Blog

Special RightCare Weekly: Response to the NEJM Conflict of Interest series

Rarely does a medical journal series (Part 1Part 2Part 3) incite such astonishment from us like the one on conflicts of interest, written this month by Lisa Rosenbaum, MD. For the most prominent journal of American medicine to offer so much precious real estate for arguments that are half-baked and tendentious is amazing.

We’ve reviewed the series, and urge you to do so as well. We’re not sure what this sensational call to turn back the clock on conflicts of interest indicates, but we would be remiss not to inform our network about it.

We hope you will review the various reactions we’ve provided in the links below, and let us know what you think in the comments.

 

Our main responses:

Shannon Brownlee, MSc: The Conflict Denialists Strike Back

“Do I think researchers who have conflicts of interest are unethical and greedy? I’m sure some of them are, but most are simply kidding themselves that they can take the money, allow industry to control the agenda, and still conduct unbiased research.”

 

Vinay Prasad, MD MPH: Why Lisa Rosenbaum Gets Conflict of Interest Policies Wrong

“This is an important question: Who should be on guidelines and advisory panels?  I think surely not people with financial conflicts of interest. I don’t even think we will miss the so-called ‘content experts.’ … In the era of clinical trials, the expert is the person who best understands trial design and bias, and not the one with the best knowledge of the purported pathophysiology of disease.”

 

Vikas Saini, MD: New England Journal of Medicine Auditions For the Role of the Fox News of Healthcare

“To my pharmascold friends, I have a confession: I, like Rosenbaum, thought that your deep suspicion of industry studies was an over-the-top emotional reaction, and a knee-jerk anti-corporate bias. Until I starting reading the studies carefully. I mean really carefully – poring over the tables in the appendix, and calculating rates that weren’t presented but were discernible in the data. At which point my jaw dropped.”

 

Three thoughtful responses have been posted by Austin Frakt and Bill Gardner at The Incidental Economist. They’re sympathetic to the core of Rosenbaum’s view:

Austin Frakt, PhD:

“Lisa is right that once intuitions—moral and otherwise—like these enter the picture, we’re already in difficult terrain. Problems arise by unexamined convictions, she wrote. But, for me, problems arise by examined ones as well. I do think money influences, as do relationships and beliefs. But when I examine my own feelings about these, I’m no closer to understanding the extent to which I use them in my own biased way, if at all.”

 

Bill Gardner, PhD:

“Austin’s right. Just knowing that Jones consults to Big Pharma doesn’t help you evaluate whether Jones’ study is valid. I don’t think there is a fair or even effective way for an individual reader to use meta data about authors to evaluate an individual article. I don’t read those footnotes either. Nevertheless, it is vital that those footnotes are there. Meta data are essential for meta analyses, which are systematic reviews of the effectiveness of research.”

 

Frakt again: How physicians use financial conflicts of interest disclosures

“However, we must acknowledge that citing some examples of problems with industry-sponsored work does not, itself, demonstrate that bias, on the whole, is more common under that kind of funding, let alone by how much. A key danger in assuming that other types of sponsorship are not accompanied by significant conflicts is that it could lead to the wrong policy solution. … This points directly to some other ways to alleviate the concerns COIs raise, and not just for industry-sponsored studies but for all studies: beef up research reporting.”

 

Additional responses from our friends:

Larry Husten, MD:

“The question is not were the guideline writers good people,” said Stein. “I know them. They are ethical people and physicians. The question is if they were unduly and subconsciously influenced by their relationships with pharma. […] Bias does not make you ‘bad’– it makes you human.”

 

David Newman, MD (in the comments):

“Being a ‘world renowned expert’ is wonderful, but excellent literature tells us that there are virtually always many alternative options—other experts who have no financial relationships that could potentially represent a COI.”

 

Roy Poses, MD:

“By publishing this series of high visibility articles, the New England Journal of Medicine seems to have deliberately muddied the waters of discussion about conflicts of interest.  This is sad, because the journal was once considered the foremost English language scholarly medical journal, but it now seems to be publishing polemics.”

 

Wally Smith, MD:

“In an unbelievable twist of logic, Rosenbaum seems to be arguing in this article for more, not less of these questionable activities, in the interest of advancing science, until we prove patients are directly hurt by them, i.e., we have a “wreck.”  Heck, let’s get rid of traffic lights too, while we’re at it.”

 

Susan Molchan, MD, MA (also here):

“Lesson learned: Don’t trust what comes out of a drug company (or medical journals?) and verify, verify, verify.”

 

Merrill Goozner, MA:

“A three-part series on conflicts of interest in medicine by the new national correspondent for the New England Journal of Medicine has provoked a firestorm of criticism. It also reveals its author, Dr. Lisa Rosenbaum, has a lot to learn about journalism ethics.”

 

And finally, a vigorous defense of the series by David Shaywitz, MD, PhD:

“However, Rosenbaum’s essay is sure to resonate with what might even be the silent majority of academic physicians, scientists, and patients who recognize the potential benefits of less stigmatized interactions with industry experts, but who, thus far, have been too intimidated to speak out.”

 

While this debate continues, remember that the medical-industrial complex grinds on:

The University of Minnesota’s Medical Research Mess – Carl Elliott, New York Times

Centers for Disease Control and Prevention: protecting the private good? – Jeanne Lenzer, The BMJ

Drugmakers funnel payments to high-prescribing doctors – Bob Herman, Modern Healthcare

Right Care News

Read More