a narrative…

Posted on Sunday 24 May 2015

In  wtf? for real… I was criticizing the editorial by Editor Jeffrey Drazen [Revisiting the Commercial–Academic Interface] and series by reporter Lisa Rosenbaum [Reconnecting the Dots — Reinterpreting Industry–Physician Relations, Understanding Bias — The Case for Careful Study, Beyond Moral Outrage — Weighing the Trade-Offs of COI Regulation] in the New England Journal of Medicine advocating the relaxation of their policy prohibiting authors from writing editorials or reviews that might benefit companies with whom they have a financial connection. That policy was introduced by former Editor Arnold Relman, an opponent of the increasing connections between the pharmaceutical industry and academic medicine. In 1980, he wrote an editorial about what he called the medical-industrial complex and the dangers of conflict of interests:
by Relman A. S.
New England Journal of Medicine. 1980  303[17]:963-970.
[partial text here]
Under his guidance, in 1984 the New England Journal of Medicine became the first journal to require authors to declare their financial connections with industry. Then in 1990, they added a policy that prohibited authors from writing editorials or reviews that might benefit companies with whom they had a financial connection. Arnold Relman was succeeded as editor in 1991 by Tufts Professor Jerome Kassirer who continued and perhaps extended this posture against the financial connections between academic authors and industry.

In wtf? for real…, I was lamenting current Editor Jeffrey Drazen advocating an easing up on this restriction on editorialists and review authors. I cited Relman’s 1980 editorial and a later one by his wife, Marcia Angell, in 2000 when she was editor for a time [Is Academic Medicine for Sale?] as the strong ethical stands I preferred. But, as Sandra Steingard pointed out in a comment, I had left out Jerome Kassirer who was also an advocate against commercial influences in the journal’s articles and the businification of medicine in general. In his editorial in 1996 written with Marcia Angell, then his Assistant Editor, they directly addressed this issue of editorialists and review article authors.

The editorial was prompted by publishing a review article of diet medications in the same issue as an article reporting an ominous side effect [pulmonary hypertension]. They discovered only after the issue had gone to press that the review’s authors had significant PHARMA financial connections.  Their editorial reaffirmed the policy from 1990:
New England Journal of Medicine. 1996 335[14]:1055-1056.

…Since 1990 the Journal has had a policy that prohibits editorialists and authors of review articles from having any financial connection with a company that benefits from a drug or device discussed in the editorial or review article. This policy was an extension of our earlier policy, announced in 1984, that required authors merely to disclose their financial connections with industry. In the case of scientific reports, disclosure seemed adequate. Scientific reports are self-contained. They present original data, and readers can judge for themselves whether the authors’ interpretations are supported by the data. Editorials and review articles are different. They are not self-contained, and there are no primary data. Instead, editorialists and authors of review articles evaluate an issue on the basis of what they select from the literature as relevant. In the case of editorialists, their task is to use the study they have been asked to editorialize about as a springboard for an open-ended consideration of an important issue. It is expected that they will provide an unbiased and authoritative opinion about the matter. That is why we insist that editorialists have no financial ties to products that figure prominently in their work…

After the Journal instituted its 1984 policy requiring disclosure of conflicts of interest, other major medical journals adopted similar policies, but so far we stand alone in our contention that disclosure is not enough in the case of editorials and review articles. In our view, the increasing involvement of researchers in commercial activities makes this policy all the more important. Readers must be able to rely on editorialists to be disinterested. We hope that we will soon be joined in our policy by our sister journals.
Kassirer’s resistance to the intrusion of commercial influence ultimately came up against other forces in the halls of the New England Journal of Medicine which had just built a $50M headquarters building and was in the process of capitalizing on its time-honored brand in multiple other ways. By 1999, this conflict lead to him being fired:
New York Times
July 27, 1999

The top editor of The New England Journal of Medicine is resigning under pressure in a dispute with its owners, the Massachusetts Medical Society, over the marketing of the journal’s prestigious name as part of an expanding publishing empire. Dr. Jerome P. Kassirer, 66, will step down as editor on Sept. 1 and then begin a seven-month sabbatical until his contract expires on March 31, he and Dr. Jack T. Evjy, the society’s president, said in interviews yesterday. Dr. Kassirer and Dr. Evjy declined to provide specifics of the dispute beyond saying it involved sharp differences in "administrative and publishing issues."

But other editors said the dispute reflects tensions generated as the society, like other traditional nonprofit medical organizations, seeks to generate more revenues to expand its influence in an increasingly competitive and political world of health care. Founded in 1812, the journal, based in Boston, has a circulation of 240,000 and is widely regarded as one of the world’s most rigorously edited scientific publications. In recent years, though, the Massachusetts Medical Society has added other publications for doctors and health newsletters intended for the general public. The society also recently built a plush headquarters in suburban Waltham and hired more staff members to deal with health and political issues.

Dr. Kassirer resisted this trend. "Does the society want to become a business?" he asked in his annual report last year. The report described ”a perceptible change in the nature of internal discussions about the Journal” and criticized what it called proposals for the society to ”brand” the journal by using its logo and name in creating new publications.

Dr. Kassirer has earned praise for his stewardship as the journal’s editor-in-chief since 1991. He was credited with appointing larger numbers of foreign scientists to the journal’s editorial board and attracting larger numbers of papers from foreign scientists. He also expanded the number of reviews and other features to lessen the journal’s esoteric nature and broaden its appeal to practicing doctors. Dr. Kassirer said he ”expected to stay a longer time, but it is not in the cards.” His resignation had nothing to do with the content of journal and he never felt constrained in expressing his opinion, he said, and "the medical society never tried to interfere"…

One of the journal’s main competitors, the Journal of the American Medical Association, is also searching for a new top editor. In January, Dr. George Lundberg was dismissed as editor for timing publication of a survey on attitudes toward sex during the impeachment hearings of President Clinton.
In his parting editorial, Kassirer said:
Goodbye, for Now
by Jerome P. Kassirer, M.D.
New England Journal of Medicine. 1999 341:686-687.

Because the officers of the Massachusetts Medical Society and I could not resolve our differences over administrative and publishing issues, they decided to seek a new editor-in-chief, and I leave the post in a few days…

I have been privileged to use the Journal’s bully pulpit. In my 70 editorials I have criticized for-profit medicine’s shortcomings, managed care’s flaws, the federal government’s misguided actions, and organizations that tried to undermine science for political motives. I have called attention to the progressive fragmentation of the health care system and the increasing number of uninsured persons. I have been critical of the American Medical Association and the National Rifle Association (several times each), the American Association of Health Plans, and the Health Care Financing Administration. I have been an advocate of high ethical standards and professionalism and have repeatedly called attention to financial incentives that might erode the integrity of physicians and threaten patient care. Very recently I offered a definition of editorial
That last line referred to his stand against the firing of JAMA Editor George Lundberg mentioned above. He was replaced by Assistant Editor Marcia Angell  as interim Editor, but she withdrew from the running as Kassirer’s replacement saying she was going to write a book on alternative medicine. It was during her one year as interim that she wrote the editorial mentioned in wtf? for real…:
New England Journal of Medicine. 2000 342[20]:1516-1518.
As it turned out, Arnold Relman, Jerome Kassirer, and Marcia Angell all did go on to write books – but they weren’t just about alternative medicine:
Jeffrey Drazen, the current editor, replaced interim Marcia Angell in 2000:
New York Times
May 12, 2000

Dr. Jeffrey M. Drazen, a leading asthma researcher at Harvard with strong ties to the drug industry, was named the editor of The New England Journal of Medicine here today. But the journal’s tough conflict-of-interest rules will prevent Dr. Drazen from writing certain articles and editorials for at least two years. Pledging to protect the integrity of The Journal’s information, Dr. Drazen, a professor of medicine at Harvard, said he would recuse himself from the editorial process for any papers submitted that relate to asthma or to nine major companies from which he has received research grants or consultation fees.

Dr. Drazen, 53, helped pioneer asthma drugs now taken by four million asthmatics worldwide. In today’s news conference, he strongly defended the need for doctors to work closely and carefully with the drug industry. He called the industry a powerful force without which basic research findings made through taxpayer grants from the National Institutes of Health could not be converted into new therapies to improve patient care and public health.

Last February, after an internal investigation prompted by articles in The Los Angeles Times, The Journal found that it had violated its own rules in publishing 19 articles by Dr. Drazen and other authors with industry ties. The Journal said the articles should have been written by scientists without such connections, but its editors blamed themselves and said Dr. Drazen had disclosed his industry support.

Asked today at the news conference about that episode, Dr. Drazen said that as The Journal’s new editor in chief he would hand over all manuscripts dealing with his specialty or products made by the nine companies to deputies "and make sure that they are on the agenda at a time when I do not come to the editorial meeting." In such cases, Dr. Drazen said he wanted "The Journal to be able to judge the science that comes in, if it is good or bad, without me having anything to do with it."

"I do not want to influence things in either a positive or a negative way,” he said. ”We want the good science and good information to get out there” in The Journal, which is one of the most influential in the world. Dr. Drazen, who will leave his Harvard post, will be the Journal’s third editor in chief in less than a year. His selection follows several years of turmoil between the editors of The Journal and its owner, the Massachusetts Medical Society, concerning the society’s increasing business ventures. Dr. Jerome P. Kassirer was fired as the top editor last summer because of conflicts with society officials over proposals to promote Web sites and create new specialty journals using The New England Journal of Medicine logo. In recent years, The Journal has become a huge source of revenue for the medical society, largely through increased drug company advertising. And the society has become heavily dependent on the Journal’s profits to maintain its new $50 million headquarters here…
I appreciate Sandra’s reminding us of Jerome Kassirer‘s place in this story. In my case, in 1999-2000, I was isolated from such things, aiming towards my own retirement. This narrative explains why I still saw the NEJM as it was in my youth ["What is this doing in the New England Journal of Medicine?"], and was so incredulous at reading Jeffrey Drazen‘s editorial and Lisa Rosenbaum‘s series. It also gives me a chance to acknowledge the yeoman’s efforts of Drs. Relman, Kassirer, and Angell in trying to push back against the capitalization and invasion of medicine by industry. It also explains Dr. Drazen‘s history and how this editorial and series must have been percolating for the fifteen years of his tenure as editor of the NEJM. There are mixed reactions to this series in the medical community and at large. I freely admit that my negative reaction is visceral. I can mount arguments with the best of them, but they come after the fact. I’ve lamented the growing medicine-as-business trend since medical school, and that lamentation has turned into a conviction. I don’t think I’m even capable of seeing the other side of this argument any more. There’s just been too much damage…

    May 24, 2015 | 5:00 PM

    can’t believe dr nash is dead dr mickey.
    dr nash’s theoretical contribution (nash embedding theorem) is a central theoretical result as to why my fMRI result works so well.

    i use a method called locally linear embedding which uses his theory to explain the result. that is part of the reason it is so powerful: it allows theorems about disease to be formulated in terms of sentences, which can then be tested by appropriate experimental design and observed results from the scans.

    this is extremely tragic and a little too serendipitous for my taste, given that the rockefeller doctor son took his own life on june 13 2014 (apparently his father’s birthday, and also the birthday of dr nash).


    it makes me wonder if the rockefeller patriarch and nash were good friends, given that nash’s work was primarily government funded during his years of productivity.

    so so sad 🙁 never got to meet the man before he passed. i remember emailing dr john hopfield at princeton about my desire to connect with dr nash (even for one conversation).

    sad sad sad

    May 24, 2015 | 11:17 PM

    welp dr mickey looks like i learned something new today.
    i learned ‘alien hand syndrome’ is actually considered a neurological disease?

    i’ve also had a hard time finding reliable evidence as to whether lawyers have used alien hand syndrome to dismiss any potential sexual assault case. theoretically speaking, it seems that this would be hard to argue against.

    i also found this:


    and i’m even more alarmed.

    volition argument aside…. really? we’re not even at the level of understanding the technology, let alone understanding the neurological underpinnings of such a syndrome.

    times like this make me realize why the world has gone crazy. alien hand syndrome. we haven’t even figured out how to calibrate our measuring devices to *DETECT* volition, yet we’ve somehow found correlates of alien hand syndrome using fMRI data.


    James O'Brien, M.D.
    May 28, 2015 | 7:47 PM

    There are two overriding issues in terms of personality structure in academics that need to be discussed.

    1. The baby boomers now in charge of academic departments and journals and every other institution clearly have lower ethical standards than the generations they followed.

    2. Many researchers now seem to be in the cluster B personality camp, which is great for salesmen, but what you really need are researchers in the cluster C personality group.

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