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Is the pen mightier

Is it time to turn the heat up on the medical journals and their nice little earners?

In his book, The Trouble with Medical Journals, Richard Smith, the former editor of the British Medical Journal (BMJ), claims that medical journals are overly influenced by the pharmaceutical industry (indeed he uses the term `bought') to such an extent that the journals should cease to publish trials from the industry.

This opinion was echoed by Richard Horton, the editor of the Lancet, at a recent conference where he said that on several occasions he had been threatened by pharmaceutical company executives who wanted to reverse changes made to clinical brand publications during the peer review process.

I read Smith's book with interest and was concerned greatly by some of the accusations he made within its pages. As a great defender of the industry, I believe that most initial comments made about pharma are exaggerated and that it fails to defend itself sufficiently when such accusations are made.

Smith's allegations are of particular concern as he illustrates his points using a number of examples and the book is relatively well referenced, although some of his references are rather dated and, I suspect, would be unlikely to survive a rigorous pharma company review.

As such, I decided to do some research of my own, albeit among a handful of individuals. While this may have resulted in some rather biased views, the outcomes surprised me.

Fiscal splendour

I was told by editors of medical journals that the pharma industry is inherently corrupt, comprising unethical heathens with no conscience who lavish clinicians with so much money and goodies that their judgement is impaired. Editors, on the other hand, are saints, or pretty close to that. Despite this suggestion, however, not a single clinical writer I spoke to was willing to go on the record with their thoughts. These editors are too powerful, if I am quoted I might never work again, one of them told me.

It reminded me of one pertinent point in Smith's book where he states: `There is a tendency to see the industry as the villains and the doctors as the innocent victims, but that is horribly oversimplified.' I wondered if at any point he was tempted to insert `journals' in place of `doctors' in this context. Just whom is compromising who?

The journals are primarily commercial ventures and those further down the pecking order are surviving on tiny profit margins, always close to the edge. My chats with them were an eye-opener.

They depend so heavily on advertising and reprints that they go so far as to run articles past companies in advance of publication to make sure they comply with the Association of the British Pharmaceutical Industry (ABPI) Code, in order to guarantee reprints, and would never print a negative study as they fear it might impact on advertising.

I am sure that this would appall the editors of the big five, the Annals of Internal Medicine, BMJ, The Journal of the American Medical Association (JAMA), the Lancet, and the New England Journal of Medicine (NEJM). Without doubt, having your trial or review published in any of the big five bestows upon it a greater level of credibility than any other journal. But
how different are they?

An editor of one of these `big' journals told me confidentially that, on a number of occasions, they have actively pursued particular pharmaceutical clinical trials for publication. What would motivate one of the major journals to do that? The answer is the same motive that drives those journals positioned further down the pecking order.

These high-brow medical journals are also primarily commercial ventures that benefit from the publication of major trials in terms of prestige, publicity and fiscal return. Prestige because the clinical community is keen to read the study and publicity, both self-generated and fuelled by the study participants and industry, because of the kudos; the fiscal aspect however came as something of a surprise.

I may well have been rather naive before embarking on this exercise but the stark realities of the fiscals are staggering: reprints are very expensive items. Despite numerous calls on the pharma industry to be transparent and open in its dealings with publications, medical journals can charge a King's ransom for reprints.

Companies and journals both realise the benefit of publication in the major journals and the industry pays the price. It can cost hundreds of thousands of pounds to secure reprints for a global corporation; $1m is not unusual.

What this means to journals is a healthy annual income and significant yearly profits. My sympathy for the publications has fast disappeared.

Medical journal editors regularly claim that the industry is compromised because of its need to hit profit targets. I cannot imagine that editors, who are responsibile for both the editorial content and the productivity of their journals, are not then also compromised by their need to hit the bottom line. To say they are not compromised by such grubby things as profit margins, but that industry and medics are, is to take the argument one step too far in my mind.

I honestly do not think that pharma's vested interests result in the type of corruption frequently implied by medical publications. Most clinical studies are run by medical departments. Most medical departments comprise clinicians. These clinicians are bound by an ethical code regardless of whether they work for a pharmaceutical company or for the national health service.

These people do have their own personal biases, perspectives and agendas, but I have yet to meet one who makes me concerned over their moral fibre. I am sure there are exceptions but those I have interacted with have been the opposite of criticism levelled by journals.

Clear agendas

It also concerns me that editors seemingly think clinicians who participate in clinical studies have so little to lose that they will capitulate to the industry's every request.

The scientific writers I spoke to, often the conduit between industry and clinicians, were adamant about this issue. Doctors have too much to lose by compromising themselves for one study. There is terrible pressure on clinicians to be published (their career paths are determined by the number of publications they achieve each year) but often the industry is interacting with the leading clinicians in the world and they are much too smart to be so easily bought.

Smith's book is somewhat depressing. However, his prod at the pharma industry pales into insignificance in the context of clinical fraud, the commercial needs of publishing houses and the highly acclaimed, but evidently flawed, peer review process.

Ultimately, journals and industry are just two in a complex web of stakeholders in a publication. The publishing house, the peer review process, the trial data, the clinicians and the, often independent, writer all play a part. Recent changes in many companies, placing publication strategies into separate groups away from the commercial teams, have been designed to respond to some of the criticisms, but I'm not sure that it is the right answer.

Pivotal studies deserve to be widely communicated to those affected. If the distance between those who have the ability to help communicate those studies and those who are responsible for the study is too vast, it may be that the very people we are trying to help will ultimately suffer.

Journals are not overly influenced by pharma but they are compromised by their commercial relationship. The industry has made great strides to respond to criticisms of its approach to trial publication; the publications should now follow suit.

The Author
Liz Shanahan is MD of SantÈ Communications

15th January 2007

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