The American Medical Student Association released its 2013 PharmFree Scorecard this month, continuing to pressure and encourage medical schools to improve their policies on conflicts of interest and interactions with industry. These policies have impacts on students’ medical education, the future of the medical profession and the care physicians provide. As patients we should be able to trust that decisions about our care are based on science and our best interests, not the marketing strategies of the pharmaceutical industry.

Now in its sixth year, the AMSA Scorecard rates U.S. Medical Schools on 11 key model polices that institutions should implement to reduce inappropriate interactions between the industry and medical school faculty and students. In the 2013 Scorecard, fully 115 (73 percent) of the 158 U.S. medical schools now receive an aggregate grade of A or B for their policies, compared with 102 last year and just 45 in 2009.

Dr. Elizabeth Wiley, AMSA national president, praised the progress made: “The PharmFree Scorecard is a successful, evolving tool which assesses the policies of academic medical centers and medical schools… With all of the compelling data about how marketing influences even the best-intentioned physicians, it is gratifying to see that medical schools are taking the necessary steps toward practicing evidence-based medicine, which translates into better patient care.”

The Scorecard analyzes and scores gifts and meals from industry to doctors, paid promotional speaking for industry, acceptance of free drug samples, interaction with sales representatives and industry-funded education. Ninety-seven percent of all eligible medical institutions sent their policies to AMSA for analysis this year, up from 92 percent in 2009, a striking confirmation of its significance for medical school leadership.

Dr. Maurice Clifton, Sr. Associate Dean for Academic Affairs at the new Commonwealth Medical School in Scranton, PA, told Community Catalyst that “The scorecard was an essential tool that helped us develop a comprehensive policy to ensure appropriate interactions between students, faculty and industry in the academic clinical setting.”

Commonwealth Medical School, which welcomed its first class in the 2009-2010 academic year, received an aggregate “A” grade, with the highest scores possible on 10 of the 11 model policies. In March, Commonwealth MS joined other Pennsylvania medical schools and academic medical centers in a meeting convened by Community Catalyst to discuss best practices and strategies to implement the policies that the Scorecard measures.

Highlights of the 2013 AMSA Scorecard:

• 93 schools (59 percent) now have model polices prohibiting all gifts and on-site meals, up from 19 (12 percent).
• 79 schools (50 percent) have a curriculum on conflicts of interest, up from 12 (8 percent) in 2008.
• Schools with model policies on speaking arrangements have grown tremendously; 44 (28 percent) schools ban or severely restrict participation in speaker bureaus compared to 31 (20 percent) in 2011-2 and only 4 (2.5 percent) in 2008.
• Only 41 schools (26 percent) have a model policy in terms of disclosure, requiring personnel to disclose past and present financial ties with industry (e.g., consulting and speaking agreements, research grants) on a publicly-available website and disclosing these relationships to patients.
• Policies restricting industry support for Continuing Medical Education are now in place in only 28 schools (18 percent), but this is nearly double the number of schools in 2010.
• Access by pharmaceutical sales representatives remains a major challenge, with only four schools (2.5 percent) prohibiting sales reps from meeting with faculty and trainees regardless of location, or prohibiting sales reps from marketing their products.

A webcast of a live discussion of the AMSA Scorecard release can be found here. This National Grand Rounds was organized by the National Physicians Alliance, and includes a description of the updated methodology for the 2014 Scorecard for medical schools, as well as the new Scorecard for teaching hospitals, which were designed by AMSA and the Pew Charitable Trusts.

Community Catalyst is also producing “A Policy Manual for Academic Medical Centers and Medical Schools,” with Toolkits on the policies rated by the AMSA Scorecard – you can download the the first one, on medical school curricula on conflict of interest, here.

The 2013 AMSA PharmFree Scorecard, the NPA National Grand Rounds and the Community Catalyst Policy Manual are made possible by a grant from the state Attorney General Consumer and Prescriber Education Grant Program, which is funded by the multi-state settlement of consumer fraud claims regarding the marketing of the prescription drug Neurontin. Partners in the PACME project are AMSA, Community Catalyst, the National Physician’s Alliance, and the Pew Charitable Trusts. For more information, contact Marcia Hams, at mhams (at) communitycatalyst (dot) org.

Marcia Hams, Director of Prescription Access and Quality, Community Catalyst

With headlines about Sen. Chuck Grassley’s investigations into industry payments to psychiatrists rolling in as predictably as, well, payday, PostScript thought it would be good to get a little perspective from someone in the field.

So we talked last week with Dr. Joseph Sokal, an associate professor of psychiatry at the University of Arkansas – Little Rock, and chair of the ethics committee at the National Physicians Alliance. 

Here’s what he had to say about the industry’s footprint on the field and what Grassley’s inquiry means for his work.

PS – Do you think your field has special need for pharmaceutical collaboration or, conversely, a special susceptibility to pharma influence?

JS – To date the data indicates that psychiatrists often lead other specialists in taking money from the pharmaceutical industry.

There are a number of forces at play here. One is psychiatry’s movement towards a more biological, brain-based model of psychiatric illness and a correspondent emphasis on pharmaceuticals to correct underlying, “chemical imbalances.” This has naturally led to closer relations with the pharmaceutical industry who play a critical role in developing the treatments that most in the field rely on.

Pharma also heavily funds research that helps advance many an academic career. It is too much to say that philosophy only follows funding in this case, but it is naïve to think that philosophy has not been effected by this funding source. Psychiatry is one of the most poorly paid specialties in medicine, making money from the pharma industry that much more attractive. 

Add to that the emergence of relatively safe antidepressants in a culture very interested in happiness but not necessarily so interested in reflection, and a healthy pharmaceutical industry that has championed those diagnoses that lead to greater profit, and you have the environmental conditions for a perfect storm.

Clearly, psychiatry needs to clean its house. With that said, it is clear that this is a major problem for medicine as a whole, and focusing exclusively on psychiatry would be significant mistake.

PS – So you’ve already talked a bit about the changes you’ve seen in the field over the last thirty years—do you see that the awareness is changing also?

JS – I do think that there is an increasing awareness that this is a meaningful problem that must be addressed.

PS – Does Grassley’s inquiry into the financial statements of the American Psychiatric Association (and his earlier inquiries into Dr. Biederman and Dr. Schatzberg) have impact on your work, and if so, on what level?

JS – Yes. When the major professional organization for my field is being critically evaluated it affects the public’s view, which ultimately affects the work I do with patients.

PS – As a member of the University of Arkansas medical faculty, have you seen your institution take steps on these issues?

JS – UAMS does have guidelines for interacting with Pharma reps. The NPA ethics committee is also working on guidelines to address several aspects of medicine/pharma relations.

PS – Do you have the sense that these will be stronger than many med schools?

JS – Yes. At the NPA, we are fundamentally committed to strengthening the public’s trust in the integrity of medicine. This means actively addressing and sanctioning behaviors that undermine physicians’ fiduciary relationship with patients or give the impression of doing so. Because of this, we intend to set the highest possible standard. It is worth noting that the NPA does not get any of its funding from the pharmaceutical industry.

The Prescription Project, National Physicians Alliance, Prescription Access Litigation (PAL) and US PIRG have submitted public comments opposing an FDA Draft Guidance that would allow drug companies and their salespeople to distribute reprints of medical journal articles discussing off-label uses to physicians.

The groups outline numerous reasons why the distribution of reprints by pharmaceutical representatives does not facilitate evidence-based decision making and could jeopardize patient safety and public health. They urge the FDA not to issue the Draft Guidance in its current form and to hold public hearings on industry marketing of products for off-label purposes.

Off-label prescribing, the prescribing of drugs for non-FDA approved purposes, is legal. However, the marketing of drugs by pharmaceutical companies for off-label purposes is not legal. Currently, pharmaceutical companies can provide medical journal articles discussing off-label uses to physicians only if the physician asks for the information. The FDA guidance would loosen that restriction.

A whole lot of bloggers have taken on last week’s ghostwriting study in JAMA. Here are a few of our faves:

National Physician’s Alliance, the RxP partner group of physicians to which JAMA author Joseph Ross belongs, has this analysis of the latest chapter in the Vioxx saga.

Here’s NPA member Howard Brody’s take at the Hooked blog.

And in other blogs:

Daniel Carlat at the Carlat Psychiatry Blog compares the Pentagon’s use of thought-leaders (in this exhaustive New York Times investigative report) with Pharma’s strategy to push its message through ‘hired gun’ physicians.

Researcher and watchdog Aubrey Blumsohn has built a Scientific Misconduct Wiki to pair with his Scientific Misconduct blog.  Blumsohn writes:

Hopefully this will form the seed of a peer reviewed online journal devoted to Scientific Integrity. For the moment, it will serve as a non-collaborative repository for reports and academic analysis of the integrity scandal involving Procter and Gamble and the drug Actonel (including the serious implications of the failed but rather sad attempts at coverup and delay by ‘regulators.’”

And here’s a real time example of a university enforcing its policy of financial disclosure for physicians.  Pharmagossip and Pharmalot posted on a story in The Cincinnati Enquirer that the University of Cincinnati has a closer eye on psychiatry professor Melissa Delbello these days after big discrepancies in the size of her paycheck from AstraZeneca came to light.  The letter from Sen. Grassley probably helped things along, but it’s good to see an academic medical center acting on its conflict of interest policies.

Using court documents from lawsuits over Merck’s Vioxx, a study in this week’s Journal of the American Medical Association found that Merck often wrote first drafts or commissioned for-profit ghostwriters to write academic articles on the pain drug, then paid academic thought leaders for claiming primary authorship. Half the time, those doctors did not disclose that payment in publication, and often the corporate ghostwriter was not listed among authors at all. 

In a companion editorial, JAMA editor-in-chief and RxP advisory board member Catherine D’Angelis M.D. decries the practice, writing, “it is clear that at least some of the authors played little direct roles in the study or review, yet still allowed themselves to be named as authors.”  The lead author of the paper, Dr. Joseph Ross of Mount Sinai School of Medicine in New York, is a member of the National Physicians Alliance, a partner of the Prescription Project.

Read more in the Washington Post, the Boston Globe, and the New York Times.

The National Physicians Alliance is calling on doctors to push back on Big Pharma’s marketing machine by just saying “no” to branded tchotchkes, drug samples and sales rep pitches. Launched Tuesday, NPA’s “Unbranded Doctor” campaign urges docs to join a national network of physicians committed to reducing the influence of pharmaceutical marketing on the medical profession.

The campaign features a special website, http://unbrandeddoctor.org/ that offers docs “how tos” on becoming “unbranded,” including clever flyers and posters designed to inform patients why a doctor has chosen not see sales reps or distribute samples as well as sources of independent medical information and industry-free CME. The site also offers “Unbranded Doctor” coffee mugs, back packs, t-shirts and other products to replace the drug company-branded items that pollute doctors’ offices. For more information about the National Physicians Alliance, go to www.npalliance.org.
 

This week, drug giant Merck is out $671 million in combined settlements in one whopper of a health care fraud case.  Prosecutors for the states and federal government alleged that the maker of Vioxx and Zocor overcharged 49 states and the District of Columbia for four popular drugs, and bribed doctors to prescribe them with kickbacks disguised as consulting fees.

Read AP coverage here.

Row Row Row…Whose boat?

We admit, in the shadow of bribery, fake-rowing seems like a little white lie, but it’s one that may have turned into big bucks for Pfizer, the maker of Lipitor.   A month ago, Dr. Robert Jarvik, the Lipitor frontman that gives millions of primetime viewers the heebie-jeebies during commercial breaks every night, was outed for never having actually practiced medicine.

Now, courtesy of some digging by two Michigan House Democrats, it turns out Jarvik doesn’t row, either, as he’s seen doing in a recent Lipitor commercial (even though his stunt double’s on the team.)

Congress must decide whether the American public was more fooled by Jarvik’s doctorness or his rowing prowess, and why back in 1997 permitting pharma to run TV ads seemed like such a good idea.

Check out the PAL blog’s ideas for Jarvik’s replacement.

Industry-free CME at Sloan-Kettering: a case study

The Carlat Psychiatry Blog found this article in Medical Meetings Magazine on how Sloan-Kettering Memorial Cancer Center in New York cut industry out of its CME curriculum.

Some seemingly simple steps were taken to make up for the 25 percent of industry funding the center turned back:  Conference organizers used more cancer experts already in-house, moved the meetings from hotels to the conference center on campus, cut out catered lunch, and reduced advertising in mailers and medical journals. According to officials at the world-renowned cancer hospital, response has been positive and attendance steady. 

Vanderbilt gets on gift-ban bandwagon

Vanderbilt University Medical Center has banned gifts from pharmaceutical and devicemakers, an announcement that comes in the wake of news that the vice chancellor of health affairs was appointed to the board of Merck.

According to the Fairview Observer, the policy does not affect researchers, only clinicians, and there is no provision for oversight or penalties.

[Yeah, but who wants to anger Commodore Cornelius?]

Between the lines

Gooznews had his reading glasses on for this one:  a sentence in a New York Times story about spine device researchers who invest in the technologies they test.  Count me in, says Goozner, among the “few [who] would argue that doctors should never be allowed to invest in new technologies.”

“Why draw the line at research?” Goozner writes. “Is it okay that the doctor prescribing a particular drug has a huge hunk of his or her retirement portfolio in the stock of the company that makes that drug?”

What Would Nightingale Do?

Without much formal conflict-of-interest training or guidelines, nurses are prime targets and perhaps the next frontier for pharmaceutical detailing, according to this new article in PLoS Medicine.

Portrait Gallery

A nice profile on RxP ally, AMSA PharmFree coordinator, and Tar Heel of the Week Anthony Fleg appeared this week in the Chapel Hill News and Observer.

And the New Jersey Business Journal interviews state Attorney General Anne Milgram.  There are ten questions, but they all fall under the general category : “Why you gotta be so mean to pharma?”

State Round-up

This Charleston Gazette piece looks at the debate around a law recently passed in the West Virginia legislature that would require pharmaceutical companies to disclose all gifts to physicians to a state-wide board.

Pharmalot reports that New York State Senator Tom Morahan has asked the state health commissioner to look into a report that NY Medicaid spent $82.8 million on psych drugs for kids in 2006, many of which were off-label.

The Vermont legislature still stands behind the prescription data confidentiality law it passed last spring, according to a vote on a motion to repeal the embattled law at the state house this week.

Vermont was sued by health information companies who sell the data and awaits a trial in May.  A similar 2006

New Hampshire law was overturned by a district court judge and awaits decision by the  U.S. Court of Appeals.

From the Oops department… Covetous reporters, critics of pharma and all those ever bested by office culture had a good laugh this week after the leak of top secret documents related to Eli Lilly’s high-stakes Zyprexa negotiations to a lucky New York Times reporter was linked back to an error by a Lilly lawyer who used the auto-fill in his email headings one too many times. The docs were supposed to go to Bradford Berenson, Esq., but the unintended recipient was none other than Times pharmaceutical reporter Alex Berenson. Pharmalot has more here.

From the Let the Good Times Roll department…

Comes a good post from the New Orleans-based National Physicians Alliance doc, alias KidShrink, who made a point of speaking up and saying ‘not cool’ to a pharmaceutical Rep-Elf stuffing physician mailboxes with branded trinkets. Queen of England and King cake, all in one post.

A market research survey of 180,000 docs conducted in the fourth quarter of 2007 found that 19 percent of responding physicians said they refused to see drug reps, no matter what. That sounds like good news, until you get to the part where 73 percent will see a detailer “at any time of day, any day of the week.”  But give that the survey conductor, SK& A Information Services, is a healthcare marketing firm, we can’t blame them for some spin. [Disclaimer: this short article does not make clear what percentage of the 180,000 docs called responded.]

Such data may have played a role in this: PhRMA, the trade association for American pharmaceutical manufacturers, says it’s taking another look at its sales and marketing tactics. The trade association has taken some flak for its 2002 *voluntary* code of ethics, which was widely heralded by the medical community as a little better than no code at all.

Sen. Herb Kohl (D-WI), a co-sponsor of the Physician Payments Sunshine Act, sounded a bit skeptical about what such discussions might lead to.

“I would be pleased if the pharmaceutical industry seriously strengthened their self limitations,” Kohl told the AP. “However, if their voluntary approach hasn’t worked over the past six years, I’m unsure whether it would work now.”

In the other house of Congress, Rep. Henry Waxman announced that in his digging he’s discovered a meeting the pharma representatives had with the FDA in April that led to the FDA’s guidance that would allow sales reps to show doctors journal articles on off-label use as part of their pitch. Waxman leaked that in November, and we’re keen to see what comes of this latest development.

State of the States

Tomorrow, the New York State Assembly hears three bills on pharmaceutical reform: one would require public disclosure of gifts from pharmaceutical companies to prescribers, another would prevent companies from selling prescriber data without his/her consent, and a third would create a mandatory state clinical trials registry housed at DHS. RxP, AARP, NLARX, National Physicians Alliance and others will be testifying in support – we’ll keep you posted.

And yesterday, the New York Times ran this damning piece about how the top-tier spinal implant researchers are also top-circle investors in the companies of devices they are researching. As for the rest, you probably know it already…(since this story is on top of most e-mailed at nytimes.com). If not, read this.

A triad of good editorials appeared recently in (chronological order) the Grand Forks Herald (registration required), Beloit Daily News, and the St. Cloud Times, concerning the recent news that a group of Minnesota and Wisconsin hospitals and clinics were shipping their pharma freebies (and conflicts) off to Cameroon. The St. Cloud Times specifically cites the Physician Payments Sunshine Act as a measure worth consideration to curb the marketing influence pharma currently wields over medicine.

This piece from the Barre Montpelier Times-Argus looks how some of the state’s mental health advocacy groups are swearing off pharma, and how much salt one should take with reports like Mental Health America’s annual depression and suicide state ranking (Cheer up Utah!), once the backer (Wyeth) is factored into to the picture.

“The mantra in Vermont and the United States that this is unrestricted money is a myth,” Ken Libertoff told the Times-Argus. “It really has distorted treatment and advocacy in the field.”

Libertoff runs the Vermont Association for Mental Health, which forewent pharmaceutical grants last year. He said he’d begun to feel that accepting the industry backing was changing the nature of his organization’s advocacy work. Wisconsin isn’t doing so hot when it comes to following up or following through on medical complaints. Just eight percent of medical complaints filed between 2002 and 2006 were acted on by the board of medical licensure.

Scrutiny of such investigations has been growing, perhaps in the wake of a New York Times report last May that documented a Minnesota psychiatrist who’d been repeatedly sanctioned by the medical board continued to consult for pharmaceutical companies.

Academy bristles at OIG report

And in a follow-up to last week’s article on the OIG report that the NIH has taken a hands-off approach to monitoring conflicts of interest, the Chronicle of Higher Education takes its turn. With a definite dog in this fight (since the NIH has said universities should police their own grantees), the Chronicle doesn’t pull punches when it comes the research monolith in Bethesda.  “In harmony with its distaste for the police function,” the Chronicle writes, “NIH takes a minimalist approach to checking on conflict of interest among its grantees — so minimalist, that any less would be none.” Ouch.

From the blogs:

Here is Howard Brody’s attempt to keep his argument against conflicts of interest on track, and why it’s not akin to hating capitalism….Just in case you were confused.

At the Carlat Psychiatry Blog, Dr. Carlat has an email exchange with American Journal of Psychiatry editor Dr. Robert Freedman that leaves him baffled. Us too.  First, Freedman disclosed an unpaid relationship with investigators, then in an email to Carlat, said it was just in case he had to contact pharmaceutical investigators…in the future. Is that like the Boy Scout Motto for conflicts of interest? 10 yards, 10 years: a modest proposal

And what would Superbowl week without a football-related pharma story? After all, PostScript is headquartered in Patriot Nation. So in the spirit of all that side-effect-induced suspense between downs, this Boston Globe column suggests we take the next decade off the pharma ads during sports programming.

Yesterday, PostScript visited the John Joseph Moakley courthouse in Boston.  After getting a wee bit lost, we made it safely into the U.S. Court of Appeals, which heard the appeal of a decision by the First District Court in New Hampshire last April overturning that states’ ban on the sale of prescriber data for marketing purposes.

PostScript has not minced words about the practice of data–mining (for proof, look here). As a matter of tradition, we didn’t mince much here, either. 

In the case IMS inc. v Kelly Ayotte, Judges Lipez, Selya and Siler heard arguments in support of the overturned law from state counsel Laura Lombardi Esq., and Sean Flynn Esq., legal consultant for the Prescription Project, which filed an amicus brief alongside the New Hampshire Medical Society, NLARX, NPA, AARP, PPC.  (See end for acronyms – it’s like a crossword.)

Counsel for the defendants, three data-mining companies that buy the information from the pharmacies and sell it to the drug companies, argued that the overturned prescriber data confidentiality law amounts to content discrimination, privileging payors who want to reduce drug costs with data while restricting sellers (pharma companies) from the same data sets.

IMS counsel argued also that the state had brought no evidence that the sale of prescriber data had led to sub-optimal prescribing. This is a sticking point. After all, you can show that NH doctors have been prescribing lots of brand name drugs, and you can show they prescribed ones that had sub-optimal effects – Vioxx, say.  But it’s hard to compare that to what doctors would have prescribed if detailers had not been snooping around in their prescribing data.  Would reps have used other tactics?  Would those have sold less or more brand-name drugs? No one knows.

Since the influence of gifting and relation-building on prescribing behavior is well-documented, the state thinks – and we agree — that docs would generally prescribe less brand name and more proven older drugs if detailers weren’t hanging around so much.  But without another state to look to (New Hampshire was the first one to pass a data mining ban like this), the evidence is inferential, even common-sensical – but not documented yet.

The IMS counsel also warned the court that without accessing to individual prescribing records, pharmaceutical companies would have to increase their marketing force. But with the R& D pipeline tapped, generic prescriptions on the rise, and frequent news of pharma layoffs and an ongoing round of executive musical chairs, how much bigger can the sales force reasonably get before they run out of things to sell?

Attorney Flynn made rebuttal for the state, noting that if the district court’s decision is allowed to stand, a healthy handful of really good laws prohibiting the release or use of consumer data would be threatened, including the Driver Privacy Protection Act, Video Privacy Protection Act, Stored Communications Act, Electronic Communications Privacy Act, and Fair Credit Reporting Act.

Judge Lipez asked why, if the New Hampshire law affects the conversation in the doctor’s office between a detailer and doctor, the plaintiffs contend the case is not about commercial speech.  “They’d know a lot less about that doctor than they did before,” Lipez said. To PostScript and a lot of docs out there, that doesn’t sound half-bad.

Flynn emphasized that the law does not impinge speech but rather access – access to information created by the doctor and the patient.  If there were any grounds for a speech restriction argument in this case, Flynn added, it would be that the sale of this prescriber data to salesmen and -women impairs doctors’ right not to speak. 

“It’s the doctors and patients who are speaking,” Flynn said.

For more information, see the Prescription Project fact sheet on data-mining, Flynn’s legal memo on the New Hampshire decision, and www.reducedrugprices.org.

acronyms: NLARX = National Legislative Association to Reduce Drug Prices; NPA = National Physicians Alliance; AARP = American Association of Retired Persons; PPC = Prescription Policy Choices

Two Maine physicians, Drs. Ben Schaefer and Bethanie Picker, threw in their hats Monday for LD4 in the op-ed pages of the Bangor Daily News.  LD4 is a law passed in Maine earlier this year that gives doctors a choice to keep their prescribing data from being sold to the pharmaceutical sales force via a nifty process called “data mining” (more on that here and here).  The law is being challenged by industry and the middle men running the sale, who claim medical data is the ticket to better health care. 

Schaefer and Picker say yes, data matters, but so do the hands it is in, and they think prescribing data in the hands of sales people with a Lipitor quota to hit is hardly a guarantee of better medicine or patient care.

If Dr. Schaefer’s name looks familiar, you might have seen his letter to the editor in the Wall Street Journal on Saturday.

“Frankly,” he wrote, “I am tired of hearing Big Pharma complain. There may be a crisis looming, but it is largely a self-made crisis and not even close to the one faced by patients who haven’t been able to afford their medicines in recent years.”  If you are a subscriber, go here.  And he and Picker have been in the op-ed pages before in support of stopping the sale of prescriber data for marketing purposes.

What to make of Dr. Schaefer’s rising word count? Well, the conversation around conflict of interest is certainly not a new one, but one could argue (and we will) that the debate is heating up. PostScript takes it as a good sign that doctors are joining in as vigorously as Picker and Schaefer have. 

After all, medicine is not just practice but an idea, an ethic, and a critical, if broken, social contract.   Healing patients is good, yes, but healing them and also thinking about how it’s done and how it could be done better – in this case, without the over-the-shoulder help of the pharma’s sales team – is even better. 

Schaefer and Picker are both members of the National Physicians Alliance, a great group of docs and ally of the Project.   Other NPA docs in print (and online) are Daniel Carlat,  Howard Brody, and NPA blogger Chris McCoy.  But the common thread here is not the newsprint, but their self-made roles as citizen MDs.

Let’s be clear; we’re not talking about the long-standing tradition of the doctor-writer, the William Carlos Williams way of putting down the art and science of medicine in poems, or of Atul Gawande, who writes with a definite audience in mind (readers of The New Yorker, for one). 

Instead, Schaefer, Picker, and other physician-advocates like Carlat, Brody, Joshua Sharfstein and Roy Poses, to name just a few, are writing because they believe there are things that need to be said, opposed, and fought for.  As those practicing medicine, they have the twin right and responsibility to do it. And, let’s face it, the letters behind their name to get heard.