Conflicted?

As I mentioned in my last post, I am currently enjoying the bliss and happiness of wedded life.  And to answer one obvious question, no, my wife and I are not on a honeymoon.  We’re putting that off until later.  (Otherwise, I’d have a lot of explaining to do right now!!)  However, amidst the joy and pleasure of the last few days, I’ve received a few inquiries from my regular readers and Twitter followers, particularly those who know me well.  Specifically, they want me to explain who the “lucky woman” is.

In other words, they’re asking me—as they would any professional writing about his or her field of expertise—to disclose any potential conflicts of interest.  I figured it’s best to put it out in the open, once and for all:  I’m married to a pharmaceutical sales rep.

At first, I wondered whether such a disclosure was necessary.  This blog is not a commercial enterprise (i.e., I make no money from it), my posts aren’t intended to guide practice, and my writing—like that of almost anyone in the blogosphere—represents my own personal opinion.  Besides, I’ve been up front with my employers, and colleagues, and peers about my relationship, and it has never presented a problem.  Nevertheless, I know that this blog has attracted attention from other mental health professionals and from some patients and certain websites that advocate on behalf of patients, so I believe it’s only right to disclose this fact.

For readers who only know me from my blog posts, this disclosure may come as a surprise.  And more specifically for those who understand modern psychiatry or pharma sales (or both), it might very well be a reason to question what I write on this blog.

How so?  Well, I could, for instance, advocate in favor of my wife’s drug but for none of her competitors’.  I could write negative stories about other medications but nothing critical about hers.  Or, unbeknownst to readers, my wife and I could share detailed information about patients—or about the inner workings of the pharmaceutical industry—so that I can write posts that disparage her competitors and/or strengthen her sales pitch for her drug.

I can state emphatically and unequivocally that none of the above has come to pass.

What attracted me to my wife were her wit and charm, her character, her world view (the world beyond psychiatry, that is), and her own personal background—some of which is strikingly similar to my own.  Not her smooth-talking sales pitch or the fact that I might get some perks or kickbacks from the company that provides her paycheck.  (For the record, I have received no “perks” or “kickbacks” from her employer, nor has anything of the sort been offered or implied.  Moreover, I am not in her “territory,” so my prescribing patterns have no bearing on her success, or vice versa.)

As it turns out, we share even more than I had anticipated.  She is thoughtful and insightful, yet justly skeptical and always curious for evidence to support what she says or what I prescribe.  She can engage in intelligent conversation about the future of psychiatry, but she also doubts the universal efficacy of psychopharmacological intervention.  Furthermore, just as I find myself routinely questioning conventional psychiatric practice, she is also a keen observer of her own industry.  She has been quick (and correct) to denounce the unethical behaviors of some of her competitors, many of which have come to light in the last few years (thanks, in part, to my fellow bloggers).  She also recognizes the deficiencies of the medical model of psychiatric illness—and, frankly, the limitations of her own drug—and implores her customers (i.e., doctors like me) to see their patients as whole, living beings, rather than simply as consumers of her product.

I’ll admit that some predictable difficulties have emerged in our unlikely partnership.  For instance, I have a scientific background, many years of medical training, and vast exposure to patients with complicated life stories.  She, on the other hand, is employed by a corporation, has to follow strict guidelines, and only interacts with patients (and anonymously, at that) in a doctor’s waiting room or parking lot.  Each of us is astonished by the frequent discrepancy between what she is expected to discuss with doctors, and what actually happens in the psychiatrist’s office.  And don’t get me started on the issue of what we each believe is a “fair” price for a new drug.

At the same time, however, we’ve learned from each other’s experiences.  I don’t discuss the specifics of clinical cases with her, but she understands that there are multiple dimensions to any patient (far more than the DSM-IV or clinical trials would predict).  I now know far more about how drugs are marketed to doctors, and how my colleagues use (or don’t use) such information.  Whether these observations make her a better salesperson or me a better clinician, neither of us can accurately judge.  Speaking for myself, however, I think they’ve made me a more informed—and more critical—prescriber.

So in sum, I don’t see my relationship as a conflict, but rather as a source of wisdom and insight.  Or, at the very least, a way to keep grounded in the reality of medicine as both as a healing art and as a business.

But I must conclude with one additional point.  As some of my readers know, I have had my own personal history as a psychiatric patient.  I speak with some confidence when I say that I believe I’ve overcome the challenges of my past, but I also know that nothing is ever 100% certain.  Nevertheless, my hope for rehabilitation, recovery, and ultimate freedom from long-term psychiatric care, is something I bring to every patient, because it’s a part of my own experience I wish to share with others.

Unfortunately, I know too that my history—in addition to my relationship status—makes me an “easy target” for those who wish to criticize the unholy alliances and conflicts of interest that seem rampant in psychiatry.  I believe, however, that both aspects of my past strengthen my observations—and criticisms—of the state of this field today.

In the end, I know that I cannot please everyone.  Thus, I’ll concentrate on keeping (a) myself, (b) my wife & family, and (c) my patients, happy, healthy, and empowered.  I would be overjoyed if my blog continues to educate, entertain, and inspire discussion.  But I would also understand any suspicions that may emerge among my readers.

I can only hope that I’m judged by the accuracy of my words, the novelty of my ideas, and the strength of my actions—not by any perceptions, accusations, or expectations of bias.

If I fail at this, I want to know.  I want—and need—to set it right.

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11 Responses to Conflicted?

  1. Rob Lindeman says:

    And so it is a near certainty that the lucky woman is extremely attractive, energetic, enthusiastic and persuasive. I’d say you are lucky man!

    On a serious note, you’ve spoken for yourself. Would you say your new bride is vigilant not to let slip that her husband is a psychiatrist, so as to boost her “street cred” with potential clients?

    Finally, you seem to imply that she details psyche meds. If it were just inhalers and stuff I don’t think you’d have much to write about this.

    Good luck to you kids, in any case – many years of happiness!

  2. AA says:

    Steve,

    It is interesting that the people who feel they have to provide explanations as you did in this situation, don’t owe us a darned thing. Whom you marry and congratulations by the way, is none of our darned business.

    Anyway, the focus needs to be on what you write. In my opinion, you do a darned good job. I also greatly appreciate the fact that you give everyone an opportunity to comment without censure and judgment and don’t act high and mighty because you’re a medical professional and peons like me aren’t.

    • stevebMD says:

      Thank you, AA.

      Regarding my “giving everyone an opportunity to comment,” please note that I have recently activated “comment moderation.” I will continue to approve all comments– even those that might be critical of my position– but I will not approve those that contain personal attacks against me or my wife.

      • AA says:

        Yup, personal attacks have no place on any blog no matter what your position is. I totally understand you activating “comment moderation”

  3. stephany says:

    I agree with the disclosure, regarding the upfront disclosure needed for readers here, thanks for doing that Steve. There is always a potential for COI when a doctor writes/blogs about psych meds and a spouse promotes them to doctors for a living! I can see why they moved you out of her territory!

    I assume you met at work, so it was probably company policy for her at least to disclose to her boss she was marrying a doctor in her territory.

  4. Congratulations on your marriage. I appreciate your candor. Your disclosure is an excellent example of how potential COIs should be handled, namely, let those concerned know what’s going on.

    By the way, if you can get me some free samples of interesting Rxs with euphoric effects, I won’t tell anybody where I got them.

  5. Carol Levy says:

    Gotta admit at first I thought you were making a joke about her job because of the inherent irony.
    As long as you and she are okay with it who the heck are we to worry. I am sorry you felt you needed to mention your psych. hx.

    I do not know what hx my neurosurgeon has with say surgery for seizures or what his wife, if he has one, does for a living.
    I would hope that a seizure history from the past would not well up again while he has a scalpel to my brain but I also feel he does not have to tell me about this.

    You are brave to share both (and from your description of the Mrs. very, very lucky.

    (I do not do comment mod. on my blog but after some awful posts from someone (or someones but think same person with aliases) who does not believe those with chronic pain are anything but fat, lazy ,and looking for a handout I have considered it (I also get a lot less comments then you) and understand perfectly why you have enabled it. So.
    Go now, sit down, and have a nice cup of coffee or wine with the Mrs.

  6. Iatrogenia says:

    Congratulations to both of you, Dr. Steve. I wish you all the best.

    As a patient advocate, I appreciate the information. But for me, it’s not necessary. Intimate relationships have so many dimensions, potential conflict of interest via professional associations is hardly a reason to back away from a good match.

    People often marry people they meet through work. No surprise there. After James Carville married Mary Matalin, who’s to criticize someone else’s choice of mate on the grounds of COI?

    As for your personal history, you will always have to come to terms with that, as we all do.

    Sometimes people who have been made into victims become self-righteous and persecute others. Lack of ideological purity is an easy target — how could the issues with psychiatry be any more complicated?

    Even among the most vocal critics of psychiatry, all kinds of personality issues and quasi-ethical inconsistencies abound.

    Your blog speaks for itself and, as you embark upon your career, I am sure your patients will receive sensitive, highly informed treatment — which is all I ask from any doctor.

  7. Congrats on your recent marriage! As to disclosures – do what you feel is right. I think sometimes the problem with modern medicine is that we don’t listen to our guts nearly enough.

  8. doctorz says:

    Steve, we as serious psychiatrists tend to analyze too much. I don’t think that any reasonable person would question your values or judgment in choosing a loving and compatible life partner on the basis that your bride happens to be employed in any industry of which you have been rightfully and objectively critical, and in doing so, have probably alienated members of your own profession as well as hers. Similarly, your wife has assumed some professional risk as well, in committing herself for life to such a man, with whom she likely shares such Aristotelian cardinal virtues, namely courage and justice, which by the way, also make for successful unions.

    Stigma associated with any group is often sowed by a small minority of its membership, and that is as true in the pharmaceutical industry as it is in the profession of medicine, albeit the latter entity is held to a higher standard, as it should be. We must remember that the unholy alliance that exists between Big Pharma and Psychiatry could not have occurred without the complicit cooperation of physicians, and because of that fact, Psychiatry is more to blame than Corporate America for the mess we’re in. But reputations are the responsibility of individuals, and from my observations, you and your wife, have represented your respective guilds with integrity.

    In closing, please allow me to say that you may face, in the course of what I hope is a long and gratifying marriage, many more internal and external conflicts that will tempt your hair to gray and your countenance to wrinkle prematurely. But, in the end, it is those very shared values, that will strengthen your bond and souls.

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