Carl Elliott is the author of White Coat, Black Hat: Adventures on the Dark Side of Medicine. Elliott is a professor at the Center for Bioethics at the University of Minnesota. His work has appeared in The New Yorker, Atlantic Monthly, the Believer, Slate, the London Review of Books, and theAmerican Prospect. His six previous books include Better Than Well, Prozac As a Way of Life, Rules of Insanity, and A Philosophical Disease.
This post originally appeared in two parts at the Chronicle of Higher Education's Brainstorm blog.
In June, I will be returning to Washington for the annual Pharmed Out conference, a project located at Georgetown University Medical Center. It is one of my favorite events of the year, in part because of the wide array of academics, journalists, and activists who attend, but mainly because of its extraordinarily committed, outspoken director, Dr. Adriane Fugh-Berman, and her merry band of student volunteers. Adriane agreed to an interview by email.
Would it be fair to say that your project was funded by a felony?
Yes, we were funded by the Attorney General Consumer and Prescriber Grant program, a novel and never-to-be-repeated program that resulted from a settlement between Pfizer and all 50 states and the District of Columbia. We promised so much that before we got the grant, the grant administrators asked us to cut down what we promised to do. We refused — and in the end, we exceeded what we promised.
Just by chance, we had begun our project by shooting an interview of Shahram Ahari — a former drug rep for Eli Lilly who is now a medical student — talking about how he had sold Zyprexa. That was just days before the story broke in The New York Times about how Lilly hid data about adverse effects. Jim Ridgeway, the investigative reporter and filmmaker we worked with, realized that what we had was newsworthy and insisted that we release a quickly edited video clip. We didn’t even have a phone line yet, let alone a Web site. So we released the video on YouTube, crediting the not-yet-existing PharmedOut, with Georgetown’s media office as the contact number. It received a lot of media attention. The video “Zyprexa Drug Rep” has been viewed more than 150,000 times.
Since then, we’ve done novel research on, for example, promotional tone in medical journal articles, and how marketing messages are inserted into CME. We created the first educational module that has convinced physicians that they are personally affected by promotion. And we’ve had groundbreaking conferences, the third of which will be held at Georgetown on June 14-15. It’s called “Missing the Target: When Practitioners Harm More Than Heal,” and will cover the potential adverse effects of marketing drugs and medical devices.
How did you get started as an activist?
I came out of women’s health advocacy work, and we were fighting medicalization of childbirth, menopause, and menstruation, so I feel I always had that bent. Being a reformer suits my crabby nature.
I come from a family of utterly fearless women. I’m the most cautious, but apparently still less afraid than most. My parents were both anti-Vietnam war activists. My mother was very active with Women’s Strike for Peace, and met with Vietnamese women in Djakarta. My brother was president of SDS [Students for a Democratic Society] at Rutgers. I think I learned to walk at demonstrations.
I got involved in feminism, women’s health, worked at Planned Parenthood as a teen, then a reproductive health clinic as a counselor and medical assistant. I would sometimes ask docs to treat women who couldn’t afford care. I decided it would be easier to become a doc then beg docs to help people. Anyone who hasn’t been through medical training romanticizes medicine; med school and internship were so tough in unexpected ways.
I know exactly what you mean, but maybe you should explain.
Med school was anti-intellectual and inhumane. First there was the vast quantity of mind-numbing rote memorization of largely irrelevant material in the basic-science years, followed by the clinical years, in which we learned tradition, myth, and ritual. The overwhelming amount of material in the preclinical years makes students pine for shortcuts. No wonder they’re ripe for the simplistic, definitive messaging of drug reps later. Third year was one long hazing ritual; then in fourth year we were accepted into the fold. And in gratitude, we would accept and perpetuate the whole dehumanizing training system.
Questions were punished. Empathy for patients was discouraged. I was horrified that there seemed to be no connection between medicine and public health, and only a tenuous connection between medicine and science. (Whenever docs are caught out doing something nonscientific, they say, medicine is an art, not a science.) And only lip service was paid to the concept of patient autonomy, or making medical decisions in the context of a patient’s own life and values.
So when they removed your soul in medical school, did it hurt? I was under the impression that soul extraction was a pretty simple procedure, but to be honest, I found it excruciatingly painful.
Yeah, they need to work on the informed consent for that procedure.
I think all of us found ourselves doing things or thinking things we would not have imagined being capable of. Being deprived of sleep, food, and the company of loved ones is terrible for the soul. I remember reading an account of a hungry, exhausted intern who wolfed down the dinner of a patient who had just died. No physician would be proud of that, but we would all understand it. We need to change the training system. Physicians-in-training who are treated compassionately will treat their patients with compassion. Medical training is changing, but not fast enough.
Can you think of any particularly bad moments that seem emblematic to you?
The interns discussing how we envied patients because they were lying in bed and eating and watching TV. It’s terrible looking back on how distorted our thinking was. One of my internship mates ended up in a mental institution; another intern attempted suicide. Standing in a supply cabinet looking for a kit to cath someone who hadn’t peed in 18 hours and realizing, “Hey, I haven’t peed in 18 hours either.” On a psych rotation, handing out an account of a patient permanently damaged by electroconvulsive treatment to fellow students and having them hand it back, saying, “I don’t want to hear the other side if it involves more reading.” Being criticized for putting my arm around a pregnant teen on the way to the exam room. Realizing that preference in IV fluids or antibiotics varied by medical specialty as opposed to patient or disease characteristics. The utter exhaustion — falling asleep on a bus to my clinic for four hours, as the bus crisscrossed the Bronx. The guy I lived with didn’t make it home one night because he fell asleep on a dumpster at a subway station.
What about your writing? When did that start, and how?
I always wrote. I come from a family of writers and activists. Words were important. My father was a professor working on his fourth book on American government when he died at age 39. My mother wrote as well — a column for a small newspaper, letters to the editor. She would have written more had she not been left widowed and penniless with a nine-year-old and a 19-year-old. She never finished a cookbook she started, but my brother, a chef, later wrote one. I was made to write letters as a child, and my family wrote letters to each other. I remember coming home once to an eight page screed from my mother unfurling from a kitchen cabinet.
Anyway, my mother went into the restaurant business, which she ran like a social-service agency. She hired a busboy too damaged to speak, poor single mothers, a prostitute from Chinatown. She brought in chefs from China. Our restaurant launched many others in DC. She was so generous to everyone. We never had money, but we had lots of fun and ate like kings. Food, in my family, was the most important thing. My grandmother believed you should be able to recreate any dish you taste. Not that she deigned to make much non-Chinese food. She did make a great apple pie, from sour, quarter-size apples from a tree in her backyard. I didn’t realize that she had learned to make apple pie in some YWCA American acculturation course she took after coming to the U.S.. As a child I thought apple pie was a Chinese dish. The day my grandmother made a bad dish was the day we knew she was dying.
How have you managed to keep Pharmed Out going?
Those of us who started the project came out of nonprofit groups so we knew how to work crazy hours, convince volunteers to work harder for free than they ever worked for pay, and stretch a penny until it screams. We have an incredibly smart, savvy, responsive, creative team.
Our strength has always been the industry insiders who have provided us invaluable information on marketing practice, and the utter dedication of the doctors, scientists, students, artists and all the individual donors — who have kept the project going despite our having no external funding support since 2008. Every single person whom I paid off the initial grant continued to volunteer for the project after the money ran out. Our Web master supported the site for years; every academic stayed on. Even our work-study student continued to work for free after our funds ran out. Our fabulous anonymous team is what makes this project great. Because so many team members — not just industry — must remain anonymous, we made a decision not to name those team members who could be named. Our staff has been phenomenal. Alicia Bell, now a med student at the Medical College of Virginia, was the founding staff-person who became an amazing colleague over our first four years; without her we would not have achieved the impact we did. Beth Johnson and Nicole Dubowitz have also been great. But every one of our projects is a team effort. As director, I get way too much credit. I have a brilliant, efficient team that reminds me often of one of my mother’s favorite quotes: “The difficult with ease, the impossible with time.”