Saturday, May 12, 2007

On decorum in medicine

A quotation by the Irish priest Steve Gilhooley set me thinking about medicine, and the Alice in Wonderland world of medical leadership in particular. The quotation was delivered as part of a sermon on El Salvador. Gilhooley spoke passionately from the pulpit:

"I said to them, '70,000 people have been butchered and none of you gave a shit.'"

There was silence. A priest had sworn in the pulpit.

"And the reason I know none of you gave a shit," he continued, "was because none of you fell off your seat when I said '70,000 had been butchered', but nearly all of you fell off your seats when I said 'shit'."

For the background to this sermon and its consequences read here. Much of Gilhooley's feelings about the church would apply to the current sad state of medicine.

Says Gilhooley [of the church] "There are those who would rather hide the truth. Those whose priorities have become so skewed that they would protect [sexually] abusive priests before they would protect those who fight for justice and transparency. These are the people who are really in control in the Church. Well, let them get on with it. Let them bury it in the ground, and then we'll all start something else."

The desire to maintain decorum and status in medicine seems also to overwhelm all standards of decency. Our profession is inclined to fixate on the irrelevant while ignoring some very bad things. Does civility matter? In the words of David Kern: When you're in an argument with a thug, there are things much more important than civility. I do not like incivility. Yet, I like thugs even less.

The desire to maintain civility, decorum and status instead of ethics explains for example why we as doctors feel quite comfortable with a drug "regulatory" agency in the UK (the MHRA) that simultaneously
  1. conducts a high profile campaign against the nutritionist "Poo lady" Dr Gillian McKeith for selling unproven herbal sex aids [Link]
  2. ignores all of the very worrying revelations about the drugs we ourselves prescribe
The need to maintain decorum means that it is hard to deal with the difficult and important problems or to deal honestly with the failures of "important" people. It is a lot easier to think about the "Poo lady" than to explore honestly how we were misled by both companies and regulators over Zyprexa, SSRI's, Vioxx and many other drugs (Link,Link,Link, Link,Link).

The emphasis on decorum and status explains why it is considered by some as "impolite" that I accrued extensive tape recordings (sample here or here) of colleagues and pharmaceutical company executives involved in an unsavory scientific "collaboration" that threatened to damage the science I love and to distort our understanding of a drug [Link]. Does civility matter under such circumstances?

The emphasis on decorum and status explains why the BBC had to conduct it's own investigation [Link] of the worrying events surrounding clinical trials of the drug Seroxat and the company GlaxoSmithKline (GSK) as the medicines regulator (the MHRA) simply dragged it's feet for years conducting an internal investigation of its own collusion with the deception. And to cap it all, key figures within the MHRA are previous employees of GSK.

The need to maintain decorum means that even though it seems very likely that both patients and doctors have been misled, that prescribing decisions have been made on the basis of faulty or hidden data, and that patients have suffered or have died as a result of regulatory malfunction, we doctors remain silent (see extensive discussion here and here).

The need for decorum explains why the General Medical Council (GMC) muttered into their beards when presented with evidence of alleged research misconduct involving Dr David Jefferys. Jefferey's was high in the pecking order, and in a position where the need for integrity was part of the job description. He was former director of the Medicines Control Agency and chief executive of the former Medical Devices Agency (both organisations merged to become the Medicines and Healthcare Products Regulatory Agency, the MHRA). This week the General Medical Council also refused to scrutinise in any way the activities of another very important doctor, Dr. Alastair Benbow of GlaxoSmithKline. This despite obvious public concern and a BBC investigation. The GMC refused on the basis that there has not been a criminal or regulatory investigation of GSK (taking the obfuscation full circle). I have no idea how much Dr Benbow knew and when he knew it, but a proper, open and transparent public investigation is urgently required. The GMC cannot claim to be concerned about the scientific integrity of doctors when it behaves in this manner. Indeed the GMC appears to care nothing about the integrity of the research upon which our patients rely.

At the other end of the pecking scale, the GMC has felt quite happy to persecute whistleblowers such as Dr Rita Pal while hiding reports relating to the very serious problems she raised. The recent suspension of yet another Asian doctor for shouting abuse at a Pfizer drug representative was also easy for the GMC, and was presumably felt to have had less impact on the reputation of anyone who mattered [Link].

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Anonymous said...

That God we have some doctors who are able to see medicine for what it is. I have been trying (for years) to get information from the MHRA about Bayer's drug Baycol. It's not the fact that the drug damaged me that matters, but that every attempt to get information shows that this was an accident waiting to happen, and that the MHRA and your profession don't give a SHIT.

Anonymous said...

Thank you.

Struck off for shouting at a drug rep! He should have received a medal. How many patients have died as a result of drug reps (thousands) versus abusive GPs.

Anonymous said...

Spot on again. You know, you'd think that the GMC would know from distant training, to more closely inspect the s**t that they dabble in, but perhaps they wade so deeply in it these days that they cannot see it for what it is.

InformaticsMD said...

Yes, this "PC" problem will kill what's left of medical integrity.

I found this in dealing with some real schmucks doing some really crappy things at Yale: link.