Interview with Psychiatrist Daniel Carlat, M.D.

Dr. Grohol: Are you still holding to your “no drug reps allowed” policy?

Dr. Carlat: Yes, that started back in April… Actually, April 10, I remember the date, because I remember why I banned drug reps. A couple of reps came in from AstraZeneca who were pushing Seroquel for the treatment of bipolar disorder. One of the reps in particular was using such a hard selling, bullying approach to try to convince me to prescribe this medication that I was totally turned off. I kicked them out of my office, , (in a nice way), went to my secretary and said, “, we have to stop scheduling any more drug reps.”

Ultimately, the medical information that I’ve obtained from drug reps has not been useful to me. It’s not been medical education, it’s been advertising. Even when they do bring out a couple of peer reviewed papers, they are only the papers that they feel represent their product in a favorable way. You’ll never see them bring out a paper saying anything good about a competing product, or a paper saying anything bad about their products. If that’s the way doctors end up educating themselves about medicine, we’re going to all get sued for malpractice.

Dr. Grohol: So are you still accepting free samples from drug companies?

Dr. Carlat: Well, I do. Although I am sensitive to the critique that samples are just another way of marketing their product. And that’s certainly true. But, on the other hand, I do have a few patients that really depend on those free samples, who are poor, so I continue to allow the reps to drop them off.

Dr. Grohol: And do you see the hypocrisy between saying “I don’t want to listen to you anymore, but keep giving me your free samples.”

Dr. Carlat: Well, I certainly see that accepting free samples is in some way saying I will accept a benefit from you, but I’m not going to accept your more blatant forms of pharmaceutical promotions. So to my mind, free samples are a benefit for some of my patients. They give me samples partly to benefit my patients and mostly, to encourage me to prescribe more of that medication. I think I’m savvy enough to be able to see through that and not allow my prescribing to be manipulated by free samples.

Dr. Grohol: How have the counter detailing visits been going? Any new ones scheduled?

Dr. Carlat: I’ve done about 10 counter detailing visits, or talks and I’ve found it really interesting. I haven’t accepted money for them, although for a couple of grand rounds, universities have sent me checks anyway, even when I’ve asked them not to.

So now I have a couple of checks totaling about $1,500 in my desk drawer, and I’m not going to cash them. I’m trying to figure out what to do with them. I’m thinking about giving them to the Boston Food Bank as a protest against allowing drug companies to ply doctors with free food and free lunches.

Dr. Grohol: [laughs] That seems appropriate.

So you’ve been a blogger now for over a year. What have been the most unexpected benefits of blogging and the unexpected downsides?

Dr. Carlat: Probably the most unexpected benefit is that I’ve met a lot of people who are like minded, who have noticed my blog and who have introduced themselves to me. I didn’t realize when I started a blog that I would be, joining a little community of like minded folk, who would be able to email each other, chat a little bit, share information, invite each other to meetings and whatnot.

And then the other unexpected benefit is being approached by either government authorities or media outlets to offer to bring my message out to a much broader platform than I would have otherwise ever thought I could. It’s amazing to me, but Senators and Congressmen read my blog, both state and national. And various media; I got a call out of the blue recently from NPR, a great program called On Point with Tom Ashbrook. I would have never thought in a million years I would ever be on that program. The producers happened to see my blog. They were doing a program on pharmaceutical industry influence on medicine, and they asked me to comment with an author of a book, Melody Peterson. Things like that happen. Very unexpected.

Dr. Grohol: That must be a little amazing and humbling at the same time.

Dr. Carlat: It is.

Dr. Grohol: How about the downsides?

Dr. Carlat: The downsides are when you’ve got people who really hate you and everything you stand for, making their position clear, either on the comment section of my blog, or in their blogs. And I’ve been called a “self styled gadfly”. One recent blog posting was headlined something like, “Now all listen to the magnificent

Dr. Carlat: Well, it stings a little bit when these things happen.

Dr. Grohol: You need to develop a little bit of a thick skin in order to…

Dr. Carlat: Yes. Well, I’m a psychiatrist. Most psychiatrists have to have a pretty thick skin anyway.

Dr. Grohol: Understood. [laughs] So I found the top five commented posts on your blog and I was wondering, out of those top five what is your favorite post, and what do you think made it one of the most commented on your site?

Dr. Carlat: I think my favorite was the recent post on the financial scandal that hit Harvard, and the three child psychiatrists who had not declared most of the 4.2 million dollars in industry money they had received over the last seven years. What I found interesting, about writing that post, although time consuming, was getting the opportunity to do a bit of investigative journalism. I went into the basic source data for that story, which was the data that was published in the Congressional Record.

I went through and did some calculations and figured out that while that story was spun as being about doctors directly accepting industry money and not disclosing it, the real story was somewhat different. If you actually looked at the figures and the line items, probably 90% of that money did not come directly from pharmaceutical companies, but it came through these third party medical education companies, apparently for payments for writing articles in CME publications, giving talks at dinner programs, things like that. And so for me it was such a perfect illustration of everything that’s wrong with the medical education industry that I think I labeled it, “The Perfect Storm.”

And it was nice. And I got a few comments, but for me, even better than the comments was the fact that I felt that I had provided some documentation that will never go away; as long as the Internet exists, anyway. It will always be there for people to look at.

Dr. Grohol: People seem to like to take extreme positions on issues such as conflicts of interest, that it’s a black and white issue. Your entries about this topic seem to be more moderate and reveal the many gray areas when we’re talking about conflicts of interest. For instance, we were just talking about the Harvard Medical School psychiatrists.

I think initially you had come out and said “maybe it was an honest mistake,” and were afraid that maybe there was a witch hunt in progress. Which is actually a concern when you see people starting to talk about these large chunks of money and where they came from. But it seemed the more you delved into that topic the more you kind of changed your opinion.

Dr. Carlat: Yes. I think in general there is a tendency, as you say, for people to adopt extreme positions on this issue. And there’s a whole movement of people that believe that the solution is to just cut off all industry involvement with medicine. I think that’s definitely throwing the baby out with the bath water because it’s clearthat we are able to treat patients and get them better because of the pharmaceutical industry. As a physician I prescribe meds all the time, and if I didn’t have those tools at my disposal many of my patients wouldn’t get better.

So, we need doctors to work with companies that do great research and development. And I also feel that there are some appropriate relationships between doctors who receive pharma funding and other professional organizations. So, for example, the APA, the American Psychiatric Association, which is an association that I’m involved in. I’m on a couple of committees, I’m an elected member of their assembly from the state of Massachusetts.

One of the things that they do is they allow doctors who have industry ties to be on the committee to come up with the next DSM, the next Diagnostic and Statistical Manual. And they also allow such doctors to be on the Practice Guidelines Committee. There are some who believe that’s completely inappropriate, that it leads to disease mongering, doctors creating diagnoses in order to sell more drugs that are made by the companies that pay them.

I think that’s going overboard. I don’t think that happens. I’ve met and talked with too many of these doctors who take money and who are completely ethical and who would never do such a thing,.

And even in my Carlat Psychiatry Report newsletter, which doesn’t accept any industry funding, I do at times interview as experts doctors who take a lot of industry money. The reason being that often they are the ones who have the most expertise on some of these issues. So, if I were to not allow myself to interview these people I wouldn’t be able to adequately educate the psychiatrists that read the newsletter.

So, no, you can’t take an extreme position here. You have to strategically look at specifically what are the most nefarious sources of industry money and target those sources, and allow us to benefit from the good aspects of the relationships.

Dr. Grohol: So, what color is the couch in your office room?

Dr. Carlat: I don’t have a couch in my office. I have two easy chairs, both of which are green.

Dr. Grohol: Ah, I see. [laughs] Very good. Thank you very much for your time today, Dr. Carlat.

Dr. Carlat: Thank you.