A game of inside baseball is being played between two of the most venerated medical journals, and journalists may want to be sure they have a seat near the dugout. The game centers on one of the most important aspects of reporting on medical studies: identifying and making sense of researchers’ potential financial conflicts of interest.
In nearly every medical study, usually somewhere near the end or on the bottom of the first page, the authors declare any conflicts of interest or disclosures they may have that relate to the topic of the study. For editorials and commentaries, authors include the same, though many high-impact journals do not publish review articles and similar viewpoint-based papers by authors who have real or perceived conflicts of interest.
A lengthy three-part series at the New England Journal of Medicine, introduced by NEJM editor Jeffrey Drazen, M.D., asks whether those sorts of financial conflict-of-interest policies and regulations are wise. In the series, Lisa Rosenbaum, M.D., argues that such policies potentially jeopardize medical advances and effective patient care by “prevent[ing] the dissemination of expertise, thwart[ing] productive collaborations, or dissuade[ing] patients from taking effective drugs.”
Part I concludes with rhetorical questions regarding “appearances” of a conflict of interest, suggesting that “reasoned approaches to managing financial conflicts are eclipsed by cries of corruption even when none exists.” Part II explores ways of understanding bias. Part III, “Beyond Moral Outrage – Weighing the Trade-Offs of COI Regulation,” ask readers to vote on what a journal editor should do in three case studies.
Of course, the NEJM led the charge against conflicts of interest in the early 1990s, particularly with a 1993 article by Dennis Thompson that pointed out the key conundrum: It’s not whether the potential for financial gain clouds the judgement of doctors and researchers or not. It’s that no one – doctors, researchers, journal editors, journalists, patients – can be sure if and when it does.
A scathing commentary in The BMJ by three former NEJM senior editors, Robert Steinbrook, M.D., Jerome Kassirer, M.D., and Marcia Angell, M.D., charges that “the NEJM has now sought to reinterpret and downplay the importance of conflicts of interest in medicine by publishing articles that show little understanding of the meaning of the term.” They point out that both judges and journalists are expected to avoid hearing cases and reporting stories, respectively, when financial conflicts of interest are involved. Why then should it be different for doctors when “none of us is immune to human nature?”
Expressing dismay at weakening policies under Drazen, they reiterate: “The essential issue is that it is impossible for editors and readers to know one way or the other.”
The former NEJM editors denounce Rosenbaum’s arguments as straw men, maintain that “financial conflicts of interest in medicine are not beneficial, despite strained attempts to justify them and to make a virtue of self interest,” and insist that editorial responsibility requires rigid conflict of interest policies such as the zero-tolerance one at The BMJ. “Physicians and the public rely on journals as unbiased and independent sources of information and to provide leadership to improve trust in medicine and the medical literature,” they wrote. “Yet financial conflicts of interest have repeatedly eroded the credibility of both the medical profession and journals.”
An editorial at The BMJ published the same day calls the NEJM series an “ill advised journey” and expresses deep consternation “by a possible retreat from policies that prevent experts with relevant commercial ties from authoring commentary or review articles.”
Why does all this matter to journalists? If NEJM does back away from their policies and other journals follow suit, it becomes more difficult for journalists to assess these commentaries and review articles. Journalists should still be seeking independent experts for their stories – HealthNewsReview.org provides a list of them – but review articles are valuable for understanding a potential consensus on a particular body of evidence. HealthNewsReview.org has been covering the NEJM series, most recently with articles by Kathlyn Stone and by Kevin Lomangino. The NEJM series is a long one to take in (The BMJ commentary calls it “rambling”), but journalists who rely on medical research for their reporting will want to keep an eye on how this plays out. If NEJM continues batting at these conflict-of-interest policies, it could affect the way journalists assess future reviews and commentary.
My favorite example of financial conflicts of interest influencing a NEJM review article is
Neal L. Benowitz, M.D.
N Engl J Med 2010; 362:2295-2303
June 17, 2010 DOI: 10.1056/NEJMra0809890
I discussed this in more detail on the list. http://healthjournalism.org/list/html/ahcj-l/2015-06/msg00006.html
Basically Benowitz was on the scientific advisory board for Pfizer, and he recommended a Pfizer drug, varenicline (Chantix) in the conclusion, even though he didn’t mention it in the body of the article.
Unlike the Cochrane review http://community.cochrane.org/features/pharmacological-interventions-smoking-cessation-overview-and-network-meta-analysis , the NEJM article didn’t mention the (cheaper) cytisine or bupropion, varenicline’s competitors. In fairness, Benowitz has written about cytisine elsewhere, and cytisine is only approved in parts of Europe. Search Benowitz NL on PubMed. But the NEJM sometimes mentions drugs that aren’t approved in the US. Maybe cytisine should be approved in the US.
If you’re working on this story, you might call Drazen, Rosenthal or Benowitz and ask them about this. Isn’t this an example of at least unconscious bias in favor of a drug company that you’re working for? Why did Cochrane mention those 3 drugs when the NEJM mentioned only 1? How many layers of editorial review did that article go through?
Thanks for pointing out the pieces that Kevin Lomangino and Kathlyn Stone wrote for HealthNewsReview.org.
Special kudos also go to Dr. Susan Molchan, one of our expert contributors, who was one of the first to jump in and criticize the NEJM series with two different blog posts:
I believe that her early and strong voice prompted others to weigh in with their own critiques.
Thank you, Norman, for that great example of precisely what the problem is. And thanks for adding those links, Gary — I had missed those!
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