Wednesday, 4 January 2017

Review: Bad Pharma by Ben Goldacre

Hey guys! A few years ago, I read and loved Bad Science by Ben Goldacre -- it's actually partly what led to my love for experimental design and the scientific method. Bad Science featured debunkings of the MMR vaccine-autism scam, TV nutritionists, detoxes and homeopathy, and it was great fun. 

So when I saw Bad Pharma on the shelf in my local Waterstones, I knew immediately that I wanted it. Unfortunately, I didn't enjoy it quite as much.

Bad Science was a 5-star book, but Bad Pharma only 3.5. Here's why.

Bad Pharma discusses all the ways medicine is flawed by the pharmaceutical industry and regulators and governments and bad research practices. 

Honestly, I think the title is largely a marketing ploy, because the book is half about pharma companies and half about other reasons medicine is broken. 

I wasn't particularly interested in some pharma witch-hunt; while I was unpleasantly surprised by some of the pharma shenanigans (shenanigans, I should say, which cost lives) with drugs like paroxetine (which can increase suicidal ideation in children, yet the drug company was cool with it being prescribed for children off-label when it only had a license for adults), my interest is really in trial design and science about science.

So I read the stories of bad behaviour by the pharmaceutical industry with some interest, and the stories of regulators' failures to regulate with exasperation, but I was most interested in the positive suggestions Goldacre had for better practice, and his discussions of trial design. 

I liked Goldacre's mix of reliance on systematic reviews and on his own experience as a doctor and popular science columnist, and I also liked how he didn't sensationalise things: he said early on (paraphrased) "the pharmaceutical industry is not hiding the cure for cancer - the real harm here is a lot more subtle but still kills people". So at least, apart from the title, he's not just selling books to conspiracy theorists using sensationalism.

The book got a bit boring as he comprehensively laid out all the ways in which doctors can be influenced by pharma companies' marketing departments, from ghostwriters of scientific papers to branded freebies to Continuing Medical Education seminars funded by pharma companies. That said, it was interesting to see that there is evidence that doctors who took money from drug companies or partook in this kind of thing were more likely to prescribe the company's drug and thus potentially harm patients by not giving them the best treatment. And I suppose the boringness and banality is an indication of just how pervasive the problem is and how hard it is to tackle -- it's just business as usual.

Anyway, my favourite parts were definitely the parts of the book about trial design. I adored learning about forest plots, two of which you can see below. These have a dot for the main result of each trial in the area, with the line representing the error bar. Dots on the left show the new treatment is better while dots on the right show the placebo or existing treatment is better, and if the line touches the vertical central line then the results are not statistically significant. The circle on the bottom shows the total. On the right there's a cumulative version of the graph, showing what it would look like if a meta-analysis was done after each new study, so the error bars get smaller and smaller and we see the progressing state of knowledge in the field. 

I liked the Bad Trials section, which talked about problems in trials from straight-up fraud to tricks like stopping a trial early or only testing "ideal" patients (ignoring the actual patients who'll be taking the drug but wouldn't qualify for a trial) or comparing your new treatment to something like placebo instead of the best currently available treatment (it doesn't mean much to say your treatment is better than nothing when the patient is choosing between drugs, not between your treatment and nothing, most of the time), or trials that measure surrogate outcomes (like cholesterol) instead of real-world outcomes (like heart attacks), or trials that say they're going to measure something and then end up measuring something else because that makes the results look better. 

I also liked the Bigger, Simpler Trials section, which describes something Goldacre himself is involved in, in which GPs with patients with a disease for which there are multiple treatments and no one knows for sure which is better can press a button to have the prescription randomised, and then feed the information on how the patient is doing back into the system -- essentially a huge, automatic trial, at no extra cost or danger to health. This works in the UK because of their huge patient database and centralised medical system. I think it's a cool idea.

His section on Missing Data was cool too, on how negative results usually aren't published. This was especially interesting because it corrected a misconception of mine --  I assumed this was because journals weren't accepting these papers, but Goldacre showed that, on the whole, they were. The big problem with negative results not being published is that it pollutes the field; even with a systematic review/Cochrane review or forest plot, the benefits of the treatment will be overstated, putting patients at risk. I liked the idea of preregistering trials and was dismayed by hearing about failed attempts at this, like when journal editors said they'd only publish preregistered trials and then didn't do that, and how the European medicines regulatory authority keeps a register for transparency and then refuses to publish any of it (at least until 2012). 

Something a bit annoying was how the cover said "...and how we can fix it", and Goldacre kept implying that you/we would be able to do something about this, but then most of the suggestions at the end of the chapter were only relevant to doctors or regulators or drug reps or medical students. Patients and citizens mostly only had the option to lobby. Now, that's fine! That's realistic, and I have no problem with it -- but it's a little disingenuous of the marketing department to pitch it as something laypeople have total control over, and then have the inside of the book say differently. It's probably not something Goldacre had control over -- this marketing problem annoys me with lots of books. 

The main reason I'm knocking off 1.5 stars is that I didn't like how hard I was being pushed and expected to feel angry -- even the front cover says "This is a book to make you enraged" - Daily Telegraph. Yes, absolutely, there is dirty work going on -- but the book was very obvious and consciously manufacturing outrage, and whether or not outrage is merited I would have preferred if the facts and analysis were presented to me, just without the "this is how you should feel after reading". 

In short: I loved the parts about trial design and was somewhat alarmed by the many failings of the industry -- I just could've done without the witch-hunt vibe. 

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