Insel and Obama Want Transparency-Let’s Oblige

Two events occurred last week that will have significant ramifications for psychiatry. On March 23, The Physician Payments Sunshine Act was signed into law by President Obama. The act was embedded in the larger healthcare reform package, so it didn’t receive a lot of fanfare, but it is huge. The Sunshine Act will require that all drug and device companies report all payments made to physicians and teaching hospitals. All payments will be available on the Health and Human Services website, which will publish unprecedented detail about such payments, including the precise nature of the “service” provided, the date of each check, and the name of the drug or device that a promotional talk supported.

Thus, for example, if you are on AstraZeneca’s speakers bureau, your talk won’t simply be classified as “professional education”-instead, your patients will learn that you were paid $2000 on a particular date for marketing activities in support of Seroquel. This granularity of information constitutes true transparency, as opposed to the rather opaque information provided on the physician payment registries posted voluntarily by some companies.

The second, related, event occurred the day after the Sunshine Act became law. Thomas Insel, the Chief of NIMH, published a commentary in JAMA, the Journal of the American Medical Association, entitled "Psychiatrists' Relationships with Pharmaceutical Companies: Part of the Problem or Part of the Solution?" While acknowledging (as we all should) that some collaboration between physicians and pharma is a good thing, Insel concluded that industry influence has radically skewed psychiatric practice in favor of the most expensive drugs, even when evidence shows that cheaper generics work as effectively. He also bemoaned the fact that effective psychotherapeutic techniques are "woefully underused and frequently not reimbursed."

Finally he called on organized psychiatry to lead the way to reform:

"The focus on financial conflicts of interest in psychiatry is an opportunity to take the lead in setting new standards for interactions between all medical disciplines and industry. Academic leaders, professional societies, and patient advocacy groups could turn the tables of public trust by developing a culture of transparency for psychiatry's collaborations with industry, including the clear separation of academic-clinical missions from industry marketing."

As it turns out, at our Annual Meeting in New Orleans this May, we have the opportunity to show the public that psychiatry is, indeed, committed to the highest ethical standards. The American Psychiatric Association’s Assembly will vote on whether to approve the recommendations contained in a report written by Dr. Paul Appelbaum and his Work Group on Relationships Between Psychiatrists and Pharmaceutical and Medical Device Industries. The bottom line recommendations of the report are:

1. Psychiatrists should not accept gifts from industry (except for medication samples).

2. Psychiatrists should not give company-sponsored promotional talks, nor should they attend such events, unless they are accredited by the ACCME (the organization that creates and monitors the standards in continuing medical education).

3. Psychiatrists should not participate in “consulting” meetings if they are actually promotional meetings in the guise of consultation.

Many of these provisions have already become policy at the major academic medical centers in the U.S. For example, the major Harvard Medical School hospitals have banned industry gifts and forbid faculty from giving promotional talks. Johns Hopkins, Stanford and several others have followed suit.

Inexplicably, these recommendations have been rejected twice at APA Assembly meetings, where APA members have taken umbrage at the implication that their opinions could be swayed by a free lunch or by a few thousand dollars in payments for drug talks. But the drug companies themselves understand the promotional value of the smallest of gifts, and an increasingly critical public has little patience for doctors who claim that they are impervious to marketing.

I urge all psychiatrists to show their support for the Appelbaum recommendations. You can find out who your Assembly representatives are through your district branch’s website. Give them a ring or send them an email. Let them know that it’s time for psychiatry to take back the ethical high ground.