1 Boring Old Man

^{Over the past two decades, largely because of a few widely publicized episodes of unacceptable behavior by the pharmaceutical and biotechnology industry, many medical journal editors [including me] have made it harder and harder for people who have received industry payments or items of financial value to write editorials or review articles…}

^{A few? You’ve got to be kidding me – they’re everywhere! And it’s not just editorials and review articles. How about all those RCTs that were really written by paid expert medical writers instead of the guest authors, the key opinion leaders, whose names appear on the by-line? Didn’t you read my last post? what Dr. Healy said "But perhaps an even greater shame will be seen to lie with the fact that, during this era, most publications on on-patent drugs in our best journals were ghost-written"?}

^{In the mid-1940s, Selman Waksman, a soil microbiologist, and his team discovered streptomycin, an antibiotic with action against the tubercle bacillus. Although he was able to show efficacy in the laboratory, Waksman realized that if his discovery was to be of value to the world, he needed a partner capable of manufacturing adequate amounts of the material under conditions that would make it suitable for use in humans. He therefore struck a deal with Merck to produce streptomycin for clinical use. Soon thereafter, the British Medical Association undertook a large randomized, controlled trial of streptomycin for the treatment of tuberculosis. The results, including a description of the utility of streptomycin and resistance to it, were published in the British Medical Journal. This partnership between an academic researcher and a drug company went on to alleviate substantial human suffering and should be a model for current behavior. Unfortunately, it is not.}

^{But that’s not the rule. That’s an exception. Waxsman was one of those exceptions in science. He had ‘nailed’ the treatment of Tuberculosis. He didn’t have to sell us anything or refine any arguments.  We were eager to hear what he had to say. And we already knew about his industry connections. There weren’t any secrets or hidden motives to wonder about.}

^{The National Center for Advancing Translational Sciences of the National Institutes of Health, the President’s Council of Advisors on Science and Technology, the World Economic Forum, the Gates Foundation, the Wellcome Trust, and the Food and Drug Administration are but a few of the institutions encouraging greater interaction between academics and industry, to provide tangible value for patients. Simply put, in no area of medicine are our diagnostics and therapeutics so good that we can call a halt to improvement, and true improvement can come only through collaboration.}

^{That interaction and cooperation between academia and industry may well facilitate improvements in something. But what does that have to do with the question of bias when academics with a financial relationship to a company write a review or editorial about that company’s product in an academic journal? An academic can interact and cooperate without money changing hands…}

And so it goes as my bias generates contrarian counters to his arguments. Back in the days of the Academy in Ancient Greece, a time when they fell in love with the rules of argument and logic, they initially thought they could reach absolute truth with their debates. So they studied logic and cataloged wrong arguments as the fallacies. Then along came questions of bias, and motive, and later even unconscious motive. And the sacred olive groves of Plato’s Academe [and later Aristotle’s Lyceum] moved from the quest for dogmatic truth to becoming cloistered havens for skepticism and a questioning attitude. And Academia has been under siege ever since [with arguments not unlike the ones coming from this NEJM series].

In psychiatry, this kind of rationalizing away Conflicts of Interest has characterized the current era with disastrous results. We almost don’t have much we can call academia any more. When we look at RCTs, it’s hard to even locate an industry-funded Clinical Trial that isn’t ghost-written  with authors on the by-line with extensive financial connections to industry. The sacred olive grove full of scholars has been replaced with professional Key Opinion Leaders, professional Medical Writing companies, Clinical Research Organizations, and Pharmaceutical Marketing Departments.