The war on the NEJM

Under attack by the red brigades of transparency

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The war against the New England Journal of Medicine has gained visibility after Charles Ornstein traced its developments in the pages of the Boston Globe.  The story was amplified in a number of trade publications, and was even picked up by a NPR-affiliated show.

This has emboldened the attackers to open fire on Twitter with calls for “transparency,” “open science,” and a “unified research community.”   Their ideological alliance is with the BMJ.

Those who refuse to partake in the cause of transparency live in a world of “silos,” “conflicts of interest,” and “industry ties.”


The NEJM‘s lukewarm attitude towards the movement is “an oppression,” says Eric Topol, as quoted by Ornstein.  Did he intend to use a term with Marxist connotation? The loose coalition of scientists, healthcare journalists, and muckrakers ready to overthrow the established order might as well be known as the Data Liberation Front!

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The Institute of Medicine and the doctrine of perpetual conflict.

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The Institute of Medicine’s 2009 report on Conflict of Interest in Medical Research, Education, and Practice aims to encourage institutions to develop conflict of interest (COI) policies to safeguard against circumstances in which individual members of the institution, or the institution itself, could risk neglecting primary professional interests (e.g., the welfare of patients or the integrity of medical research) in favor of secondary interests, such as financial gain.

As the IOM correctly notes, the means by which COI leads to a failure of professional responsibility is through bias, conscious or unconscious.  Conflict of interest policies, then, are codes of conducts erected to prevent bias from unduly influencing one’s professional actions.

I have no objection to the aim of the report or to the way in which the IOM defines COI (p. 46).  But given that the overwhelming bulk of the document’s analysis and recommendations serve to specifically guard against conflicts of interest arising from financial relationships and, furthermore, from financial relationships with commercial rather than non-commercial entities, it is worth examining whether this emphasis does not itself reveal a bias or prejudice against private enterprise.

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Austin Frakt’s conflict of interest disclosure

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Austin Frakt is a health care economist, creator of The Incidental Economist website, and a regular contributor at the New York Times’ Upshot.  A few days ago, he published a great piece about the best evidence for the treatment of insomnia.  I enjoyed reading it, learned from it, and passed it on to personal connections who suffer from insomnia.  As of now, this article is still at the top of the “most emailed” list for the NYT, and I will keep it as a reference for my patients.

In that piece, Frakt presented to the reader the objective information comparing different treatments for insomnia.  To do so, he reviewed the medical literature about clinical trials where drug treatment was tested against a form of psychotherapy (cognitive behavioral therapy).  The results Frakt reported seem to clearly favor behavioral therapy over drugs.

Yet, for all his claim to simply present objective data, Frakt disclosed a number of personal biases that could very well have influenced his interpretation of the medical literature and put him in conflict with his stated goal.

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The murky call for transparency

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Yesterday, Bill Gardner weighed in on the conflict of interest firestorm set-off by Lisa Rosenbaum.  On the surface, his New Republic article seemed to offer a middle-of-the-road and nuanced counterpoint to the vigorous—and at times spiteful—counterattacks to Rosenbaum’s NEJM series.  But despite his efforts to achieve a balanced perspective, Gardner failed to resolve the question with clarity.

While he conceded that Rosenbaum made valid points, Gardner advanced the standard and seemingly indisputable 3-part argument in favor of COI disclosure

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COI and empirical fundamentalism

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Over at the Incidental Economist, Austin Frakt has published a thoughtful commentary on Lisa Rosenbaum’s NEJM series on the obsession over conflict of interest. Frakt is supportive of Rosenbaum’s position but also touches on a dimension to the story which I did not address in my admittedly polemical piece yesterday.

Frakt’s most important statement is actually not in the post itself but in a Tweet linking to it.

Frakt is absolutely right and his statement points to a very fundamental assumption that underlies not only the COI concerns, but the legal practice of medicine in general.  Namely, the assumption is that in science and medicine, we should “let the data speak for itself.”

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COI in medicine: the pharisees exposed!

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Irvine Page’s 1987 medical textbook Hypertension Mechanisms begins with the following acknowledgment:

My special thanks are due to the Ciba-Geigy Company, who not only has contributed generously to the financing of this book, but who–over the years and more than any corporation–has recognized and encouraged the development of research in hypertension

The famed Cleveland Clinic physician-scientist, who died 4 years after the book was published, would not live long enough to have to apologize publicly for this colossal evidence of conflict of interest (COI).  It would take a few more years and a few scandals to set into motion the current phobia against industry influence.  In fact, Page would undoubtedly be stupefied by the rituals we now go through to show that our research and opinions are unblemished by the taint of for-profit corporations.

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The problem with transparency

The opaque logic of public interest policies

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While the NIH is tightening its rules concerning what financial ties university researchers must disclose before getting public grants, the FDA may be loosening its own criteria for excluding potential advisors based on their industry connections.  It seems that as a consequence of the disclosure business, the only experts who would pass muster were no experts after all

Meanwhile a story in Cardiology News this month tags yet again Dr. Paul Ridker with the issue of conflict of interest.  It seems the inflammatologist felt obligated to elaborate once more on his “lengthy disclosure slide” before giving a lecture at a scientific meeting.  But Ridker is now taking a more offensive stance and argues

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