Daniel Carlat, M.D. is a psychiatrist in private practice in Newburyport, Massachusetts. He graduated from a psychiatric residency at Massachusetts General Hospital in 1995, and is the founder and editor of The Carlat Psychiatry Report, a monthly CME newsletter. Dr. Carlat reports the following conflict of interest: He publishes an industry-free CME newsletter, so he would stand to benefit financially if drug companies were not allowed to fund his competitors. In 2007, Dr. Carlat started a blog entitled The Carlat Psychiatry Blog after having an influential op-ed piece published in The New York Times about industry-funded continuing medical education (CME).

John M. Grohol, Psy.D.: You started your blog just over a year ago after having an op ed piece published in the New York Times about the conflict of interest in industry funded, continuing medical education.

How has the continuing education industry changed since then in response to efforts such as yours?

Daniel Carlat, M.D.: The op ed did garner a fair amount of response, both positive and negative; negative response being mostly from medical education companies that stand to profit, from the CME business.

A number of things happened after that op ed was published. One of them was the Josiah Macy Foundation organized a meeting of prominent figures in medicine, and this group issued a report recommending that medical education no longer be funded by industry.

Soon afterwards, the American Medical Association came out with a report through its main Ethics Committee (CEJA, the council for ethical and judicial affairs). This report on medical education was about two years in the making and they also recommended that continuing medical education no longer be funded by the pharmaceutical industry, basically saying that the marketing aims of drug companies have become overly intertwined with continuing medical education.

These physician groups were both saying that have lost control of the content of their accredited medical education, and that we need to take that control back. I’m not talking about promotional talks here—I’m talking about accredited, Category One CME, which is the credit doctors need in order to maintain their medical licenses in most states. So this type of education is really is a big deal, and has implications for the wellbeing of out patients.

Aside from these two reports other things happened. The Senate Finance Committee, under the leadership of, Senator Charles Grassley, came out with a report, saying that after interviews with different stake holders, they felt that many of the CME programs had become promotion activities for pharmaceutical companies.

They sent a letter to that effect to the ACCME, (which is the overall regulatory body for all CME). And then that set in motion a number of activities in the ACCME

It seems that every couple of months now if you go onto the ACCME website they have come up with another set of proposed guidelines to make more impenetrable the firewall between medical education programs and industry sponsorship.

For example, they have redefined what a commercial entity is in order to limit the involvement of advertising companies in CME. In the past pharmaceutical marketing companies could actually also create CMEs.The ACCME looked at that and said, “No, guys. If you as a promotional marketing company want to create CMEs you will have to be very careful. From now on, you have to spin off the CME part of your business into a separate corporation. You can still be sister companies, but it has to be separated in some reasonable way.”

Most recently, ACCME has proposed that when any CME company comes up with a proposed topic for a course they have to do their needs assessment and their topic choice based on independent information sources. They listed a bunch of potential information sources, like medical organizations, and government-funded organizations that can suggest unbiased topic areas. The idea is that this would theoretically prevent a company from just deciding, for example, to create a course about injectable antipsychotics just because Janssen is funding that program (Janssen markets Risperdal Consta, an injectible antipsychotic)

So now, if they do decide to come up with a program on injectable antipsychotics and Janssen is funding it, they are going to have to demonstrate to the ACCME that they came up with that topic and they generated that topic in an independent way without any influence of the promotional needs of the company.

The most recent development is that Pfizer, one of the largest drug companies in the world, announced that they would no longer directly fund CME that was produced by independent medical education companies. That has caused an uproar in the medical education community, which is about a 1.2 billion dollar business,. However, one has to wonder, even with all these new developments, if there are ways for those companies to make end runs around the new regulations.

And I think in the case of Pfizer, it’s pretty clear that Pfizer is saying that, while they won’t directly fund medical ed companies anymore, they will fund education programs that are sponsored by medical societies or academic medical centers, even if those programs are run and produced by private med ed companies. So the money will now go to the medical society, and then from the medical society it will still go into the same coffers as before–the med ed companies!

Will there be a little bit more adequate oversight of the content? Hopefully there will be. But I think that ultimately the same education companies that are one hundred percent dependent on grants from pharmaceutical companies for their business, those companies will still be very much involved in producing the content of these educational activities.

Dr. Grohol: So it sounds like it almost becomes an increasing shell game of how many filters can we put the money through before it actually gets to the same people. And it begs the question, will we ever see real reform in the CME industry?

Dr. Daniel CarlatDr. Carlat: Well, we will. But it is a very, very slow incremental process. This reminds me of, when the campaign manager for President McKinley was asked what were the most important things in politics. And he said, “There are two important things in politics. The first one is money, and I forget what the other one is.” It works very similarly in the pharmaceutical marketing industry, and it really is all about the money.

So if there is reform, the way that the reform will come about is that the drug companies themselves will realize that their profits and their bottom line are threatened by their continuing involvement in sham educational activities. And once they realize that their bottom line is affected, then they’ll pull out very, very quickly.

Right now it’s difficult because if a particularly ethical company, decides, “This really is very embarrassing and demeaning for us and doctors to be putting on these sham educational programs. We don’t really need to do it anymore, we have plenty of other outlets for advertising that are legitimate. Let’s just stop doing it.” Well, then their shareholders are going to be complaining that they’re taking away a valuable marketing tactic from their business and putting them at a competitive disadvantage to all the other companies that have not been so ethical. Companies are always looking behind their backs at what their competition is doing to make money.

Dr. Grohol: Sure.

Dr. Carlat: So, somebody is going to have to take a stand at some point, or regulatory bodies will do it for them. If companies, both the drug companies and the med ed companies don’t materially change their ways, aside from these shell games and these smoke and mirrors operations, then the Senate Finance Committee will begin to, not simply write letters asking questions and expressing displeasure, but they’ll start to ask Congress to change the laws so that this kind of thing can’t happen anymore.

Dr. Grohol: Recently you’ve had some pretty strong words for George Lundberg and Medscape on your blog about their CME efforts. In an ideal world what could Medscape and other companies like them do to reform their CME in the short term?

Dr. Carlat: Well, I think both George Lundberg and myself are very blunt and frank people. And it’s true that in a recent video editorial broadcast on Medscape, Dr. Lundberg really lashed out. In my opinion he lashed out at everybody who’s trying to bring more honesty into medical education.

Dr. Lundberg certainly isn’t a bad or unethical person, but he is a person who has cast his lot with a private, very profitable medical education company, Medscape, which is, again, almost one hundred percent dependent on pharmaceutical company funding for the production of their medical education. So, anything that threatens that spigot of money is going to threaten everybody that works in that company, and will certainly personally threaten Dr. Lundberg’s position as editor of their medical site.

One of the things that he said was that Medscape is “good, clean, and transparent.” And that bothered me because the real issue, and where the rubber meets the road in this entire debate, is when you look at the actual educational courses, are they biased, are they promotional, or aren’t they? I can give you a lot of rationales for why these things might become promotional, but if you look at them and they are just perfectly good unbiased education, then it really doesn’t matter who’s paying for it.

But when I looked at the psychiatry offerings after Dr. Lundberg published that editorial, I was astounded at how transparently and blatantly commercial and promotional all of the psychiatry CME courses that I reviewed were. It wasn’t as though the bias was even difficult. It was like shooting fish in a barrel.

You just look at anything on their site. I looked at one event, one course for ADHD medications, and the first 10 slides in the online program were essentially commercials for the latest Shire products in ADHD. In another example there was a course on a new antipsychotic called Invega, which is produced by Janssen. And this antipsychotic has only one little niche advantage in the very, very crowded and competitive field of antipsychotics, which is that it doesn’t get metabolized through the liver, and so it’s a good medication to prescribe for someone with liver disease

So, in the Janssen funded antipsychotic program the entire program is based around the case study of, wouldn’t you know it, a patient who had liver failure. The program took the audience by the hand and said, “Let’s look at this important case example of a patient with liver failure. Let’s look at what would be the best medication to treat this person with if he’s psychotic. Guess what? The best medication is Invega.”

And you keep going through the website, and it is so obvious that the money and commercial influence are infiltrating the CME programs, which is really why I ended up lambasting Dr. Lundberg in a couple of blog entries. I received a fair amount of flack from various people who felt I was a bit nasty. But there’s no question that passions do run high in this debate..

Dr. Grohol: So how do they change their business, though? If their business is dependent 100% on pharmaceutical companies to fund them, I mean Medscape would be out of business tomorrow.

Dr. Carlat: That’s ture, Medscape would be out of business, if they felt they needed to continue to produce accredited CME. However, the amount of money companies spend on accredited CME is 1.2 or so billion dollars a year. The amount of money companies spend on non accredited medical education, i.e., various forms of advertising, promotion, dinner talks, dinner programs, web based non CME programs is in the tens of billions of dollars. There’s plenty of money out there for a company like Medscape if they decide that they want to continue to depend on pharmaceutical money. They simply could no longer call their offering “accredited” CME.

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.

The Carlat Psychiatry ReportDr. 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.