Medicine and the Media

Naming names: is there an (unbiased) doctor in the house?

BMJ 2008; 337 doi: http://dx.doi.org/10.1136/bmj.a930 (Published 23 July 2008)
Cite this as: BMJ 2008;337:a930

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Displaying 1-5 out of 5 published

5 August 2008

We thank David JR Hutchon, Tom Jefferson, and Tammy L Boyce for their comments regarding other forms of bias besides industry bias. Central to the question about conflicts of interest is the unique role of industry bias compared to other forms of bias (personal, legal, perhaps even religious). In contrast to the multiple directions other forms of bias can take, industry bias has been consistently documented to be unidirectional: making products seem safer and more effective.1-4

What’s more, financial conflicts are subversively powerful. Everybody wants to believe he or she is above doing bad science, or touting a drug for a few thousand bucks, and the people who are consulting for industry and doing biased studies will claim their integrity is above reproach. But the evidence is clear: money talks.

The assurance that industry can use its formidable powers to trump even the best, publicly funded science is evident in the following statement by an industry insider who told the BMJ why the ALLHAT study, which was by his own admission a good study, would be easily buried by industry PR: According to Kevin Brode, (then) vice president of sales and marketing at marketRx, a firm that provides strategic marketing information to the pharmaceutical industry, “Doctors say they’ll change their prescribing habits after a negative study, but their prescription behaviour tends not to bear this out." Why not? "The reality is no one promotes a diuretic. So you’ve got one study that says yes, you should [use a diuretic], then starting the day after, you’ve got a $10 billion industry. . . and 55 promotional events . . . for an ACE inhibitor coming back in and saying ‘Here’s why my ACE inhibitor is safe and here’s why you should be using this.’ I mean, it’s promotion. Can ALLHAT stand up to that?"5

Our list was merely intended to be an additional resource of industry -independent experts for journalists who currently are inundated by industry PR, industry associations, and industry-paid KOLs or key opinion leaders. We trust our critics do not object to journalists having such an additional resource.

Nor is The List intended to “demonize” those who work for industry, as suggested by Boyce. There are plenty of superb researchers out there who have COIs with industry. We offer this list to our colleagues in the interest of giving them a way to find experts whose opinions might well agree with those who have conflicts, but who can say they came to their conclusions and they conducted their research without that particular bias. We didn’t create The List in order to exclude anyone, instead we wanted journalists to include those who too often are not consulted.

If the two of us have a bias, it is toward helping our colleagues try to balance the unidirectional influence of pharmaceutical money. We value the experts on this list not because they are anti-industry, but rather because they are skeptical, rigorous, and because those who have potential financial conflicts are willing to disclose them.

Jeanne Lenzer and Shannon Brownlee

Reference List

1. Brownlee S, Doctors Without Borders Washington Monthly. pp 2004. http://www.washingtonmonthly.com/features/2004/0404.brownlee.html

2. Stelfox HT, Chua G, O'Rourke K, Detsky AS. Conflict of interest in the debate over calcium-channel antagonists. N Engl J Med 1998;338:101- 6.

3. Turner EH, Matthews AM, Linardatos E, Tell RA, Rosenthal R. Selective publication of antidepressant trials and its influence on apparent efficacy. N Engl J Med 2008;358:252-60.

4. Bodenheimer T. Uneasy alliance--clinical investigators and the pharmaceutical industry. N.Engl.J.Med. 2000;342:1539-44.

5. Lenzer J. Marketing: Spin doctors soft pedal data on antihypertensives. BMJ 2003;326:170.

Competing interests: None declared

Competing interests: None declared

Jeanne Lenzer, medical investigative journalist

Shannon Brownlee

New York, USA 12401

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31 July 2008

Lenzer and Brownlee rightly draw attention to the problem of undeclared commercial interests which conflict with the public interest and influence media reporting of medical advances, but there is a danger that their diagnosis and proposed solution ignore the underlying causes.

Any commentator can exercise deliberate or unwitting bias in assessing the worth or significance of a health news story, and commercial interests do not present the only potential conflict. Ideological, political or religious interests also have the power to corrupt. Any affiliation, not just a link to a commercial enterprise, can lead to bias, and almost everybody has some sort of affiliation, so few people are truly independent. However, the absence or presence of such affiliations does not prove or disprove bias. The actual, rather than potential, independence of a commentator depends on qualities that are difficult to measure, such as personal integrity and expertise, rather than proxies, such as declarations of ‘no commercial interest’.

More importantly, while efforts to identify conflicts of interest is important, there is an unhealthy trend towards the demonization of everybody who is associated with the commercial sector. Commercial interests are not always corrupting, and much high-quality, honest work is carried outside universities and other supposedly-independent research institutions.

But a very major contributor to the current problem is the time pressure under which journalists have to operate. It is always dangerous for any journalist to rely on just one commentator for opinion, even if they do appear on an ‘approved list of independent experts’, but it can often be difficult to get experts on the phone to express an interesting and coherent opinion. Ideally, journalists should be able to gain a range of expert views, allowing them to identify and detect any outlying opinions that appear to have been influenced by bias, lack of expertise, etc. It would be far better to encourage more experts to make themselves available for comment, than to come up with lists of approved sources.

Competing interests: Both Boyce and Ward have acted as experts in the media on various issues. The views expressed are our own and do not represent our organisations.

Competing interests: None declared

Tammy L Boyce, Research Fellow Public Health

Bob Ward, Director, Public Policy, Risk Management Solutions Ltd, London, EC3R 8NB

King's Fund, London, W1G 0AN

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I was absolutely fascinated to read of the work by Lenzer and Brownlee and its self-made declaration of how to get into the list (which I am certain will become one more must have in anyone’s curriculum). The declaration is however, a one-way street. It implies that only those who have had or still have some kind of relation with pharma are biased. That may be so. But how about those who work in government (who make decisions and audit them), academics and professionals whose sole business is research and those who make a living out dissemination of health stories, such as journalists and most of all the scientific media?

Tom Jefferson
Cochrane Vaccines Field Rome, Italy
Jefferson.tom@gmail.com

Competing interests: I had my last direct contact with a pharma company some 5.5 years ago, however I now work for government, so I am riven by conflicts of all kinds, most of them too boring to recount here. My only other conflict is my revulsion towards data-free witch hunts.

Competing interests: None declared

Tom Jefferson, Coordinator

Cochrane Vaccines Field, Via Adige 28a, 00061 Anguillara Sabazia

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25 July 2008

I looked through the list of unbiased experts and only recognised one name. This simply reflects my very lowly position in medical research and politics.

Being unbiased is not perhaps as easy as it seems. For the past four years I have been investigating and writing about the practice of cord clamping at birth in the developed world. What seems like a fairly simple intervention and effect question becomes quite complex.

Immediate cord clamping at birth is an intervention for which there is no evidence of benefit. The WHO, FIGO and PAHO all say that immediate cord clamping is not necessary for effective active management of the third satge to prevent post partum haemorrhage. WHO specifically says the cord should not be clamped for about three minutes for the benefit of the baby.

Yet the NICE guidelines on caesarean section and intrapartum care both recommend immediate cord clamping. The caesarean guideline is particularly unsatisfactory as it uses an inappropriate reference to support the possible risks of delayed clamping. This reference specifically points out that there are no risks shown in all RCT published to date.

Why should there be any bias? As far as I am aware there is unlikley to be any financial motivation. All the drugs used in active management of the third stage of labour are inexpensive. The drive to maximised the amount of retained blood for cord blood and stem cell collection is unlikely to be a factor and I would not like to suggest that the many dedicated to research in this field have any influence. Tradition and resistance to change may well be factors especially if it seems that the adverse effects of immediate cord clamping at birth are relatively minor. However it is hardly a principle of medicine to only practie for major beneficial effects. Honour and reputation, the difficulty in admitting and recognising a failure to analyse all he evidence fairly could well be another factor. For cord clamping the effect may be minor in the majority for a few it could well be much more serious or fatal for the baby. Is this not enough for NICE to align with the rest of the experts in the world and how should we go about influencing NICE?

Competing interests: None declared

Competing interests: None declared

David J R Hutchon, Consultant Obstetrician and Gynaecologist

Memorial Hospital, Darlinton

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24 July 2008

We would like to correct several items caused by our oversights during the complicated matter of handling an Excel database (a matter that is about as fun as smashing one's head with a hammer):

First; Alastair Wood’s name was mistakenly listed on page 1 rather than page 2. Dr Wood has been a respected and independent source over the years. Two years ago, he took a position with Symphony Capital which he openly disclosed. We value him as a “Page 2” expert along with others who have disclosed such potential or real conflicts.

Second; Adriane Fugh-Berman is an associate professor, not a professor, and finally, Alan Cassels is at the University of Victoria not the University of British Columbia.

Competing interests: co-authors of story

Competing interests: None declared

Jeanne Lenzer, journalist

Shannon Brownlee

New York 12401

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