Doctors without borders: why you can't trust medical journals anymore

Washington Monthly, April, 2004 by Shannon Brownlee

Angell was still defending that decision a decade later, as editor-in-chief at the Journal, when she wrote in 2000 that disclosure was not sufficient to preserve the integrity of the science that appeared in her journal's pages: "We believe that a policy of caveat emptor is not enough for readers who depend on the opinion of editorialists." Why was it necessary to defend the journal's policies? Partly because authors were ignoring them. In 1997, when Sheldon Krimsky, a professor of public policy at Tufts University, surveyed 61,134 articles in some 181 journals, he found that only 0.5 percent disclosed a conflict of interest related to the topic of the article, an impossibly low number given the fact that a quarter of biomedical researchers at the time were receiving funding from industry. The reason for this low rate of disclosure, as Krimsky notes dryly in his book, Science in the Private Interest, is that "author compliance is not especially high."

"Lots of eminent people took great offense at being accused of being influenced," Relman told me recently. "'What an insulting thing to say. I value my reputation; doctors and scientists know best. Trust us.' I spent the first 25 years of my career doing clinical research and being one of them, and I know the feeling." As Harvey Lodish, professor of biology at MIT, huffed to Technology Review in 1984, when Relman first required disclosure at the Journal, "Scientists have all kinds of private consulting arrangements with biotechnology companies and many own stock in these companies, but that's nobody's business. It has nothing to do with the quality of their research."

"They actually believe that they aren't influenced," says Angell. Aside from the fact that it's not in physicians' self-interest to acknowledge the effects of corporate money, they may have a hard time seeing the problem for the same reason fish don't know they're swimming in water: Doctors are surrounded by conflicts of interest almost from the moment they arrive at medical school. Pharmaceutical companies begin wooing young doctors with small tokens at first, pens and coffee mugs emblazoned with drug logos, then escalating to pizza night for medical residents, dinners at expensive restaurants and tickets to sporting events. Most schools offer a class in medical ethics, but there's no requirement that they discuss conflict of interest. Besides, a few lectures can't outweigh the message young doctors absorb every day, as they watch the icons in their profession--their professors, visiting lecturers, heads of departments--taking gifts, speaking on behalf of companies, flying first-class to medical meetings in Paris and Honolulu. By the time medical residents enter private practice or the lab, the gifts from industry no longer seem like gifts, but entitlements just another way to be compensated for all those brutal, slogging years of lousy pay and long nights.

A journalist friend of mine recently told me about the day his then-girlfriend, who was a neurosurgeon, received a check for several hundred dollars in the mail, along with a note from a drug company representative. It seemed his girlfriend had made favorable mention of a particular drug during a lecture she delivered a few days earlier, and the money was just a little thank you from the manufacturer. When my friend told her she could not in good conscience cash the check--that it was a conflict of interest--she looked at him, he said, as if he were speaking in some unintelligible language.