The following is a guest blog post from Kathlyn Stone, who is an Associate Editor for HealthNewsReview.org.
After reading the NEJM’s recent reader poll on conflict-of-interest rules, one gets the sense that the NEJM is still trying to frame the discussion. The poll appears as a follow-up to Lisa Rosenbaum’s widely panned 3-part series on physician-industry ties and a related editorial by the NEJM’s editor-in-chief, Jeffrey Drazen, both of which suggest that criticisms of physician-industry financial ties are overblown.
The poll presents three hypothetical potential contributors to the journal and asks readers to put themselves in the “role of editor and help us decide” about these potential contributors’ suitability as NEJM review authors. Each of the three hypothetical experts has some type of financial arrangement with the pharmaceutical industry – either royalty payments, speaking fees, or commercially supported research at a university that covers everything except the researcher’s salary.
Noticeably absent was a “Case #4” describing a potential author with no conflict of interest. This is striking considering that during the 1990s and up until 2002, the NEJM would not publish editorials or review articles by authors with any conflict of interest (COI).
More than 30 readers – most of whom identified themselves as physicians – commented on the poll and used the space afforded to comment on the Rosenbaum series as well – and it seems many still aren’t buying what NEJM is selling.
David Newman, an emergency medicine physician in New York, finds the NEJM’s efforts to recalibrate thinking regarding COI “disappointing and tone deaf.”
“Pharmaceutical company money, and the purchase of influence, has been the single most powerful distorting force in healthcare in a generation—this is undisputed. This overwhelming and uncontested monetary force has come between guideline panels and recommendations, government agencies and quality markers, healthcare policies and subjects, and doctors and patients—this too is undisputed (there is endless literature, ignored by Dr. Rosenbaum, to demonstrate these influences). There is a reason more than two thirds of Americans are taking a prescription drug, an embarrassing statistic.
Those who accept pharmaceutical money in any form are, typically, good people with high morals and benevolent intentions. Please do not let us conflate their intentions with their impact. And let us not turn back the clock on attitudes toward financial COIs.”
Newman also asks why NEJM’s poll didn’t offer a fourth alternative.
“The only reason to choose any of the individuals in these cases would be if there were no available alternatives.”
Rohan Perera, a cardiovascular disease physician in Port Jefferson, NY, suggests the NEJM has failed in its efforts to draw a parallel between blockbuster-hungry Big Pharma and Jonas Salk, the inventor of the polio vaccine who refused to patent the vaccine and thus enrich himself.
“Dr. Rosebaum’s greenwashing of a very powerful stakeholder in health care deserves some outing. Edward Bernays, I believe pioneered the use of psychology to garner sympathy for the devil. One does not have the luxury of space to quote case by case of thousands of documented industry malfeasance suffice to say that Big PhRMA and allied giants of capital are no Jonas Salks.”
Piero Baglioni, an endocrinologist in the UK, voiced the concern of other commenters that the journal was not giving equal voice to those with an opposing view on COI issues.
“I belive [SIC] that Dr Drazen would show aequanimitas if (and only if) he allowed an authority of the same level of Dr Rosenbaum to write a 3-article series in the Journal on the reasons (and there are many) why physicians should be very careful in their «dance with the porcupine». I am afraid this will not happen.”
Others have written more extensive responses to NEJM’s push to embrace the inevitability and positivity of physician-industry ties. These include Susan Molchan’s two HealthNewsReview.org articles, “Criticism of NEJM’s defense of industry-physician relations” and “Responding to parts 2-3 of New England Journal of Medicine’s series on pharma-MD relations,” as well as Larry Husten writing in Forbes, “No, Pharmascolds Are Not Worse Than The Pervasive Conflicts Of Interest They Criticize.” Contributors to the Lown Institute website including Shannon Brownlee, Vikas Saini, and Vinay Prasad have also weighed in on the debate, with Saini describing the series as NEJM’s “audition for the role of the Fox News of healthcare.”
More recently, on his PulmCrit blog, Josh Farkas at the University of Vermont equates NEJM’s recent focus on physician-industry ties to a concerted “media campaign” designed to change attitudes. He writes,
“Perhaps the most interesting component of the media campaign is the reader poll about the adequacy of various hypothetical authors for a review article. Three potential authors are described, all of whom have significant COIs. The design of this poll itself is biased, by presenting no authors without COIs. A more transparent approach might be to simply ask readers “do you think review article authors should be allowed to have COIs?”
If anything, the NEJM’s efforts to “greenwash” the potential harms of industry influence on scientific medical publishing has pushed more individuals to articulate their views on COI. And it’s also drawn attention to the fact that NEJM itself is not without conflict when reporting on such matters–all the more reason for its editors to be vigilant in protecting against commercial bias. As the always-quotable Richard Lehman pointed out in his journal review at the BMJ, the only conflicts declared by Drazen and Rosenbaum are their affiliations with NEJM.
“But that is a pretty massive conflict, isn’t it?” Lehman wrote. “How much of the NEJM‘s income comes from reprint sales to the pharmaceutical industry? Sorry, I didn’t catch that… commercial confidentiality?—ah, I see.”
Addendum on June 3: See this update – “Former NEJM editors slam ‘backtrack’ on conflict of interest” from The BMJ.