suspicious minds…

Posted on Friday 17 December 2010

I was pointed to this article because of it’s meta-analysis of logic, but even though it doesn’t have to do with my recent topics, the analytic process of the author deserves wide attention:
He begins with a review article in the American Journal of Cardiology [Beta-Blockers in Hypertension] that concludes:
    … it is time for a reexamination of the clinical evidence for the use of β blockers in hypertension, recognizing that there are patients for whom β blockers, particularly those with vasodilatory actions, are an appropriate treatment option.
I. SUSPICIOUS LITERATURE: Review Articles, Specific Treatment Recommendations

Dr. Poses then looked at the logic of the article. First, it references studies that compare β-blockers [often combined with diurectics] against other anti-hypertensives that raised questions of metabolic consequences with the β-blockers. Then, it looks at studies comparing  vasodilating β-blockers [not included in the first group of studies] to placebo that do not report metabolic consequences. Ergo vasodilating β-blockers are better[?]. Poses points out the logical fallacy – Special Pleading [see Nizkor: Logical Fallacies].

II. SUSPICIOUS LOGIC: In this case, apples are compared to oranges – and the conclusion that oranges are better does not follow from the specific comparison

He then finds evidence of secret authorship – a ghost in the machine:
    I would like to thank Tamalette Loh, ProEd Communications, Inc. [Beachwood, Ohio], for her editorial assistance and literature validation in the preparation of this report.
III. SUSPICIOUS AUTHORSHIP: A ghost in the machine

Poses then has to do some sleuthing. He find other articles touting the wonders of said vasodilating β-blockers assisted by Tamalette Loh one of which connects her to PHARMA:
    Editorial assistance, specifically revisions to the final draft, was provided by Tamalette Loh, PhD, at ProEd Communications, Inc.®, whose services were also funded by GlaxoSmithKline. Dr Loh’s revisions were reviewed and approved by Dr McGill.
and another article by Dr. Ram [author of the proband article, Beta-Blockers in Hypertension] that makes the same PHARMA connection:
    Dr Ram is in the speakers’ bureau pool of Cogenix, ProCom, and Genesis, which manage medical education programs for Bristol-Myers Squibb, GlaxoSmithKline, and Novartis.
IV. SUSPICIOUS SPONSORSHIP: Money flows to the Author and the "editorial assistant" from some source with a vested interest

"vested interest" you ask? By this time, you’ve probably already figured out that GlaxoSmithKline makes Coreg, a vasodilating β-blocker. Dr. Poses comments:
The series of articles above demonstrated a phenomenon I have not seen explored before. All articles were written with some sort of assistance from an employee of a MECC, perhaps partly funded by a company which marketed a drug which was the subject of all the articles. The assistance was openly acknowledged.  The three articles had some remarkable similarities not explained by an overlap among their listed authors.  This suggested that the ostensible editorial assistant they had in common was substantively involved in the content of the papers, that is, was truly an author. Her presence was not ghost-like. However, the substance of her contribution may have been downplayed.  So let’s call her an "undercover author"  [If someone has a better term, please leave a comment to that effect]…

So the reasons I rarely read narrative review articles except to make teaching points about health care dysfunction are:
•They often are based on idiosyncratic, if not biased selections of data
•They may employ logical fallacies to make their points
•They may be written by people with conflicts of interest, that is, with financial arrangements with companies seeking to market products, particularly drugs and devices.

Shortcut: Dr. Ram is listed as being paid $55,300.00 by GSK this year in Propublica‘s database. Dr. Poses comes up clean. No surprises there…

Poses suggests that we just don’t read narrative reviews because they’re likely to be industry driven. Unfortunately, the "we" that his writings might reach isn’t the "we" that matters – those busy doctors conscientious enough to want to keep up but too busy to take the time to parse articles with this kind of thoroughness and/or read the primary studies. Seems to me that a better approach would be to hound the Journals to stop publishing tainted literature like this. Tamalette Loh of ProEd Communications obviously specializes in anti-hypertensive drugs. Maybe her argument is even right, who knows? But she could publish under her own name in the GSK handouts – then we could evaluate her argument fairly.

If it is true that review articles are generally this biased, ghost-written, then the legitimate Journals could simply reject them unless they’ve been vetted by a pro like Dr. Poses. That solution would get my vote…
My conclusions for health care professionals are: be very skeptical of non-systematic review articles, look for evidence that they are parts of stealth marketing campaigns, and do not assume all conflicts of interest are disclosed and all authorship roles revealed.

My conclusions for journal editors are: strictly demand more complete disclosure of conflicts of interest, or risk losing the trust of your readers.

My conclusions in general: until we start to sweep away the pervasive web of conflicts of interest that is draped over medicine and health care, expect further discombobulation. 


I’ve been thinking about:
    So let’s call her an "undercover author"  [If someone has a better term, please leave a comment to that effect]… 
How about surrogate author who, like the surrogate mother carries the product of the pharmaceutical company’s egg and the listed author’s sperm, does all the work, and delivers the baby [for a fee]…

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