Going to the ‘Dark Side’
(Medscape) – A few years ago, while attending a research conference, I inquired with a friend, a prominent professor from Sweden, about our mutual colleague, a young, bright psychiatrist with a great research career ahead of him. “He’s gone to the Dark Side!” was his reply.
I had not heard this term before in this setting. Images flew across my mind. Did the young man have a psychotic break? Did he get sick? Was he in jail?
Confused, I asked my friend what he meant. Laughing, he clarified, “He went to work for the pharmaceutical industry!”
Oh, that Dark Side.
It’s a term that I continued to hear when, a few years ago, I myself took a position in the pharmaceutical industry. It appears that those of us in the industry had taken the description so to heart, however jokingly, that we felt comfortable applying it amongst ourselves.
“Welcome to the Dark Side,” a colleague in industry emailed me when I told him about my new job at a biomedical research group in the United States that conducts early drug discovery work. Even my coworkers within this group would refer jokingly to our colleagues in the company’s European headquarters (where they conduct the large phase 3 trials) as the Dark Side, who in turn would use the term to refer to the commercial marketing team.
The prevalence of this term represents an easy dichotomy, pitting the Machiavellian scheming of industry against the unsullied Ivory Towers of academia. However, after 25 years and a solid career in academia, I came to see it as its own sort of Dark Side, where the drive for self-preservation outweighed actual progress.
My quarter century in academia was marked by its routine. I headed a research program on depression and bipolar illness, with one to two research assistants and fellows by my side. I treated patients about half my time, and taught residents and medical students a few hours a week or more. I performed this same type of work at Massachusetts General Hospital, Cambridge Hospital, Emory University, Tufts University. Different places, same work.
[S]omewhere in the midst of following the well-established academic psychiatrist career path, I came to believe that the profession itself was off track in important ways.
On conventional grounds, I was a success, promoted steadily to full professor, with many research grants and scientific articles. The obvious next step would have been to become a chairman in an academic department, at which point I could ride out the next decade or two of my career doing the same thing. It would take no new or extra effort on my part.
But somewhere in the midst of following the well-established academic psychiatrist career path, I came to believe that the profession itself was off track in important ways. For instance, the Diagnostic and Statistical Manual of Mental Disorders (DSM), the Holy Bible of the American Psychiatric Association, is mostly false and unscientific. Standard treatments, like antidepressants, the bread and butter of practicing clinicians, are mostly ineffective, especially for certain depressive states like bipolar depression or mixed states. Most current drugs are me-too variants of those that are either minimally effective or have had their benefit and will not produce much further gain with the same basic biological effects.
The research designs used for some studies are invalid, in my view, and overestimate drug benefits. This leads academics and clinicians to use some agents in scenarios where belief in their efficacy exceeds reality (like antidepressants for prevention of depression, or antipsychotics for prevention of bipolar illness). Some important clinical concepts, like mixed states, are established reasonably well in research but are ignored in the DSM and by the academic mainstream.
I’ve expressed my ideas, which have been well studied in my academic research, in detail in many papers and talks. Yet after two decades, I found it harder and harder to convince more of my academic peers of their validity. Getting grants was harder as my ideas became more innovative and outside of the mainstream. Publishing those ideas in prominent journals was harder too, as opposition to my views hardened among some of my colleagues with mainstream power.
Continuing this work for another two decades would mean continuing to repeat my exhortations, which I doubt would convince many more people.
Psychiatry, like all established professions, is conservative, recalcitrant, slow to change, with a primary mission of self-preservation. Even in medicine, our stated lofty goals of patient care or advancing knowledge are secondary and to be sacrificed if this self-preservation is put at risk.
This is not a criticism but rather the nature of human beings, who are inherently conservative and want to preserve the status quo to get along with others. Conformism is mental health. The mentally abnormal produce new ideas.
If the psychiatric profession were to change at all, the change would occur very slowly, and soon enough my career would be over. I realize that this is a kind of academic midlife crisis, but I didn’t see any signs that my profession would implement the necessary changes to make me feel like my efforts were successful.
I want more change, more quickly. I want to keep doing what I had been doing: conducting and promoting research on innovative ideas. Industry provided a path to make that possible.
In short, academia left me. I didn’t leave it. I’m doing the same thing I always have, with the same ideas I’ve developed for some years. But academia offered me mostly resistance and struggle, while the early drug discovery niche I have found now appears to be the opposite — seeking unorthodox views rather than rejecting them.
I used to hear the phrase “recovering academic,” stated by colleagues who had gone into private businesses or other nonuniversity jobs. I never understood it. Now I do. It’s about getting over the academic mindset that one should take a purely consensus approach to ideas, seeking to get along with everyone else so as to publish more and get grants funded. It’s about being willing to take risks.
The recovered academic is a prisoner now released from jail. He can express his views without apology and, more importantly, implement them. Because the pharmaceutical industry is in the business of doing something, producing drugs, my ideas are now also part of the process of actually getting something done, trying to produce one drug or another, or refusing to go along with one drug or another. In the past, I would have ideas and say that someone ought to do something about it; now I can be that someone.
Instead of waiting to prescribe and study whatever drugs are produced by the pharmaceutical industry, and complaining about their shortcomings, I am in a position to produce better drugs. It’s like being a chef but only being able to use certain ingredients that others give you. What if you want or need a new ingredient? You can’t create it in academia.
To paraphrase H.L. Mencken, all professors have to do is impress sophomores. This may be unkind, but in some ways it’s true. The joke in academia is that you never really want to solve a problem because then your grant funding will end. You don’t want accountability, but rather to drag a problem out over 40 years to ensure continuous funding in your academic career.
The joke in academia is that you never really want to solve a problem because then your grant funding will end.
The larger problem with the abstract nature of academia is that it’s very hard to convince academics to change their minds, because they can continue for decades in a fully successful career without ever needing to change them. They’ll never lose their jobs or be forced out of a position. That’s called academic freedom. The good part is being free to think whatever you want; the bad part is being free to think whatever you want, as opposed to what’s true.
Although the business world has many negatives, there is one key positive: You are tested by the marketplace. If your idea is terrible, you’ll lose money and go out of business. You can’t just think whatever you want.
For this reason, I’ve always found researchers in the pharmaceutical industry to be more open-minded than academic colleagues. If you told a pharmaceutical industry researcher that diagnosis X was false and it should be reconceptualized as diagnosis Y, she would be likely to say, “OK, let’s see if diagnosis Y works better in our studies with this drug.” But if you told an academic the same thing, he’d likely just disagree and rationalize why he likes diagnosis X more. You couldn’t prove or disprove the matter to him. I know; I’ve tried.
If you think that one would need just to do sufficient scientific research to prove the matter, I’ve done that, and I’ve seen other researchers do it. Scientific studies would be performed, presented, and then rejected as insufficient by the academic powers-that-be. This cycle would be repeated with even more studies, which would also be rejected as insufficient. The devil is in the word “sufficient”; an academic can want more and claim that the data aren’t definitive enough and need to be replicated. This approach frequently serves to rationalize ideas that one doesn’t want to change.
I did my work in academia, especially in earlier years, with a naive trust that academic peers would follow the science and flexibly change their views. This naiveté has been disproven. I don’t believe I’m cynical about it now, just realistic. As the great physicist Max Planck said, scientific revolutions don’t happen by changing minds but by changing generations.
That’s too slow a process for any one lifetime. As for me, I’ve decided to try to move things along where I can, where people support my innovative work and where the resources are given to me to implement those ideas.
Working within the worlds of academia and industry has brought me face to face with some common misconceptions.
The first is, again, that I have somehow “left” academia. My academic work previously involved teaching, seeing patients, and research. Only my research is now exclusive to industry. I continue to teach at Harvard Medical School and Tufts University, as I have for a decade or more, and I’m still performing patient consultations (though fewer than I once did). The difference is that I’m not being paid for these services, as is commonly the case with private practitioners who volunteer to teach at medical schools. Is that “leaving” academia? Not really.
The perception that this is an all-or-nothing, either-or decision is likely a holdover from earlier days. However, now it need not be that way, especially at an early drug discovery research group like the one where I’m employed.
A related misconception is that I’ve joined “industry” and, as a result, am now owned in some way by my employer, a private corporation. I’ve had colleagues tell me that I’ll be restricted in what I can say or do. In fact, I shared their concern enough to explore it in detail before I took this position, especially as I have an active writing career, including books for the general public, and media interviews related to political topics.
There are indeed restrictions in the pharmaceutical industry, but I found that there are differences depending on where one works. Because the root of this misunderstanding is likely uncertainty regarding how new drugs are brought to market, it’s worth briefly illuminating the key stages of that process here.
First comes drug discovery, the preclinical work in test tubes and with animals, and the early phase 1 and phase 2 clinical trials that test the initial safety and possible efficacy of those new drugs in humans. This is the work that my colleagues and I currently perform.
Second, there is drug development. If a drug is effective and safe enough in phase 2, it enters large phase 3 trials designed to meet the requirements of the US Food and Drug Administration (FDA) or other government registration bodies.
Third is commercial marketing. If a drug is effective and safe enough in phase 3 trials, and receives FDA registration, it then is marketed by sales representatives and other company staff to doctors, hospitals, insurance companies, and government payers.
Doctors and academics are aware of the last two stages of this process, whether in the form of pharmaceutical sales representatives visiting our practices, or through our interactions with the physicians and researchers who conduct the final phase 3 studies and seek to convince us to use or support their drugs in treatment. We never meet the chemists who think up the earliest compounds, or the physicians and researchers who are doing the earliest phase 1 and phase 2 trials of a new drug or mechanism that no one has ever used in practice before.
So my colleagues, when they think of the pharmaceutical industry, are likely picturing a part of the industry where I don’t actually work.
In fact, for the past 25 years, there have been many times when I could have taken a position in the phase 3 marketing-oriented stage of the pharmaceutical industry. I declined because I had the same concerns, shared by many of my academic colleagues, about the harmful impact of a marketing orientation on drug research and practice. I’ve certainly critiqued these aspects of the pharmaceutical industry in the past.
I’ve pointed out that it isn’t as innovative as it claims, producing many “me-too” drugs that may make a little profit but don’t really improve public health. It hides side effects and risks at times. It markets in a misleading way against or for certain drugs for purely commercial purposes. It markets diagnoses that aren’t as valid scientifically as many believe. It targets symptoms rather than diseases. It publishes positive studies much more aggressively than negative ones.
In my opinion, these critiques apply more so in psychiatry than anywhere else in medicine. I’ve been critical of academic colleagues who’ve been all too ready to say in paid lectures what benefits their sponsors rather than what they believed. However, with that said, I’ve also criticized the critics of the pharmaceutical industry, who often deny the independence of scientific truth and measurable benefits of certain therapies.
Advocating for a well-rounded view of academics and industry requires understanding the benefits and drawbacks of how both models traditionally operate. The pharmaceutical industry isn’t just good or bad. And academia isn’t just good.
These nuances matter, and, especially in relation to how outsiders in academia opine about the pharmaceutical industry, there is little to no awareness or understanding of these nuances. To them, it’s just “industry,” or a specific company, without any distinction between early drug discovery groups and later development/marketing groups, and without any appreciation about the culture of a specific company.
There is no monolithic “industry,” just as there is no monolithic “academia.” Drug companies differ from each other, often quite markedly, in their culture and practices. I’d never work for a number of companies, just as I wouldn’t for certain academic institutions.
So, I’ll keep doing what I’ve been doing in my career, trying to stay committed to advancing the field of psychiatry as best as I can. To do that work, I found that academia was no longer sufficient for me.
In truth, I’ve found the Dark Side everywhere, in academia and industry, while shafts of light could be seen only here and there in both places. Some places are darker; some are lighter—in both academia and industry. Maybe I can help those beams of light find each other and create a force for truth.
Editor’s note: All views expressed here are the author’s own and do not necessarily reflect those of his employers.