Drug Rep with an MD

Dr Daniel Carlat's article in The New York Times is a stunning first person account of the kind of friendship and influence that pharmaceutical industry money can buy. Dr Carlat, an assistant clinical professor of psychiatry at Tufts University School of Medicine and the publisher of The Carlat Psychiatry Report, is astonishingly candid about how he became an industry-sponsored speaker and why he gave it up in favour of running a blog and a report (that takes no drug industry money) that is meant to help doctors critically assess drug research and marketing claims.
His moment of truth arrives when a fellow psychiatrist asks him some tough questions about the side effects of Effexor-- the drug that Dr Carlat is being paid to talk up. This is perhaps the most powerful passage in the story. Dr Carlat is quoting from an industry-sponsored study which reports that patients are liable to develop hypertension only if they are taking Effexor at doses higher than 300 mg per day, when the skeptical psychiatrist says many of his patients developed hypertension on much lower doses. Dr Carlat describes his own nervousness, how he speeded up the talk and presented more data in support of Effexor. But this is also when his conscience kicks in:

"Driving home, I went back over the talk in my mind. I knew I had not lied — I had reported the data exactly as they were reported in the paper. But still, I had spun the results of the study in the most positive way possible, and I had not talked about the limitations of the data. I had not, for example, mentioned that if you focused specifically on patients taking between 200 and 300 milligrams per day, a commonly prescribed dosage range, you found a 3.7 percent incidence of hypertension. While this was not a statistically significant higher rate than the placebo, it still hinted that such moderate doses could, indeed, cause hypertension. Nor had I mentioned the fact that since the data were derived from placebo-controlled clinical trials, the patients were probably not representative of the patients seen in most real practices. Patients who are very old or who have significant medical problems are excluded from such studies. But real-world patients may well be at higher risk to develop hypertension on Effexor.
I realized that in my canned talks, I was blithely minimizing the hypertension risks, conveniently overlooking the fact that hypertension is a dangerous condition and not one to be trifled with. Why, I began to wonder, would anyone prescribe an antidepressant that could cause hypertension when there were many other alternatives? And why wasn’t I asking this obvious question out loud during my talks?"

The Real Thing

Two Days in Paris reminded me of Tom Stoppard's play, The Real Thing. The protagonist, Henry, a playwright, is married to an actress. He falls in love with another actress and as he leaves his marriage, he wonders if this new love is the real thing.
There's a passage in the play where he talks about the fact that insecurity in love stems from the suspicion that somebody else has the same kind of access to or knowledge of the loved one as we do.

"It's to do with knowing and being known. I remember how it stopped seeming odd that in biblical Greek, knowing was used for making love. Whosit knew so-and-so. Carnal knowledge. It's what lovers trust each other with. Knowledge of each other, not of the flesh, but through the flesh, knowledge of self, the real him, the real her, in extremis, the mask slipped from the face. Every other version of oneself is on offer to the public. We share our vivacity, grief, sulks, anger, joy...we hand it out to anybody who happens to be standing around, to friends and family with a momentary sense of indecency perhaps, to strangers without hesitation. Our lovers share us with the passing trade. But in pairs, we insist that we give ourselves each other. What selves? What's left? What else is there that hasn't been dealt out like a deck of cards? A sort of knowledge. Personal, final, uncompromised. Knowing, being known. I revere that. Having that is being rich, you can be generous about what's shared -- she walks, she talks, she laughs, she lends a sympathetic ear, she kicks off her shoes and dances on tables, she's everybody's and it don't mean a thing, let them eat cake; knowledge is something else, the undealt card, and while it's held it makes you free-and-easy and nice to know, and when it's gone, everything is pain."

Crazy like a fox

She's so bright, this Julie Delpy character. I've just watched Two Days in Paris, a film she wrote, directed and composed music for...and I think its somewhat autobiographical. It's the funniest movie on love I've seen in a long time, horribly funny in the way that only truth can be. It makes me think she had far more do with the script of Before Sunrise, than was let on, that Richard Linklater is probably forever indebted to her. What I liked best about this film is its intelligent banter and and how it frequently laughs at the more ridiculous and torturous aspects of love -- the ways in which we want to posess each other, how reluctant we are to really know the people we love. It is also an intensely political film in some ways - ploughing as it does into every racial stereotype, contrasting European artistic freedom with American piety and laughing darkly at male sexual jealousy. Delpy plays Marion, a Parisienne now living in New York with her American boyfriend (Adam Goldberg). They're visiting Paris for two days and the stream of Marion's exboyfriends and her flirtatious nature sets jealousy going like a fat gold watch. Marion doesn't quite see the problem, you end up sympathising with the slightly hypochondriacal, sad clown character that Goldberg so brilliantly becomes.
I also like how her character always holds up the mundane problems of love against the larger problems in the world. That appeals to me a lot. The ability to appreciate scale when it comes to problems, romantic or otherwise, is vastly underestimated, come to think of it. There's a gem of a scene which she talks about in an interview -where Marion is agonising about men one minute and the next minute, she's worried because she has read that women use four times more toilet paper than men.. "And now I think of everything we destroy," she says, all the while crying...
Pretty crazy, but rang true to me.