoc

    OldPsychDoc Senior Curmudgeon
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    We're not talking about pens or managed care here.
    We're talking about industry-academic relations that lead to situations like THIS.
    Seriously--all of us need to read this article, because ANY of us could get into a situation like this.

    (BTW--I'll believe that the drug companies are in this business for "public awareness" when they start running television ads for effective medications that have gone off-patent, instead of rolling out metabolites and repackagings of their own products as "new treatments").
     
  13. toby jones

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  14. sunlioness

    sunlioness Fierce. Proud. Strong
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    They're also, imo, the strongest proponents of biological reductionism in psychiatry and in large part behind the devaluing of psychotherapy. I personally haven't taken anything from them in the last 6 weeks. I'm still polite to them as people, but I don't want their bribes anymore.
     
  15. OldPsychDoc

    OldPsychDoc Senior Curmudgeon
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    Part 2 of the article published today. If you're interested in ethics, read it!
     
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  17. billypilgrim37

    billypilgrim37 Unstuck in Time
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    I don't think that's particularly necessary. I'm not polite to the ticks I find on my dogs. My best friend growing up became an adderall rep a few years ago, and he will never be allowed within 50 yards of me in any professional context, by punishment of the acid-spitting dinosaurs I keep in my delusional closet.

    Those folks are paid to manipulate you. That's not very polite. These are the same pretty people who were playing Frisbee in the courtyard with their abnormally-attractive friends while we were in the basement of the library studying for the MCAT.

    I'm mostly kidding with my more scathing insults. But only mostly.
     
  18. TheWowEffect

    TheWowEffect The Official WowRator
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    Wow, you are angry! I am sure you are proud of those days spent in the library basement. So, why grudge someone who made a different choice.

    While drug companies have their marketing agenda etc., there is a case to be made for a more balanced approach to dealings with them. Radical rejection is certainly not the way to go, as suggested by some posters here. The advances made in pharmacology far outweigh the risks imposed by me-too-drugs and tactics employed by drug reps.
     
  19. sunlioness

    sunlioness Fierce. Proud. Strong
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    Agree, WowEffect. And I don't hold each drug rep personally responsible for the actions of their companies. And I like being polite in general. It just makes me feel better about myself. ;) Anyway, my not taking pens or eating food is also something I am doing for myself as a reminder of what Big Pharma is in business for and what my focus as a physician needs to be. I don't delude myself that they even notice that I'm not eating their food. I don't need to announce to everyone that I'm not taking stuff (though I guess I just did here, but you know what I mean hopefully) and I still give samples to my patients because I figure that is helpful to them. *shrug* It's just the way I see it now.
     
  20. TheWowEffect

    TheWowEffect The Official WowRator
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    I guess it all depends on our "superego alignment". I personally don't see eating their food or taking pens as a big deal, just as I have no problem using their samples. It essentially boils down to what one does when writing that prescription. If you are doing what a good psychiatrists should be doing, these things don't really matter.
     
  21. sunlioness

    sunlioness Fierce. Proud. Strong
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    If it didn't matter, they wouldn't do it. The money that's paying for your catered lunch is coming from your patients. It just doesn't sit right with me. But to each his/her own.
     
  22. TheWowEffect

    TheWowEffect The Official WowRator
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    Remember, it is pharmaceutical INDUSTRY. They are in business and marketing is an essential component of any business. I am sure you would agree that they make up for a lot of this stuff with generous samples and programs for low income patients.
     
  23. sunlioness

    sunlioness Fierce. Proud. Strong
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    If that's how you see it, that's fine. I'm honestly not trying to sit in judgment of anyone else's choices.
     
  24. TheWowEffect

    TheWowEffect The Official WowRator
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    You are right. We can always agree to disagree.
     
  25. OldPsychDoc

    OldPsychDoc Senior Curmudgeon
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    I am not naive enough to believe that the wonderful pharmacological agents we have today would have gotten to our patients without the efforts of Lilly, Merck, Janssen, Glaxo Smith Kline, Pfizer, and the like. I know that it takes money to develop agents and bring them to market, and publicity to encourage doctors to use them.

    What I object to is
    --the (re)selling of metabolites and isomers as "superior" to the cheaper, older compound (Invega, desvenlafaxine, Lexapro), often using distorted and selectively presented data to do so, or the reformulation or relabeling of a product in order to extend a patent (Serafem, Symbyax, Paxil CR, Ambien CR, etc., etc.).

    --paying physicians to shill for their products as members of "speakers bureaus" and "advisory boards".

    --supporting clinical trials and failing to report negative results (or burying these outcomes under selective presentations of favorable data).

    I'm not saying that this stuff happens all the time or influences every physician inordinately (although I think some of our patients might disagree). I am saying that we need to be aware of potential conflicts of interest and how they may bias our professional judgment--and this is the kind of ethical issue that the OP was inquiring about. And I contend there IS a serious perception problem in the public when we do not pay close attention to this. Just saying "there's no problem" does not make the ethical conflict go away.
     
  26. TheWowEffect

    TheWowEffect The Official WowRator
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    Well, this is indeed somewhat balanced perspective of the issue, but this balance may be lost when pharma companies are portrayed as all evil.

    To answer another point brought out before, biological reductionism is no worse than mind-body dualism. Again, balance is important when dealing with these complicated issues.
     
  27. billypilgrim37

    billypilgrim37 Unstuck in Time
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    Their job is to manipulate me for the benefit of the people who give them a paycheck. I don't place a lot of value in that service. I've seen a significant difference in physician attitudes at my home institution, where pharm reps are banned, and outside sites where reps are present. I simply do not see any way in which they add value to the physician or the patient.

    Samples and drug reps are different things. I don't know how many studies have to be done to demonstrate that the use of samples increases overall pharmaceutical spending before we believe them. Samples are problematic, and the ways in which they are problematic are well-described in the health economics literature.

    I'm not suggesting rejecting drug companies. I'm advocating transparency and managing real and perceived conflicts of interests. Drug reps complicate all of those things.
     
  28. maybepsych

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    I have never heard that samples increase spending, but now that I'm thinking about it I can see it making some sense. I definitely want to check out some literature. Thanks for that point.
     
  29. OldPsychDoc

    OldPsychDoc Senior Curmudgeon
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    Samples are not a GIFT, they're a marketing tool. You don't see Celexa samples--not when they want you to sell Lexapro, and have the patient refill that script for the next 11 months!
     
  30. Anasazi23

    Anasazi23 Your Digital Ruler
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    I'm instantly wary of any mass-hysterical movement. Particularly those associated with the terms "grass roots" and that involve a holier-than-thou approaches. I'm also wary of the physician that can't seem to separate, understand, or appreciate the differences between an outside for-profit industry and their own moral and ethical values.

    Further, I'm against government and forced regulation which pigeon-holes me into how I make personal decisions and/or choices base on their perceived "ethics" codes.

    There are corrupt senators. Perhaps we should do away with the senate. The U.N. is grossly corrupt. Let's flatten it. The are presidents who act unethically. Let's eliminate the position of president. Many lawyers are unethical. We should eliminate them entirely.

    Should research be transparent? Yes. Are there inequities in the system and do new drugs cost billions to produce and do they market them heavily to recoup the cost and then make a profit 4-7 years later? Yes. Is the system perfect? Of course not. Would I rather have the federal government in charge of all clinical trials and manufacturing? Hell no. They can't even run the lottery correctly.

    If your own ego-strength is so weak that you feel that you can not see, hear, or speak about the realities of the current for-profit drug manufacturing system without acting unethically or amorally, then I would implore you to examine that within yourself.

    Just food for thought.
     
  31. HCE

    HCE

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    Anasazi, you make some very good points. I agree with your first statement above, but I would add that I'm against the tactics of Big Pharmaceutical and Big Insurance which both in their own way pigeon-hole physicians into how they make personal decisions and/or choices based on their perceived "ethics" codes.

    As to the second statement above, I personally think the public would be better served with the government having more control over clinical trials, and I don't think the lottery is run poorly. Whenever we're sitting around waiting for election results, and hearing about one voting irregularity after the other (e.g. dangling chads), I always wonder why they can figure out the winner of a national lottery so much faster then we can figure out who won the election.
     
  32. TheWowEffect

    TheWowEffect The Official WowRator
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    All these places that have banned drug rep contact on a group basis still allow individual contact after an appointment is obtained. This may, in fact, turn out be worse than the prior open contact during lunches and meetings. You may not see a skirt-clad beauty cat-walking your hospital corridor but she is still very much in the picture.
    Loopholes! Loopholes! Loopholes!
     
  33. sunlioness

    sunlioness Fierce. Proud. Strong
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    Not all of them do. I don't know if it's still like this because the department chair has changed since "my day", but during my internship, the general internal medicine dept at my home hospital didn't allow contact with drug reps period. Not during lunches, not by appointment. Nothing on the premises at all. Our continuity clinic didn't even have samples available. But we still experienced the flipside of this as a lot of our rotations were at the VA where there were a lot of reps around. And it didn't stop residents from going to dinners and having contact with reps that way.

    I don't know that I sense that much difference in the environment though to be honest. The only thing I can say for sure is that my current program is more likely to think to ask drug reps to fund things we want to do (whether it's certain speakers or a movie night) while in my former program it was something that just never really occurred to us to do.
     
  34. Ritz

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    The attendance in the Grand Rounds is low when there is no Lunch. Resident are busy, it saves time if they get to eat and attend the rounds at the same place. Unfortunately Psych Depts are mostly low on funds to abe able to sponsor the food for every one. There should be a reasonable balance to be able to utilize the available resources and the chair should be strong enough to limit the ability of the reps to influence the Practice. I do not think I have even written a single med because the 'rep told me so', it is plain stupid, patient interest is the number one priority. I believe most of us in Psychiatry are conscientious people(hopefully), we have already shown our disinterest in making money (not that all make less) by chosing Psychiatry.

     
  35. OldPsychDoc

    OldPsychDoc Senior Curmudgeon
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    $$$
     
  36. sunlioness

    sunlioness Fierce. Proud. Strong
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    In the program I am referring to (my general medicine internship) lunch was provided every day at departmental cost. The food got kind of repetitive after a while, but we always ate. My current psychiatry program only rarely has drug reps sponsor lunches at journal club. We still eat free though because we have more than enough department sponsored meal tickets. It just means stopping off at the caf on the way there.

    I really don't think "residents are busy and need to eat" is a compelling argument for saying drug rep sponsored lunches are ok. Maybe they are ok, but if so residents being busy and needing to eat isn't the reason. There are plenty of fields with busy hungry workers who would love to have their lunches paid for but who by virtue of the nature of their profession aren't going to have drug reps coming in and offering to buy lunch.

    And I say again . . . every doctor I've ever met has said that they are personally "too intelligent/conscientious/caring/moral/insert your favorite adjective" to be swayed by pharm reps. If that were true for every individual case, the pharm reps wouldn't bother providing that service. They're not in business to feed us. I think I'm too intelligent to be swayed by it too. But I also have to acknowledge that I am human and maybe things affect me in ways I am not always conscious of.
     
  37. Ritz

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    I am not sure how the patient could have benefited by something else if he was cheeking his medication here 'Seroquel'. It was an IRB approved study by Faculty at a reputed University Program (University of Minnesota). The patient was seen more frequently than he otherwise would have been. There is a limitation to the credibility of what ever is being Published and in the point of view it is looked at. The mother in this unfortunate case believed that the patient is not getting the right medication, but in fact he was not taking any. I am not sure what was the Out come legally. May be committing him involuntarily could have made the difference, but it was also not immediate, and that is not the most acceptable course with the families either. Not sure till what time is the Hospital Liable after discharging someone, this person was in Out patient follow up, had a case manager involved, living in half way house, getting additional check ups for medication compliance (which failed, due to patient hiding his pills). I remember it was discussed in the Press that the V. Tech massacre was at some point discharged from a hospital after evaluation by a (experienced) Psychologist. But how far do we take responsibility and blame our colleagues for patient related deaths? I know of a resident harassed by Police (on the phone) after a patient Died. There are innumerous episodes where Psychiatrists have been killed by the patients. http://www.washingtonpost.com/wp-dyn/content/article/2006/09/04/AR2006090401162.html
     
  38. Ritz

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    It is not the best practice to be judgemental about your Colleagues.
     
  39. sunlioness

    sunlioness Fierce. Proud. Strong
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    It is interesting to me that you are seeing judgment in my posts. Because I have said repeatedly that I respect any decision anyone else chooses to make on this subject. I don't have all the answers. I've gone back and forth on it in the past, and I continue to modify my own views based on new information and where I am in my life and career. And right now for me, I choose not to take gifts from drug reps because that is what I have come to on my own. Where is the judgment in that? Where is the threat? The world would be boring if everyone thought the same way and this is a complex issue with a lot of room for different points of view.
     
  40. sunlioness

    sunlioness Fierce. Proud. Strong
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    To clarify what I meant though as I see where this could sound judgmental now that I am reading it again. I don't think any of us is actually saying, "Wow. That was a really good sandwich. It was so good that I am going to prescribe Invega to all my patients this afternoon." I agree that we don't do that. And I don't think people are deliberately doing that and then claiming that they're not. But I think the marketing is subtle in many ways and affects us in ways we aren't entirely conscious of. So yes, I believe that people who say they aren't affected by advertising are being completely honest. But I also worry that being so affected isn't always on a conscious level.

    But that's all from me for now.
    :)
     
  41. OldPsychDoc

    OldPsychDoc Senior Curmudgeon
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    Part 3--"Critics say drug firms' payments to doctors are conflict of interest".

    The ethical issue in this case is not "did the doctor cause the tragic outcome?", but "Is there the appearance of a conflict of interest?" Some would argue that the very appearance of a conflict of interest is evidence of that conflict, inasmuch as it reflects on our credibility as physicians.

    Minnesota is one of the few states that requires public reporting of funds paid to physicians. I think that in the public perception*, this looks and sounds like "my doctor is on the take", and might not be advocating for my best interests, but for someone else's. I think that if as a researcher, the funds that you receive for research benefit you, even indirectly ("salary support", progress toward academic tenure, etc.), then it might be the case that you are no longer be able to advocate for your patient's interests in an unbiased manner, and you should recuse yourself from making the day to day treatment decisions about the patient's medications.

    *for examples--just read the public comments section below the article!
    An excerpt: "as if dr.'s don't make enough. i see the free lunches given to mine"
     
  42. TheWowEffect

    TheWowEffect The Official WowRator
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    I think the "poor lunches and pens" are probably unfairly targeted in this battle of the individual morals and personal ethics:laugh: Someone also just said that many restuarants, catering services and pen making companies are going to plunge into a recession as a result of this ban.:rolleyes:
     
  43. Darth Asclepius

    Darth Asclepius Dark Lord of the Sith

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    Thanks for the articles. I'm really interested in research ethics in general and this ties in the big pharma aspect as well.

    It's clear from this thread that the pharmaceutical industry is a big issue, especially in psychiatry. I think I will have to cover that one during my elective. Thanks again for the thoughtful input and suggestions from everyone.
     
  44. HCE

    HCE

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    Wow, you seem unduly worried about this whole lunch thing. I'm concerned...someone get Wow a cookie.


    OldPsychDoc....$$$ in the lottery, or in the election?
     
  45. OldPsychDoc

    OldPsychDoc Senior Curmudgeon
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    In the lottery--it MAKES money for the states. Elections COST money. Therefore, the effort required to make a process speedy and efficient is expended where it reaps the reward.
     
  46. TheWowEffect

    TheWowEffect The Official WowRator
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    Thanks for your concern. Now that you are at it, I would prefer a chocolate chip to go with Invega coffee:p:laugh:
     
  47. OldPsychDoc

    OldPsychDoc Senior Curmudgeon
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    What is that--like decaf? You get the flavor, but none of the buzz, alertness, or diuresis of regular unmetabolized coffee? :smuggrin:
     
  48. sunlioness

    sunlioness Fierce. Proud. Strong
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    I think Invega coffee would taste like regular coffee, but also make the voices go away. ;)
     
  49. Anasazi23

    Anasazi23 Your Digital Ruler
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    I was referring to stuff like this.

    I suppose I could have found much worse examples of the government ruining everything they touch. Maybe this is a slightly better lotter/government example.
     
  50. nancysinatra

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    Do you think this ineptness is a fundamental feature of ALL governments, everywhere, or just certain ones at certain times? Earlier you said something about not trusting "grass roots" movements--so would a top-down type campaign be better in your view? I'm not too knowledgeable about the specifics of any existing or proposed governmental regulation of drug companies, but it seems to me that to say that the GOVERNMENT can't do anything right, and at the same time say that the PEOPLE are not effective either (ie grass roots movements being suspect)--well, then, that's like saying we can never solve any problems at all, so why bother attacking things like conflict of interest?

    What I'M wary of is those kind of hopeless mass generalizations. Or the kind of mass confidence when you hear doctor after doctor say they've "never" been influenced by a pharmaceutical company. We had a speaker talk to our class during second year, and he told us about a study that had found that actually, doctors are influenced by those freebies far more than they realize. Individuals who would insist they were not influenced would turn out to have been influenced, actually. I'll try to look for the study.

    Sorry if I misunderstood your comments though. You did mention they were just "food for thought," not a theory of everything!
     
  51. Anasazi23

    Anasazi23 Your Digital Ruler
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    Yes, most governments, in most places.

    While it's not perfect (no system is), the capitalist model is more driven to produce a better mousetrap. Not the government, which is laden with beaurocracy and lazy ineptitude.

    What I meant by suspicous grass-roots movements was simply the implication that mass hysterical causes cause the bandwagon to fill quickly. Those opposed to hopping on are viewed as traitors, non-thinkers, insensitive, amoral, or worse.

    Indeed you're right. Studies show that prescribing influences are had through marketing. Is this surprising? Is it all naturally 100% bad? These points are never debated - it's just assumed. Again, it's naturally assumed that there is no positive aspect to their involvement. Love them or leave them, drug reps are often the first to disseminate information about off-label uses being studied and specific populations being tested. This happened with me and my use of Abilify in bipolar depression. I was using this med after I had discovered its effectiveness years before it was approved for this purpose. It made my job easier, and patients got better that perhaps wouldn't have in the same time frame. It started with a drug-rep discussion.

    Not to sound cliched, but I'm not worried about what studies show other doctors doing. I'm concerned with what I'm doing. I sleep well at night knowing that I read the literature, and am not a slave to it either. I make decisions based on as much science as we have, but am not afraid to throw the literature out the window if I know from experience that something else might work (has happened countless times). It's a slightly different point, but if every psychiatrist, indeed every physician, waited to make a clinical decision on the availability of proven efficacy in multicenter double-blind controlled trials, there'd be a lot of sick patients running around.
     

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