“The Law of the Few”

Malcolm Gladwell in his book ‘The Tipping Point’ describes what he terms “The Law of the Few”: namely that the influence of a few people can result in change in behaviour across a wider population.

This Hole Ousia post is about the education of psychiatrists and takes all its material from publically available sources. This post hopes to demonstrate the considerable reach (to the many) of a handful of educators.

This post follows on from the evidence that was gathered for my petition to the Scottish Parliament to consider introducing a Sunshine Act for Scotland. That petition closed 16 months ago following a consultation with the Scottish public who, in majority, asked that payments made to healthcare workers and academics be declared on a mandatory basis. I have argued the reasons why I am of the view that such mandatory declarations should be registered on a single, open, central, searchable, independent database.

Evidence has demonstrated that when a doctor has a financial “conflict of interest”, this can affect the treatment decisions they make, or recommend. There is longstanding evidence that exposure to industry promotional activity can lead to doctors recommending worse treatments for patients.

The post has come about following my invitations in the last month to Continuing Medical Education (CME) provided in my place of employment (NHS Scotland). I do not knowingly  attend sponsored medical education and so declined these two talks. The first was by Dr Peter Haddad (sponsored by Lundbeck) and the next one, just two weeks later, was by Professor McAllister Williams (sponsored by Lundbeck).

I am an ordinary psychiatrist working in a provincial NHS general hospital and to find such prominent individuals visiting our wee corner of Scotland left me to reflect upon the wide influence of a few key individuals.


The British Association for Psychopharmacology (BAP) describes itself as “a learned society and registered charity. It promotes research and education in Psychopharmacology and related areas, and brings together people in academia, health services, and industry.”

Professor Hamish McAllister-Williams is an Ex-Officio Member of BAP and is currently the BAP Director of Education.  Dr Peter Haddad, former Honorary General Secretary of BAP, has been involved over a number of years with BAP education providing articles and masterclasses.

Over the course of my career as a psychiatrist I have frequently heard colleagues say that BAP “is the place to go” for CME.  It is now a requirement for General Medical Council Appraisal and Revalidation to demonstrate with our College that we have participated in CME. Once this has been demonstrated the Royal College of Psychiatrists will issue a Certificate of “Good medical standing”.

As BAP Director of Education, Professor McAllister Williams recently shared this offer to trainee psychiatrists. Following the dissemination of this I took the opportunity to look more closely at the current BAP calendar for Continuing Medical Education. This again demonstrates the wide influence of a small number of individuals, some of whom would appear (within the limits of the current voluntary disclosure regime) to have potential financial conflicts of interest.

In the remaining part of this post I have included a few examples

As BAP Director of Education, Professor McAllister Williams chaired this BAP 2015 Summer Meeting: “Expert Seminar in Psychopharmacology”. The key-note speaker was Professor Stephen Stahl who many consider as one of the most influential key opinion leaders in world psychiatry.

In the USA, pharmaceutical and medical device companies are required by law to release details of their payments to doctors and teaching hospitals for promotional talks, research and consulting. This was the return for Professor Stahl at the time of his contribution to BAP as an educator of UK psychiatrists:

In the UK disclosure of payments is on a voluntary basis.

Professor David Nutt, former BAP President, has declared financial interests on the voluntary ABPI Register. Over the ABPI “disclosure period”, Professor Nutt has declared just short of £46,000 that he has received from Janssen-Cilag Ltd and Lundbeck Ltd.

There are strong links between BAP and the Royal College of Psychiatrists. The President Elect for BAP is Professor Allan Young.  Professor Allan Young is Chair of the Psychopharmacology Committee of the Royal College of Psychiatrists. Dr McAllister Williams, the BAP Director of Education is an appointed member of this Committee. Some years ago I wrote this post about the Royal College of Psychiatrists Psychopharmacology Committee.

Some years ago I put together this Hole Ousia post on Professor Allan Young and also this post. It is clear that Professor Allan Young remains a very active educator and opinion leader in the UK and beyond:

Professor Guy Goodwin was President of BAP between 2004 and 2005. In April 2014 he featured prominently on  BBC Panorama:

On the 40th anniversary of BAP, Professor Peter J Cowen was given the Lifetime Achievement award:

Professor Philip J Cowen featured in this post of Hole Ousia of some years back: All in the past? Well no. Definitely not.

Conclusion:
The recently retired CEO of the Royal College of Psychiatrists, Vanessa Cameron, who had been with the College for 36 years was interviewed for the Psychiatric Bulletin in December 2016. This was the view that she expressed:

Each time I reconsider this subject I do not find evidence to support this view. My worry is that the Royal College of Psychiatrists is being complacent in facilitating the education of the many by such a small group of individuals. The Law of the Few.

Footnote:

If you click on each invite below you will access what is available 
in the public domain regarding the educational activities of the 
recent speakers. I apologise if this is in any way an incomplete 
record.

 

Stifling distortions












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“All in the past”: well, no.

All in the past from omphalos on Vimeo.

Seven years ago this Editorial was published in the BMJ:KOL

Eleven years ago, all NHS Chief Executives in Scotland were asked to implement and govern this Scottish Government circular: HDL 62. This has not happened.HDL-62

The General Medical Council published nine years ago:  “Good Medical Practice”, which makes very clear:Annexe A, GMC

General Medical Council on conflicts of interest from omphalos on Vimeo.

Seven years ago the Royal College of Psychiatrists issued its own guidance, CR148:CR148 says (3)

Given these multiple levels of failing in governance, and in the pursuit of scientific objectivity, I have petitioned the Scottish Government to consider implementing a Sunshine Act. The research behind this can be accessed here.

I am employed as an NHS psychiatrist and have been an NHS Consultant for 13 years.

Over this time, the key opinion leaders in UK psychiatry (though I have never met) have become known to me.

Continuing Medical Education invites (generally “CME-accredited”) come to my NHS e-mail address on a weekly basis.

As an NHS employee I have had regular invites to attend “CME-accredited” conferences that include educational talks by distinguished speakers such as:

  • Professor Allan Young
  • Professor Peter Passmore
  • Professor Guy Goodwin
  • Professor Philip J Cowen
  • Professor David Nutt
  • Professor J Chick
  • Professor David Taylor (pharmacist)
  • Professor Clive Ballard
  • Professor Nick Fox

It is the case that (in 2015) we still have no way of knowing how much may be paid to any individual to educate professionals like myself

The ABPI “central platform”, which will be operational next year, allows individuals to “opt out” of revealing any payments.

Dr McCartney has long argued that the medical profession should take the lead on transparency. I agree.

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The Royal College of Psychiatrists guidance CR148 has not been followed since it was introduced seven years ago. The updated system (following my dogged persistence) still fails to require details of monetary exchange or for specific dates of (any such) payments.

The USA have introduced a Sunshine Act and so in recent years, drug companies have started releasing details of the payments they make to doctors and other health professionals for promotional talks, research and consulting:

CropperCapture[1]

Over a decade ago, I noted this letter of reply by Professor Philip J Cowen. A reply that troubled me.

Cowen, P J - Constructionism 24-5-2011Professor Philip J Cowen

A straightforward internet search would indicate that Professor Cowen has followed extant guidance regarding transparency. Here follows some of the material on Professor Cowen to be found in the public domain:Cowen, P. J,CINP, 2016 Cowen, P J - 3-3-2014 Cowen, P J - 17-11-2014 Cowen, P J - 19-5-2011  Cowen, P J - 2011 2011, RCSPsych Int CongressCowen, P J - 2014 b Cowen, P J - 2014 Cowen, P J - 2015 Cowen, P J - April 2014 Cowen, P J - April, 2012 Cowen, P J - Aug 2010 Cowen, P J - Aug 2013 Cowen, P J - Dec 2012 Cowen, P J - ECNP Cowen, P J - Jan 2015 Cowen, P J - May 2012 Cowen, P J - Nov 2012 Cowen, P J - Nov 2012b Cowen, P J - Nov 2013From “Our own window” published in BMJ rapid responses:Soft rebuttal, 2001

Sunlight, tears and disinfection

“Sunlight is the best disinfectant,” a well-known quote from U.S. Supreme Court Justice Louis Brandeis, refers to the benefits of openness and transparency.

Sunshine, tears and disinfection

Sunshine, tears and disinfection: https://vimeo.com/74513757

This film carries the suggestions of Dr Ben Goldacre from his latest book “Bad Pharma”: amazon.co.uk/Bad-Pharma-companies-mislead-patients/dp/0007350740 At the end of this very short film, Dr Goldacre, in his appreciation of transparency that the American Medical Students Association have brought to conflicts-of-interest and healthcare, stated that he felt almost weepy.

Tears, like sunlight, it occurs to me are also disenfectants. Both sunlight and tears bring clearer vision.

CREDITS:
(1) To Dr Ben Goldacre of course

(2) To Ruth Jarman and Joe Gerhardt the prize winning filmmakers of “Brilliant Noise” by Semiconductor: vimeo.com/1284717

“Brilliant Noise takes us into the data vaults of solar astronomy. After sifting through hundreds of thousands of computer files, made accessible via open access archives, Semiconductor have brought together some of the sun’s finest unseen moments. These images have been kept in their most raw form, revealing the energetic particles and solar wind as a rain of white noise. This grainy black and white quality is routinely cleaned up by NASA, hiding the processes and mechanics in action behind the capturing procedure.”

(3) “Slow Motion Strut Version Two” is the background music track by the awesome Dexter Britain (dexterbritain.co.uk)

DISCLAIMER:
I have tried to acknowledge all source material. If any copyright is breeched please let me know and I will address such failings on my part. Also this film is an artistic work and does NOT represent the views of any organisation.

The AMBITION behind this FILM:
To see the UK develop and implement a SUNSHINE ACT as soon as possible. The filmmaker has petitioned the Scottish Parliament for a Sunshine Act: holeousia.wordpress.com/category/medical-writings/pharmaceutical-industry-and-medical-education/sunshine-act-for-scotland/