Physicians, Even Those Educated in IT and Informatics, Are Not "Real" IT People

I've been participating in the comment thread on the HisTALK heath IT industry news/gossip site at http://histalk2.com/2009/09/17/news-91809/ . At this time there are 40 comments - mine start at #4. (I've also archived the thread in Word format here.)

It's been quite interesting, demonstrating that many of the harmful attitudes of IT personnel about healthcare I observed more than a decade ago are still around.

An anonymous commenter under the title "Programmer" has been forthcoming with views I think are actually common in the health IT field about medicine, science, IT flaws and shortcomings, and physician involvement in HIT. I will let you read them for yourself at the above link.

Others have indicated in that comment thread and other threads that "Programmer" is an executive with a large HIT company, but I cannot confirm this.

Among other stunning views, this commenter exhibited:

• Serious errors in logic such as repeatedly and unshakably mistaking well-documented reports about known rates of IT project failure as a condemnation that all IT projects fail, perhaps reflecting a state of denial;
  
• Lack of understanding that in scientific fields such as biomedicine, conclusions generally should be supported by reasonable evidence, not "because I think so";
  
• Lack of understanding and dismissal of the value of the peer reviewed scientific literature on health IT, and further, a seeming inability or unwillingness to peruse the "references" section of scientific articles, a profoundly unscientific approach to the world;
  
• Dismissal of the written views of organizations such as the Joint Commission, US National Research Council, European Federation for Medical Informatics and others on HIT deficiencies;
  
• Perhaps most harmfully, dismissal of faulty conceptual and physical data models, inadequate workflow and cognitive support, and IT of poor user interaction design that presents a mission hostile user experience as a real problem in critical care areas such as Invasive Cardiology (specifically, in this case). Instead, this IT person dismissed physician dismay and rejection of such ill-designed and profoundly unusable IT as a mere "pissing contest" between IT and clinicians, consistent with narrow, territorial, paternalistic, indeed autocratic IT-centric views and a reversal of enabler (clinician) vs. facilitator (IT service provision) roles in patient care.

"Programmer" also attacks (from the perspective of arrogant ignorance) the "Health IT Project Success and Failure: Recommendations from Literature and an AMIA Workshop" white paper drawing together the thinking at a workshop attended by over fifty informatics experts from all areas of medicine and technology. The role of the medical informatics expert itself, and other issues as well relating to reasons for HIT failure and difficulty are attacked and dismissed.

(If the person is a fake or "sock puppet", they're doing a mighty accurate approximation of my own uncomfortably-common observations in managing health IT and biomedical research IT projects while working with non-biomedical IT personnel, see cases here.)

The crux of the matter came out towards the end where "Programmer" maintains in Comment #28 that I am "just someone who likes to talk about IT” and he is a “real IT person.”

A "real IT person?" I've heard that before: this is the "doctors don't do things with computers" (including medical informaticists) type of comment I've heard face-to-face periodically from healthcare IT personnel since I entered the field in the early 1990's, and commented upon a decade ago here.

I've emailed Tim, the proprietor of the HISTalk site [mr_histalk AT yahoo.com], to inquire if this poster was real or just a provocateur.

Tim's response: "He's real and has been around for awhile, although lately he seems to be enjoying an escalated level of confrontation when he can create one."

I maintain -- based on personal experience and that told me by others -- that this person's views are not all that rare in the HIT vendor and hospital IS communities.

I also opine that thinking such attitudes can be dealt with by logical argument and persuasion is a belief itself lacking in rigor.

IT personnel of views as in the HisTALK comments thread represent an older culture of data processing, dating from the days of card punch tabulators that ran businesses prior to computers. It is a culture that has failed to mature with the times.

As I wrote here, the unimaginative, process over results, tight fisted control, bureaucratic data-processing culture of the business IT (management information systems) world is the lineal descendant of IBM's patchcord plug-panel programmed, card tabulating machines from which IBM made a large portion of their profit in the days before the electronic computer:

Hollerith Type III Tabulator with its control panel exposed. Photo: MNRAS, Vol.92, No.7 (1932). Click to enlarge.

Fortunately, such personnel and their designer-centric, as opposed to user- and work-centric philosophies are starting to become obsolete. This can be observed (as an example) via the mission of the iSchool consortium, of which my organization, the Drexel College of Information Science and Technology, is a member:

The iSchools are interested in the relationship between information, people and technology. This is characterized by a commitment to learning and understanding the role of information in human endeavors. The iSchools take it as given that expertise in all forms of information is required for progress in science, business, education, and culture. This expertise must include understanding of the uses and users of information, as well as information technologies and their applications. [the order of these priorities is pertinent - ed.]

Unfortunately, the data processing culture and its adherents are not becoming obsolete quite fast enough. There are still too many in the upper echelons of management, including health IT vendors, hospitals and pharmaceutical R&D environments.

Finally, IT personnel with such attitudes as displayed in the comments, from the lowliest programmer to the CEO and Board, have no place anywhere near where patient care is conducted, or where information systems serving clinical medicine are designed and built.

In line with other character types one encounters in healthcare that are often discussed on Healthcare Renewal, clinicians should not accommodate such IT personnel and these types of views.

-- SS

Addendum:

The final (at this time) comment, #40, left by the above commenter states:

#40 Programmer: If I decide to become a medical informatproctolicist, I’m going to specialize in sardonicology.

IT personnel of such views bring to life Lecia Barker's paper "Defensive climate in the computer science classroom":

“Defensive climate in the computer science classroom” by Barker et al., Univ. of Denver. Link here (subscription required). May help explain the control-seeking culture of IT personnel. As part of an NSF-funded IT workforce grant, the authors conducted ethnographic research to provide deep understanding of the learning environment of computer science classrooms. Categories emerging from data analysis included 1) impersonal environment and guarded behavior; and 2) the creation and maintenance of informal hierarchy resulting in competitive behaviors. These communication patterns lead to a defensive climate, characterized by competitiveness rather cooperation, judgments about others, superiority, and neutrality rather than empathy.

-- SS

Wyeth, Ghostwriting, Dr. Joseph Camardo and a Big Liquor Store With a Little Grocery Department

Ghostwriting is a topic covered extensively at Healthcare Renewal, including at my post "Wyeth: Ghostwritten Papers Fake, But Accurate" here, Roy Poses' "Wyeth's Industrial Scale Ghost-Writing" here, and many others about Wyeth and other pharmas that can be viewed via this link: http://hcrenewal.blogspot.com/search/label/ghost writing.

A story in the Philadelphia Inquirer yesterday about Wyeth and ghostwriting brought to mind my medical school days at Boston University, in a metaphorical and rather negative way, regarding an oddity reflecting today's pharma industry.

In those years I lived next to Boston City Hospital on the top floor of a 29-story high rise at 35 Northampton Street, at that time one of the toughest and highest crime neighborhoods in the region if not the country (I was careful and lucky, and only got mugged at gunpoint once.) I had an excellent bird's-eye view of the urban decay in the area, reflective of ethical decay in the community.

35 Northampton St., next to Boston Medical Center (formerly Boston City Hospital)

Across the street from the high rise was an oddity - a very large liquor store named Blanchard's. Inside Blanchard's was a very small grocery department of all things. Have a snack with your booze! (I went in only twice; once to see what it was all about, and again during the Blizzard of '78 to get some needed food when all transit in the city was shut down and several feet of snow -- and neighborhood guns -- inhibited foot travel.)

The area has much improved in the past three decades, but according to Google street view the liquor store is still there:

In the 1970's "Liquor Land" was a large liquor store with a small grocery department named "Blanchard's." Click to enlarge.

Why does this odd store remind me of Wyeth, and more generally today's pharmaceutical industry?

Because that industry has turned from what used to be a biomedical research & development industry with decent ethics and a small marketing arm, to large marketing industry with poor ethics and a small R&D arm.

(Or, perhaps more accurately, a large marketing industry with poor ethics and a busywork section disguised to look like R&D. As a colleague noted in my post "Pfizer/Wyeth Merger And Sacrificing The Future: Laying Off Scientific Staff All Over The Place" here, a small fraction of prime scientist intellectual horsepower and time is actually spent on true R&D today, the rest wasted on feeding the bureaucratic corpulence that is the modern pharma research lab. He observed that "what we today call pharmaceutical R&D is in reality busywork disguised to look like R&D, in effect a well engineered, well managed, massively expensive failure.")

Here is what led to my "pharmas have become large marketing firms with a small R&D effort" metaphor. It was a story in the local newspaper on ghostwriting.

The glib quotes from Dr. Joseph Camardo, Wyeth's senior vice president of global medical affairs, on the practice of ghostwriting are simply stunning:

Philadelphia Inquirer

Ghosts in the medical machine

Was drug research infected by ghostwriters? With Paxil suit in court, a Chadds Ford firm says it was ethical.

Sun, Sep. 20, 2009

By Miriam Hill

Inquirer Staff Writer

When GlaxoSmithKline P.L.C. marketers looked for doctors to promote the antidepressant Paxil, they called the project CASPPER. The name was more than just an offbeat tribute to the friendly cartoon ghost. It was a wink and a nod to "ghostwriting," a questionable practice in which scientists put their names on research written by someone else, usually a writer paid by a drugmaker.

Ghostwriting critics say it disguises marketing material as scientific research.

Charges of ghostwriting have been lobbed against many companies in recent years, including Glaxo, Wyeth, AstraZeneca P.L.C., and Merck & Co. Inc., often arising in lawsuits from consumers claiming a drug hurt them.

... Documents released in connection with 8,000 lawsuits filed against Wyeth over Premarin and Prempro show that the company, which employs several thousand people in Collegeville, paid a medical-writing firm to produce articles from 1998 to 2005 that allegedly downplayed the risks of hormone treatment and emphasized benefits.

In 2002, researchers stopped a landmark federal study after finding that menopausal women who took certain hormones had an increased risk of breast cancer, heart disease, and stroke.

"Ghostwriting was used to sway physician opinions to favor hormone use as disease prevention long after that was a scientifically defensible position," Fugh-Berman [writer Adriane Fugh-Berman - ed.] said.

Joseph Camardo, Wyeth's senior vice president of global medical affairs, called Fugh-Berman's view "baseless." Medical opinion evolves, he said, and the papers in question reflected scientific understanding then. He also said the authors alone controlled the content and writing of the papers, though some did have outside help paid for by Wyeth.

"It's really being misrepresented as something we wrote and paid for that said what we thought it should say," Camardo said. "But the authors were not paid, and the authors had the final say."

... Studies on ghostwriting have suggested that anywhere from 8 percent to 75 percent of articles in medical journals may involve the practice.

Aside from the point I raised in my post "Has Ghostwriting Infected The Experts With Tainted Knowledge, Creating Vectors for Further Spread and Mutation of the Scientific Knowledge Base?" here regarding possible severe contamination of the literature and therefore of "expert knowledge" as it exists today, Camardo's response raises a cornucopia of questions.

Regarding "Medical opinion evolves, he said, and the papers in question reflected scientific understanding then":

• Whose scientific opinion do they reflect, exactly?
• Does Camardo believe these ghostwritten papers, usually written by party "A" but with authorship claimed by party "B" (usually prominent academic physicians often nurtured by the industry into the role of "key opinion leaders", KOL's) are objective?
• Does Camardo actually believe most of the content comes from party "B" rather than party "A" in these papers?
  
• Does Camardo understand that paying a MECC (Medical education & communications company) or other firm to write scientific papers puts the author(s) of those papers in a conflict of interest position relative to the paying sponsor, injurious to objectivity?
• Is Camardo that naive to believe a paid writer would "diss" the holder of his or her paycheck?

Regarding "the authors alone controlled the content and writing of the papers, though some did have outside help paid for by Wyeth":

• Which authors is he referring to?
  
• The ghostwriters?
• Wyeth scientists?
• Academics claiming authorship?
  
• Was the "outside help" from Wyeth "authors" to the ghosts, or from the ghosts to Wyeth "authors", or from Wyeth to the academics claiming authorship, or what?
• Can Camardo produce statistics on what % of article content on ghostwritten articles Wyeth sponsored were written by the ghost vs. written by Wyeth scientists and/or the claimed academic author? If not, why not? And if not, why should any intelligent person not assume the papers are, say, 99% the product of the hired guns?

Regarding "the authors were not paid, and the authors had the final say":

• Again, which author(s) is he referring to?
• In terms of the ghosts, I assume they were not working for the MECC's for free.
• In terms of the academics and KOL's claiming authorship, they (maybe!) were not paid in money, but instead in the valuable academic currency of a publication in a major biomedical journal.
  

To claim the KOL's were "not paid" is disingenuous. In fact, I find his entire argument disingenuous, a play on words, PR "spin" completely callous to the needs for scientific objectivity, the advancement of science, and ultimately to patient's lives.

This is marketing, with poor ethics, in the extreme.

Being somewhat familiar with authorship issues as former Director of Published Scientific Information Resources and The Merck Index (of Chemicals, Drugs & Biologicals), 13th ed. at Merck Research Labs, I further pointed out in my post "Wyeth: Ghostwritten Papers Fake, But Accurate" here, that:

... in addition to the violation of accepted practices of authorship, such as specified by NIH and the International Committee of Medical Journal Editors, among others, such lucky authors [i.e., those who claim authorship of ghostwritten papers] get to "count" such papers in their academic portfolios, presumably also in violation of their own institutional policies and guidelines for fair attribution and intellectual honesty, e.g., here [Harvard - ed.]

These industry practices and Camardo's position may be based on:

• Ignorance of accepted practices of authorship of the NIH, the International Committee of Medical Journal Editors, and most academic institutions, or perhaps:
  
• Cavalier dismissal of these practices for pecuniary reasons.

Is Camardo informed and upfront? Inept? Disingenuous and dishonest? That is up to the reader to decide.

In my aforementioned post "Wyeth: Fake but Accurate" I'd also noted Wyeth attorney Stephen Urbanczyk acknowledging that the ghostwritten articles were part of a marketing effort. But he said that they were also "fair, balanced, and scientific." More spin.

This raises the following observation. It is said that you can judge people by the company they keep. I also believe that:

You can judge companies by the people they keep.

This raises the following very serious questions:

• Is the presence of a senior vice president of global medical affairs and a lawyer with such views on ghostwriting representative of the senior executive leadership's views on dissemination of biomedical scientific information?
  
• Is their presence reflective of the views of Wyeth's Board of Directors?

If so, then the objectivity of any article about Wyeth drugs is called into question, and physicians and patients should utilize Wyeth drugs (and literature on them) with great caution.

-- SS

Addendum: this from the Medical Ethics blog:

Recently released court documents in a lawsuit against drug giant Wyeth, thanks to a court action by the New York Times and PLoS Medicine, are now searchable at a University of California, San Francisco web site.

The Wyeth documents are the latest made searchable at the Drug Industry Document Archive, or DIDA, which archives the documents from several high-profile cases.

... The documents were first made available last month on the PLoS web site, but were not searchable and difficult to sort through. The DIDA site now make it possible to search for documents by name, type or content.

Also see "Ghostwriting: Why they do it" at that blog.

-- SS