The following guest post is by Jeanne Lenzer, an award-winning independent medical investigative journalist and author of The danger within us: America’s untested, unregulated medical device industry and one man’s battle to survive it. She is a longtime contributor to The BMJ and her articles have appeared in outlets such as the Atlantic, the New York Times Magazine. Washington Monthly, and Slate.
Medical journals require authors to disclose conflicts of interest, a policy that was put in place to help journal readers assess for themselves the validity of the authors’ data and claims. This requirement was the result of a series of studies that found that doctors and researchers who take money from drug or medical device manufacturers are more likely to exaggerate treatment benefits and to downplay harms.
There is no similar policy for transparency in the popular media. Despite rising wariness among the public about inappropriate tests and treatments, and increasing attention to doctors’ financial incentives, media outlets don’t routinely require reporters to reveal their sources’ conflicts of interest. This failure to provide such information about expert sources can mislead readers, as a recent article in The New York Times illustrates.
It’s time for journalists and editors to make these types of disclosures mandatory.
The March 26 New York Times article was written by Gina Kolata and headlined, “For many strokes, there’s an effective treatment. Why aren’t some doctors offering it?” The Times asserts that close to 700,000 stroke patients a year “could be helped” by the clot-busting drug tPA. There is no ambiguity in the language, even though ten of twelve clinical trials not only found no benefit for tPA, but did reveal significant increases in brain bleeds, a side effect of tPA. The overall framing of the article suggests that emergency doctors are depriving patients of a drug that could avert disastrous outcomes, including death and paralysis.
Writing last week on this blog, Mary Chris Jaklevic described the many ways this message serves to mislead Times readers. A key distortion involves the rationale for withholding tPA from stroke patients. Quoting physicians who support the use of tPA, the story claims that skeptics of the drug get their information from social media and not the peer-reviewed literature. That idea was accepted as valid by hundreds of readers who posted comments on the Times website, like Paul, from Hanover, NH, who wrote: “That younger doctors heed the persuasiveness of social media over peer review[ed] journals is the most terrifying statement in this article.” Dcbill, from Mexico, wrote, “Next time I see the doctor, I plan to ask if s/he reads actual medical journals articles [sic] or relies on blogs…”
Relying on the same pro-tPA sources, the Times also reported that many skeptics of the drug have fallen under the sway of Jerome Hoffman, MD, emeritus professor of medicine at UCLA. Hoffman is known around the world as a scrupulously independent expert skilled in appraising the scientific validity of medical studies, yet the story characterizes him merely as a “charismatic” speaker who gave talks and “sold informational tapes expounding his theory.” (The Times later published a correction stating he contributed to continuing medical education tapes for physicians and didn’t sell them.)
The Times’ take-home message? Good doctors who read peer-reviewed medical journal articles are upset with lesser doctors who read blogs, listen to Hoffman, and deprive their stroke patients of a beneficial treatment.
But would that take-home message have resonated quite so effectively–and would readers have been so quick to embrace this story’s point of view–had they known that the experts expressing support for the drug have financial and professional conflicts of interest?
According to the International Committee of Medical Journal Editors, a conflict of interest exists “when professional judgment concerning a primary interest (such as patients’ welfare or the validity of research) may be influenced by a secondary interest (such as financial gain).” While taking money from a drug maker does not necessarily lead to bad science, conflicts of interest are known to increase the likelihood of bias in favor of the sponsor’s product.
Because the Times failed to report the professional/financial interests of doctors who spoke out strongly in favor of tPA, I will do a bit of that work here:
Although none of Fonarow’s funding came from tPA manufacturers Genentech or Boehringer Ingelheim, there is an interesting but overlooked conflict that exists for doctors like him, and which readers might want to take into account. According to a study published in the New England Journal of Medicine in 1998, doctors who supported the use of a certain class of drugs were more likely to have financial ties to the manufacturers of those drugs (97 percent) than doctors who had neutral or negative views (37 percent). Yet in an overlooked twist, doctors who took money from any drug manufacturer, (including competitors) were also more likely to express positive views (60 percent).
Gina Kolata has been reporting on tPA since at least 1995, and some of that previous reporting, such as this feature she wrote for the Times in 2007, has also contained major flaws. The 2007 piece quoted stroke specialists who claimed that tPA could “save lives.” The claim was inaccurate; no study has ever shown that tPA saves lives, and one clinical trial had to be stopped early because stroke patients treated with tPA were more likely to die than patients given placebo.
After being challenged to back up the claim that tPA saves lives, the Times published a correction: tPA, they acknowledged, had not been shown to save lives. In that story, the Times also failed to disclose the extensive financial conflicts of the pro-tPA experts who were quoted.
Unfortunately, the Times is far from alone. HealthNewsReview.org analyzed 2,526 stories they have reviewed over a 12-year period and found that only about half (53 percent) of stories were rated as ‘satisfactory’ for the criterion “Does the story use independent sources and identify conflicts of interest?”
The combination of hope and financially driven hype can result in the prolonged and widespread use of ineffective and harmful treatments. In an article about the weak science behind tPA for stroke, Josh Farkas, MD, assistant professor of Pulmonary and Critical Care Medicine at the University of Vermont, describes the phenomenon:
Medicine continues to be plagued by poorly reproducible studies. The storyline is familiar. First, a very positive study is released in a major medical journal, with great fanfare. This leads to widespread changes in practice. Decades later, it becomes clear that the study was incorrect.
The Association of Health Care Journalists’ Statement of Principles call for journalists to “be vigilant in selecting sources, asking about, weighing and disclosing relevant financial, advocacy, personal or other interests.” It also urges journalists to:
Investigate and report possible links between sources of information (studies or experts) and those (such as the manufacturers) who promote a new idea or therapy.
This call is going unheeded by many journalists who either don’t disclose such interests at all or do so in a selective, possibly biased, manner.
It is of interest that the Times, while failing to mention the conflicts of several experts who endorse tPA, did initially include a false whiff of financial conflict for Hoffman. In an email to me, Kolata explained: “In medicine experts often have conflicts and as reporters we have to make judgment calls about when to list them. I have reported conflicts many times when they seem especially relevant.”
Imbalanced stories like this one don’t serve science, and they don’t serve patients. The public needs to know about financial conflicts in press reports just as urgently as physicians and researchers reading the medical journals. It’s time for journalists and popular media outlets around the globe to establish the ethical obligation of journalists to report conflicts of interest, when they exist, of all our sources and experts.
Addendum: For more information about why and how to disclose conflicts of interest, we recommend our criterion “Does the story use independent sources and identify conflicts of interest?”