PharmedOutby Marcia Angell MD, Harvard UniversityJune 6-7, 2013Most medical journals that publish reports of clinical research are owned by professional societies. Some are distributed to members for free; others are available by subscription. Some lose money for their owners; others subsidize their owners. The most extreme example of the latter is the New England Journal of Medicine , whose income makes its owner, the Massachusetts Medical Society, the richest medical society in the country. What they all have in common is their dependence on support from the pharmaceutical industry – through ads, through support of meetings, and through the purchase of reprints. This is a huge conflict of interest, even on the face of it. Journals have an obligation to report harms as well as benefits of prescription drugs, yet it is only natural that they would be reluctant to bite the hand that feeds them. I would favor eliminating pharmaceutical ads in medical journals altogether; if they want to carry ads, the ads should be for products unrelated to the practice of medicine.
In addition, the disinterestedness of medical journals is all the more important given the biases introduced by the pharmaceutical industry in the rest of the system. Negative clinical trials sponsored by drug companies are often, maybe usually, not even submitted for publication. Those that are submitted are often designed in such a way to make a positive result likely. These biases reflect the financial conflicts of interest that permeate academic medicine. In a sense, the medical journals are the thin blue line that could help to protect the integrity of clinical research. When they, too, are corrupted by conflicts of interest, there is very little recourse.
We also need to recognize the unusual position of medical journals at the interface between the public and private sectors. The costs of careful peer review and editing are substantial, and journals have a right to recoup that expense in some way. But there needs to be some recognition of the fact that privately owned medical journals often publish publicly funded research, and thus are subsidized by taxpayers. As a consequence, they should make research reports available without charge within a very short time after publication, and their net income should not be excessive compared with their costs.
For someone who was such a journal hound, it’s remarkable that I stopped reading them. It wasn’t just that they filled up with drug trials and speculative articles about an indeterminant future, it was the review articles and editorials. I’d always read them as a way to keep up, but they changed. Instead of updates, they began to feel like commercials. I didn’t know that’s what they were in reality, I just found them boring. At the time, I might’ve said that there was a new breed of doctors who were different, or maybe as doctors age, we lose interest. What I’d say now is that they were written by KOLs who were bound to some commercial or ideological effort, or worse, they were ghost written. All I really knew was that rather than looking forward to their arrival, I began to stack them to be chunked en masse – finally letting the subscriptions lapse. It didn’t feel like I’d abandoned them. It felt like they had left me. How did I keep up? I didn’t. I guess I felt like I’d rather be behind than ill-informed. I’m ten years older now than I was when I retired, and I definitely haven’t lost interest.
As much as I like Dr. Angell and her writing, her comments are shoulds. And though I understand that as an actual editor of the New England Journal, she maintained high standards, she’s not in a position to do much these days. It’s a time for action rather than words. My current hero in that regard in Fiona Godlee, editor of the British Medical Journal. It’s the only journal where I personally have a paid subscription, even though I have free access as a faculty member. I bought it because I want her to succeed. She’s everywhere: moderating sessions at the Dartmouth Preventing Overdiagnosis conference; testifying before Parliamentary committees; signing the BMJ onto AllTrials; agreeing to publish the RIAT articles; requiring data transparency for BMJ articles; an active player in the Tamiflu tangle. I can think of no other person in a high place being so courageously active in the internal reform of modern medicine and matters involving the medical industries.
The time for kvetching and exploring is passing. We know what needs to change and it’s time for action. Dr. Godlee is someone who is using her position as editor to make needed changes on a variety of fronts. She’s already one of the greats, showing us what an editor can do to right any number of wrongs. I don’t think we yet have a comparable figure in this country, but we sure need one.
Marcia Angell’s title “Money and Medical Journals” resonated with me, as I used the same title back in 2006 when l’affaire Nemeroff erupted.
Marica Angel was one of the first people to speak out about this and to document the problem in a detailed manner. I remember reading an extremely comprehensive article she wrote with Arnold Relman for The New Republic in the early 2000’s on this topic. At the time, I had become so disgusted with the practices going on all around me (gifts, dinners, colleagues thinking they were immune to all of this, seeing the weight gain that was being denied and minimized). If I raised concerns, colleagues thought I was being overly fastidious or paranoid. This was before CATIE, this was before this topic was covered by the NYT. “The Truth About the Drug Companies” come out in 2005. She did all this from the belly of the beast at Harvard Medical School. The could not have been easy. Her work was so important to me becasue it gave the data and legitimacy to what I was noticing. I gave that book to everyone who worked for me at the time. Her work helped colleagues to change policies at medical schools. Yes, Fiona Godlee is a remarkable woman but they both are.
Over the years I have watched as doctors’ change, both in my personal life and in the blogs. Moving from all things medical to a more philosophical position of; what am I doing for my patients?
One such post is the following:
http://mdredux.blogspot.com/2013/12/individual-risk-assessment-is-that.html
Dr. Gault is a long time patient advocate that questions the modern way we practice medicine with the emphasis on money, not patients.
Here we find doctors questioning the whole system and its impact on the doctor-patient relationship. Can a doctor in good faith prescribe medications that they know are not effective or have been promoted for problems they have not been tested?
http://thehealthcareblog.com/blog/2013/12/11/how-clinical-guidelines-can-fail-both-doctors-and-patients/
And finally; does all of the testing currently engaged in medicine serve the patient or the stakeholders?
http://www.healthnewsreview.org/2013/12/the-harms-of-screening-seen-this-time-in-lung-cancer-screening/
While still voices singing against the money machine that has become modern medicine, more and more voices are joining the choirs.
Steve Lucas
Dr. Steingard,
Everything you wrote is true. They are both remarkable women. At the same time, Dr. Angell’s handling of this situation back when she was editor of JAMA:
http://open.salon.com/blog/rahul_k_parikh/2009/03/29/academics_sling_mud
Makes it difficult for me to feel as unequivocally positive about Dr. Angell as about Dr. Godlee.
Please get your facts straight, Annonymous. You are confusing Catherine DeAngelis with Marcia Angell. The latter was never editor of JAMA.
Stupid error on my part. Thanks very much for correcting my unfair comment My apologies to everyone concerned.
it seems to me that professional journals and especially those in medicine are like other print media finding themselves in a new environment to which they have to adapt….
dr angel’s view of the role of medical journals is a case in point…”We also need to recognize the unusual position of medical journals at the interface between the public and private sectors.”
if the lifeblood of your institution (NEMJ) was dependent upon commercial advertising and you had become dependent on their continued goodwill you might well see yourself as an “interface between the public and private sectors”
my conception of a professional journal places it squarely in the public sector, it does not extend to seeing a responsibility to the “private sector”
it seems to me the interests of the private sector is well represented in medical scientific literature by the numerous medical journals published by private sector, for profit, commercial publishers
PBS espoused to become a public institution like the BBC but was forced to accept advertising monies to survive…the contrast between the scope and quality of the BBC in comparison to PBS provides a striking counterpoint to the problems of professional journals in a new world
it might be that medical journals need to change distribution methods, abandoning print media for which they need large amounts of advertising for digital media which reduce their distribution costs enormously and might make a fee based economic model feasible again