Star Ford

Essays on lots of things since 1989.

Fraud in medicine: worse than you thought

This was written by a doctor about personal experiences. (Headings added.)

I don’t think people understand the sophistication with which scientific journals are being co-opted for profit… There are blatantly unethical things going on such as articles that are ghost written, undisclosed conflicts of interest, and results that are incompletely reported or falsified. But more sinister are the less overt problems…

Targeted advertising

The AMA maintains a massive database with detailed personal and profession information about every doctor in the country mined from many sources. Our prescribing habits are mined from free, drug, look-up programs such as the epocrates app for smart phone. Our schedules, contacts, and relationships are mined from our smart phones and through other sources. Then advertising is very specifically targeted. The advertisement is often very soft-sell – often in the form of something that looks like an objective, scientific continuing medical education resource from a respected professional organization. For example, the pages of journals are individually collated so my journal might have an ad for Allegra and the same journal for my colleague might have an ad for Claritin. An advertiser can tell the publisher that xe wants the ad to go only to women in their first two years of practice, who have >20% Medicare patients in their practice and who prescribe Allegra more than six times per year. Sometimes, in non-peer reviewed journals, the actual content of the articles in the journal are targeted in a similar fashion. Non-peer reviewed journals can be glossy, easy to read, better written than most peer reviewed journals, more clinically relevant, and free. I don’t think most clinicians pay much attention to the nuances of a journal’s editorial practices and rigor – they read something on their desk if it looks interesting, relevant and easy to digest.

Publishing “evidence”, accidentally

Doctors can be co-opted into using their reputation to sell drugs without even knowing it. For example, I can give a talk at a conference. A couple weeks later a colleague (maybe someone I really respect) who is getting paid by a drug company might contact me saying, “Great talk! I have a similar interest. Do you want to write a paper together?” I say, “yes” having no idea that they are getting paid by a drug company to contact me. A month later the colleague sends a draft manuscript (possibly ghost written by a drug company representative). It is my talk almost verbatim but with a table that includes some new drug or a new off label use of an old drug. The text may include a sentence or two about “promising new research” or “alternatives if standard treatments fail.” If I wasn’t a journal editor and therefore alert to this type of scam, I might sign off on submitting it with minimal edit because it looks almost exactly like my talk. I agree with 99%. The colleague just contributed this one little, minor thing. It is an easy publication for me, and I need that for my academic standing. Once the drug is in print in an article written by a respected professional, it is easier for others to include it citing the first article.

Paying for “peer review”

Another example, of something that I was almost sucked into… I was asked by my professional organization if I would be willing to review an article. I was offered $500 to do so. I did not know that the $500 came from a drug company that gave the organization an “unrestricted grant” to write a review article about the disease their drug treats and send it to members of the organization. The article is written by organization staff who knows who is paying the bill and whose job depends on the organization being able to raise money from drug companies. I review it and can collect my $500 having done nothing unethical – money comes from an unrestricted fund at a non-profit professional organization and I provided a professional service for the money. The grant was “unrestricted” so the drug company can’t formally intervene in the editorial process. I don’t have to disclose any competing interests in the future and may not even know which drug company gave the money. What I say about the article or how carefully I review it doesn’t really matter to the organization. Maybe I will barely read the article or maybe I will write a good review. As long as I return a “review”, it can go out under the by line of John Doe with Dr. My Name, Professor at Respected University and as a publication of the respected professional organization. The article is officially peer reviewed (and there is no standard definition of what that means). Maybe I will write a detailed and scathing review, but if I do the editor is under no obligation to make changes. After writing a scathing review and turning down the money, I wasn’t offered another opportunity.

The professional organization maintains its reputation for producing quality academic work because, in addition to publishing this type of article/drug ad, it also publishes a very fine, well-edited journal. Members assume these supplemental manuscripts are subject to the same editorial practices and policies as the regular journal. The organization justifies the deceitful practice of writing these companion pieces as a necessary evil to raise the money to support their quality work. They disclose the financial support for the project in fine print somewhere. Since the drug company didn’t write the article, they can’t be held accountable if the article recommends drugs that don’t have FDA approval or for uses the FDA hasn’t approved. The drug company would be sued and disciplined if they wrote and distributed the article themselves. The article might not recommend something that isn’t FDA approved, and the sponsor’s drug may be a reasonable treatment. However, the article might oversell the sponsor’s drug over other equally good or better options. They might do this by focusing on things like convenient packaging, easier dosing schedule, the taste, evidence regarding how much it changes various lab values rather than how well it improves a person’s health, etc. This type of bias is usually pretty subtle so readers won’t detect it.

Ignoring the evidence

Another technique is to write a whole article reviewing the evidence that a drug doesn’t work and is of no use at all. Then the conclusion of the abstract is, “While more study is needed, X holds promise as the key to saving the world.” Most readers won’t get beyond the abstract. The concluding sentence of the abstract, is the only sentence many readers will see.

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