Academic medicine flunks the purity test. Should we outlaw tenure and NIH grants?
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Industry critics like Marcia Angell have created an entire cottage industry of conferences and books devoted to decrying the "conflicts of interest" that for-profit drug and medical device industries supposedly inject into the otherwise "hallowed" halls of pure academic research. Get the dirty money out, or so the argument goes, and the angels of academia (pun intended) will be returned to rightful control of the academy.

Not so fast. A fascinating article in the Wall Street Journal today airs some the "dirty" laundry of academic medicine: many of the attention grabbing results published in top-flight medical journals, sans industry influence, can't be reproduced independently by "greedy" pharmaceutical companies.

From the Journal:

This is one of medicine's dirty secrets: Most results, including those that appear in top-flight peer-reviewed journals, can't be reproduced. "It's a very serious and disturbing issue because it obviously misleads people" who implicitly trust findings published in a respected peer-reviewed journal, says Bruce Alberts, editor of Science. On Friday, the U.S. journal is devoting a large chunk of its Dec. 2 issue to the problem of scientific replication.

Reproducibility is the foundation of all modern research, the standard by which scientific claims are evaluated. In the U.S. alone, biomedical research is a $100-billion-year enterprise. So when published medical findings can't be validated by others, there are major consequences. Drug manufacturers rely heavily on early-stage academic research and can waste millions of dollars on products if the original results are later shown to be unreliable. Patients may enroll in clinical trials based on conflicting data, and sometimes see no benefits or suffer harmful side effects. There is also a more insidious and pervasive problem: a preference for positive results.

Eliminating financial conflicts of interest from medicine is the new gospel of pure science. Not so fast: Who watches the watchmen? All human beings are fundamentally self-interested, and declaring freedom from an obvious financial conflict can merely mask other, equally problematic (but more subtle and thus dangerous) conflicts.

As anyone who's spent time in grad school knows, academia is a really a jungle red in tooth and claw. In academic medicine the spoils of high profile publications include tenure, lucrative lab assignments and government grants, and the accolades from your peers that come with the New York Times picking up the headline from your latest Lancet or New England Journal of Medicine article.

Ironically, medical journals - often at the forefront of decrying industry bias - are part of the problem, since they too compete fiercely for subscriptions and ad revenues, and seek out "splashy" headlines with big health implications that they then peddle to major media publications. From a scientific standpoint, studies that disprove their hypotheses are at least as valuable as positive ones, but they just don't get published. Or as Atlas' Venture's Bruce Booth told the Journal, "nobody gets a promotion from publishing a negative study."

In fact, there's a good case to be made that market incentives and government regulations enforce a much higher standard of scientific credibility on firms than on individual academics. Companies have to submit all of their studies and data (positive or negative) to the FDA, and must usually complete two successful "blinded" and placebo-controlled studies for FDA approval.

Academic researchers, on the other hand "rarely conduct experiments in a 'blinded manner' [which] makes it easier to cherry-pick statistical findings that support a positive result." Bayer has reported that it has "halted nearly two-thirds of its early drug target projects because in-house experiments failed to match claims in the literature," including those from the "most prestigious journals."

Bayer's approach is unsurprising: companies have powerful incentives to weed out bad science quickly, since the pivotal clinical trials for FDA approval (called Phase III trials) can cost hundreds of millions of dollars and take years to complete. So you'd much rather kill a bad idea quickly, and cheaply, than let it get too far along in development (although, sadly, this happens all too often in the industry anyway just by virtue of the underlying scientific uncertainty).

So where does this leave us? Companies might be biased, academic scientists might be biased, and the system is rife with incentives to promote you career or your product at the expense of good science.

Should we just close up the whole enterprise? Go back to bloodletting and herbal tea?

Not at all. We don't need men to become angels to produce good science or good government. Demanding disclosure of appropriate potential conflicts, seeking peer review from a wide-range of experts with varying opinions, and keeping a healthy skepticism about the latest scientific fads (even if they're published in leading journals) are all good checks on the spread of bad data.

And despite all hand wringing about conflicts of interest, the system has worked well for decades - producing incredible new treatments for AIDS, heart disease, and cancer. We cannot eliminate conflicts - and shouldn't even try to - but they can be managed appropriately. Indeed, self-interest, harnessed through market competition, can be an immensely powerful tool for good:

The principle of self-interest rightly understood is not a lofty one, but it is clear and sure. It does not aim at mighty objects, but it attains without excessive exertion all those at which it aims. As it lies within the reach of all capacities, everyone can without difficulty learn and retain it. By its admirable conformity to human weaknesses it easily obtains great dominion; nor is that dominion precarious, since the principle checks one personal interest by another, and uses, to direct the passions, the very same instrument that excites them.

The principle of self-interest rightly understood produces no great acts of self-sacrifice, but it suggests daily small acts of self-denial. By itself it cannot suffice to make a man virtuous; but it disciplines a number of persons in habits of regularity, temperance, moderation, foresight, self- command; and if it does not lead men straight to virtue by the will, it gradually draws them in that direction by their habits. If the principle of interest rightly understood were to sway the whole moral world, extraordinary virtues would doubtless be more rare; but I think that gross depravity would then also be less common. The principle of interest rightly understood perhaps prevents men from rising far above the level of mankind, but a great number of other men, who were falling far below it, are caught and restrained by it. Observe some few individuals, they are lowered by it; survey mankind, they are raised.

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