Transparency: Houdini’s last trick

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I recall a talk on imaging biomarkers for Alzheimer’s disease (AD). “Take this with a pinch of salt. I have a financial conflict of interest (COI) in the success of these markers,” the speaker warned. I glanced at the audience – MDs and PhDs with a cumulative IQ higher than the French intake of wine. I looked for pinches. I searched for salt. I found neither.

I wondered what a speaker’s disclosure is supposed to trigger. Should we say “Stop, don’t advance your power point, until we regroup?” Demand that the statistics be re-run in front of us. Challenge, “You say p is 0.04. No, you lying Gordon Gekko, it’s actually 0.06.” Or ask “did you submit ANOVA to Tukey?” If we must ask these questions, must we not ask routinely? Skepticism is a habit, not an episodic righteous angst.

No really, I’m not being facetious, what should transparency make us do differently? His disclosure, paradoxically, made him a saint for his honesty, and gave the audience an excuse to switch off their skeptical neurons, which I suspect had been switched off all along.

Writing in the NEJM, Lisa Rosenbaum argued that we rethink our attitudes to pharma, as our obsessing with physician’s ties with pharma and our demonizing of industry have become excessive to the point of being self-defeating. The reaction to her essays were generally of brisk intelligence, but the tone ranged from pleasantly intolerant to emesis-inducing sanctimony. Strawmans emerged such as these:

“Are you saying conflict of interest doesn’t exist? How naïve.”

“No one said physicians should have no relationship with pharma. What a logical fallacy.”

One can so easily retort “no one said that anyone said that physicians should have no relationship with pharma. What a logical fallacy.” When we miss the point, strawman counterarguments are like infinite mirrors – never ending fallacies in fallacies.

Rosenbaum’s lucid prose, a rarity in contemporary medical writing, can get under the skin of the self-righteous. So thoroughly devoid is her writing of managerial double speak that you know what she’s thinking. Yet it is remarkable that in a zeitgeist of finicky optimizers – who want not just to be right but to be Goldilocks right – “it is too much” is so difficult a sentiment to comprehend.

Here are other phenotypes of confusing complaints of excess for want of zero.

“Government must regulate pharma prices because they are excessive”

Response: “That’s government takeover, a short step to national socialism.”

“ICD-10 will be futile and burdensome”

Response: “Oh let’s deregulate physicians because there is obviously zero fraud.”

Rosenbaum says our fixation with physician’s ties with industry is excessive – we need to take a chill pill. Ladies and gentlemen, do you agree? The question: is it excessive? Not: are financial ties always innocuous?

I think our obsession with pharma is insufficient. It is insufficient because it is misplaced. It is misplaced because COI is largely, not entirely, an epiphenomenon – a wart distracting us from the giant epistemological game of roulette that is played when we reward marginal improvements.

The responses to Rosenbaum’s essays confirm my fear that we cannot think of more than one bugbear at a time. The God of the Old Testament was obsessed with sex. The God of Sanctimony of the 21st century is obsessed with money. And what an odd prurience – money is a currency of corruption and an arbiter of fairness. Thou shalt not covet thy neighbor’s Ferrari if earned by righteous means.

Ostensibly, this is because we want to get to the truth. Because if a sales person for CT bought me dinner, I, a man so deprived and depraved, will be so in debt that I will influence the administrators to buy that CT scanner. I’m blissfully unaware that even free morsels lead to bias.

(BTW, I’d be quite offended if you thought money is the only thing I would lie for…)

But are we really interested in the truth, at least more than Jenny McCarthy is interested in the real cause of autism? Or are some biases more equal than others?

Let’s take regulatory capture. That’s when industry influences legislation so that they can enjoy a de facto monopoly. Or when former regulators become entrepreneurs and profit from palliating physicians from the asphyxiating regulations that they developed. Psst, that’s happening with EHRs.

Why are we bothered by a $15 gift a physician has received from Pfizer, but blasé about the ethics of the millions earned from regulatory capture? I suspect it’s because we’ve tuned out. Our bandwidth is limited. Today is the season for ties with pharma. Tomorrow, who knows what will trouble our conscience.

Regulators – good, very good; pharma – bad, very bad. Grimm brothers would have a field day.

Joseph Schumpeter said that the first thing a man will do for his ideals is lie. Ideological conflict of interest is arguably the most pernicious COI. Ideological COIs are multipolar. Even researchers have a COI – hell hath no fury like a researcher’s methodology scorned.

I recall a talk about CT colonoscopy. The speaker’s disclosure slide was busy. Her ideological COI, though undisclosed, was obviously that CT colonoscopy was her life.

“What about the incidental findings on CT?” I asked.

“That depends on your perspective – what if you were a patient whose renal cancer was picked up by CT colonoscopy?”

She was right. It’s all perspective.

Imagine you’re sitting with Ptolemy, Copernicus, Thomas Aquinas and Galileo at a bar. You ask. “Is it earth or sun at the center of the universe? Lads, have you come to a consensus?” Ptolemy replies “Nick and Leo have agreed to disagree with Tom and I. We think it is earth. It’s a matter of perspective. Tom and Leo are from different cultures but both bring something to the table.”

Matter of perspective? Value systems? In hard sciences, such as physics, someone must be talking BS because there is an objective truth – there is no difference of opinion. In soft sciences everyone, I mean everyone, thinks that they have a point. Medicine has become the softest of softest sciences, so infused is it with morality. Bias roars. Arbitrariness rules. Dollars abound. Sanctimony commands.

We live in a culture which gags to be dazzled. Pharma bedazzles by incremental improvement. It knows it has do just a little, teeny weeny bit better, because we want better at any costs.

When we get ‘better’ we froth incontinently with righteousness making ‘better’ a benchmark of quality. Because ‘better’ means there is ‘worse’ and we can’t have worse. When evidence eventually changes, as it so often does when there are small differences, as it did with noble markers of quality such as pre-operative beta blockers or chlorhexidine prep, we scream bias, $$$$, COI. Off with their heads.

Relax. It’s epistemology, my dear Watson.

“So what?” I asked at the end of the talk on Alzheimer’s disease.

“Come again?” the speaker replied.

“So what if you can predict Alzheimer’s disease? What information are you providing people other than   – if you live longer you will grow older?”

He stared briefly, and then with thinly disguised despair said, “Sorry, dementia is going to be an epidemic.” I was unmoved. “It will be an epidemic despite these clever predictive biomarkers.”

New York wasn’t built in a day. Neither did I become an insufferable ass overnight. It’s not personal. I would have asked these questions whether he was a celibate Buddhist Lama on a diet of bread and water, or the devil himself. I didn’t give a rat’s tail about his transparency because the product struck me as a ginormous exercise in utter, unabashed futility. But then I, too, have an ideological COI: I think we’re overmedicalized and that we need to take a chill pill and visit the mountains, not the CAT scan fretting like chicken littles.

So what? The most underused words in the English language. To reduce overmedicalization we must learn to be nonplussed rather than yearn to be dazzled. Skepticism is a 24/7 job – it is easier blaming dollars.

Conflict of Interest

I gatecrashed a party at the Radiological Society of North America organized by Nuance Incorporated. I guzzled the free single malt. I remember one of the sales people telling me how great Nuance is. However, I was too inebriated to remember why it is great. Please take what I say with a pinch of salt….

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  1. The patient needs an agent. Who would have the least conflict of interest, now, in representing him/her? With capitation, it feels not the docs. With salary, it feels not the docs. With FFS, it is said that volume drives us; but maybe we are still the best agent or second best? Could the PCMH or the Insurer be the best? I dont see how the ACO could be the agent with the least COI, do you? It seems a club to save money. Perhaps the patient’s attorney? Oh lordy, what if the crowd of stakeholders circling the patient were so complex that we had to leave it to the attorneys to ultimately represent the patient most effectively?